Medicaid: Concerns Remain about Sufficiency of Data for Oversight
of Children's Dental Services (02-MAY-07, GAO-07-826T). 	 
                                                                 
The 31 million children enrolled in Medicaid are particularly	 
vulnerable to tooth decay, which, if untreated, may lead to more 
serious health conditions and, on rare occasion, result in death.
Congress established a comprehensive health benefit for children 
enrolled in Medicaid to cover Early and Periodic Screening,	 
Diagnostic, and Treatment (EPSDT) services, which include dental 
services. The Centers for Medicare & Medicaid Services (CMS) is  
responsible for oversight of these services. States are 	 
responsible for administering their state Medicaid programs in	 
accordance with federal requirements, including requirements to  
report certain data on the provision of EPSDT services. GAO was  
asked to address the data that CMS requires states to submit on  
the provision of EPSDT dental services and the extent to which	 
these data are sufficient for CMS oversight of the provision of  
these services. This testimony is based on reports GAO issued	 
from 2000 through 2003. GAO updated relevant portions of its	 
earlier work through interviews conducted in April 2007 with	 
officials from CMS; state Medicaid programs in California,	 
Illinois, Minnesota, New York, and Washington (states contacted  
for GAO's 2001 study or referred to GAO by another official); and
national health associations. GAO also reviewed relevant	 
literature provided by officials from CMS and other		 
organizations.							 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-07-826T					        
    ACCNO:   A68989						        
  TITLE:     Medicaid: Concerns Remain about Sufficiency of Data for  
Oversight of Children's Dental Services 			 
     DATE:   05/02/2007 
  SUBJECT:   Beneficiaries					 
	     Child care programs				 
	     Children						 
	     Data collection					 
	     Data integrity					 
	     Dental services					 
	     Federal/state relations				 
	     Health care programs				 
	     Health care services				 
	     Managed health care				 
	     Medicaid						 
	     State-administered programs			 
	     Early and Periodic Screening, Diagnosis,		 
	     and Treatment Program				 
                                                                 

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GAO-07-826T

   

     * [1]Background

          * [2]EPSDT Services
          * [3]Medicaid Delivery and Financing

     * [4]CMS Requires States to Report Annually on Provision of EPSDT
     * [5]Quality of CMS Data on EPSDT Dental Services Has Improved, b

          * [6]State CMS 416s Are Not Always Submitted or Complete
          * [7]CMS Has Taken Steps to Improve Quality of the Data, but Conc
          * [8]CMS 416s Have Limitations for Oversight Purposes

     * [9]Concluding Observations
     * [10]GAO Contacts and Acknowledgments
     * [11]Appendix I: CMS Form 416
     * [12]Related GAO Products

          * [13]Order by Mail or Phone

Testimony

Before the Subcommittee on Domestic Policy, Committee on Oversight and
Government Reform, House of Representatives

United States Government Accountability Office

GAO

For Release on Delivery
Expected at 2:00 p.m. EDT
Wednesday, May 2, 2007

MEDICAID

Concerns Remain about Sufficiency of Data for Oversight of Children's
Dental Services

Statement of James Cosgrove
Acting Director, Health Care

GAO-07-826T

Mr. Chairman and Members of the Subcommittee:

I am pleased to be here today as you examine the Centers for Medicare &
Medicaid Services' (CMS) oversight of dental care for the 31 million
children from low-income families enrolled in the Medicaid program,^1
including the significant number of children covered by managed care.
Medicaid is the joint federal-state program that provides health care
coverage for certain low-income individuals. According to the Centers for
Disease Control and Prevention, tooth decay is one of the most common
chronic infectious diseases among U.S. children: 28 percent of children
aged 2 to 5 have had decay in their primary (baby) teeth, about 50 percent
by age 11. Untreated tooth decay may result in pain, dysfunction, and
other problems that may lead to more serious health conditions and, on
rare occasion, result in death. Low-income children--such as those
enrolled in Medicaid--are estimated to be twice as likely to have
untreated tooth decay as children in families with higher incomes.

In 1967, Congress established a comprehensive health benefit for children
enrolled in Medicaid to cover Early and Periodic Screening, Diagnostic,
and Treatment (EPSDT) services.^2 In 1989, Congress further defined EPSDT
services to specifically include dental services.^3 As the agency
responsible for overseeing the administration of states' Medicaid
programs, CMS has an important role in ensuring that states comply with
federal requirements, including that each state report annually to CMS on
certain aspects of dental and other EPSDT services. Despite the known
prevalence of tooth decay in the Medicaid population, recent CMS estimates
of the provision of dental services, based on state reports to CMS,
indicate that only about one-third of Medicaid children received a dental
service in fiscal year 2005.

^1Estimated enrollment for all children in Medicaid in fiscal year 2006.

^2Social Security Amendments of 1967, Pub. L. No. 90-248, S302, 81 Stat.
821, 929 (1968) (codified, as amended, at 42 U.S.C. S1396d(a)(4)).

^3Omnibus Budget Reconciliation Act of 1989 (OBRA), Pub. L. No. 101-239, S
6403(a), 103 Stat. 2106, 2262 (1989)(codified, as amended, at 42 U.S.C.
S1396d(r)). EPSDT services include comprehensive, periodic evaluations of
health, developmental, and nutritional status and dental, vision, and
hearing services for individuals under age 21. EPSDT dental services must
include dental services that are (1) provided at intervals that meet
reasonable standards of dental practice; (2) provided at other intervals
as medically necessary to determine the existence of a suspected illness
or condition; and (3) include relief of pain and infections, restoration
of teeth, and maintenance of dental health.

My remarks today will address the data that CMS requires states to submit
on the provision of EPSDT dental services and the extent to which these
data are sufficient for CMS oversight of the provision of EPSDT dental
services for children enrolled in Medicaid. My testimony is based on
reports we issued from 2000 through 2003,^4 an assessment of CMS's
reporting requirements and state-submitted reports obtained from CMS in
April 2007, and a review of selected CMS reports on EPSDT services and of
related literature in April 2007. Our past work on the data CMS requires
states to submit focused on the broad range of required EPSDT services,
including dental services, but did not focus specifically on dental
services data. We have supplemented these findings with information from
our past work on oral health, including factors contributing to low use of
dental services by low-income populations. We also updated relevant
portions of our earlier information through interviews conducted in April
2007 with officials from CMS and state Medicaid programs in California,
Illinois, Minnesota, New York, and Washington--states we contacted in our
earlier work^5 or which were referred to us by an official from a national
health association who considered the states' experiences to be relevant
to our current work. We interviewed officials from national health
associations, including the Children's Dental Health Project,
Medicaid/SCHIP Dental Association, the National Academy of State Health
Policy, the National Oral Health Policy Center, and the George Washington
University Medical Center for Health Services Research and Policy. All of
our work was conducted in accordance with generally accepted government
auditing standards.

In summary, CMS collects annual data from states for purposes of
overseeing the delivery of dental and other required EPSDT services. Each
year, states must submit EPSDT reports known by the form on which they are
submitted, the CMS form 416. The CMS 416 report (hereafter called the CMS
416) is designed to capture data such as the number of children who
received any dental service, a dental preventive service, or a dental
treatment service. CMS has indicated that the CMS 416 is used to assess
the effectiveness of state EPSDT programs to determine the number of
children provided child health screening services, referred for corrective
treatment, or receiving dental services.

^4See Medicaid and SCHIP: States Use Varying Approaches to Monitor
Children's Access to Care, [14]GAO-03-222 (Washington, D.C.: Jan. 14,
2003); Medicaid: Stronger Efforts Needed to Ensure Children's Access to
Health Screening Services, [15]GAO-01-749 (Washington, D.C.: July 13,
2001); and Oral Health: Factors Contributing to Low Use of Dental Services
by Low-Income Populations, [16]GAO/HEHS-00-149 (Washington, D.C.: Sept.
11, 2000).

^5For our 2001 study on federal government efforts to ensure state
Medicaid programs provided covered EPSDT services, we contacted selected
states, including Washington, and we visited California, Connecticut,
Florida, New York, and Wisconsin. See [17]GAO-01-749 .

The CMS 416s, however, are not sufficient for overseeing the provision of
dental and other required EPSDT services in state Medicaid programs. We
reported in 2001 that not all states submitted the required CMS 416s on
time or at all. CMS 416s that states did submit were often based on
incomplete and unreliable data. States faced challenges getting complete
and accurate data, however, particularly for children in managed care.
According to agency officials, CMS has taken steps since our 2001 report
to improve the data. For example, CMS has conducted reviews of some
states' EPSDT programs that included assessments of states' CMS 416 data.
CMS officials said that 11 states' EPSDT programs had been reviewed since
2002. CMS has also required since 2002 that states collect data on
utilization of dental and other required EPSDT services from managed care
plans. State and national health association officials told us that these
data have improved over time. But concerns about the CMS 416 remain.
Concerns cited by state and national health association officials we
contacted included inconsistencies in how states report data, data
inaccuracies, and problems with the data captured that preclude
calculating accurate rates of the provision of dental and other required
EPSDT services. Further, the usefulness of the CMS 416 for federal
oversight purposes is limited by the type of data currently requested.
First, rates of dental services delivered to children in managed care
cannot be identified from the data. Second, the data captured do not
address whether children have received the recommended number of dental
visits. And third, the data do not illuminate factors, such as the
inability of beneficiaries to find dentists to treat them, which
contribute to low use of dental services among Medicaid children.

We discussed the key findings of our testimony with CMS officials and
obtained from them technical corrections, which we incorporated as
appropriate. CMS commented on our earlier reports upon which our testimony
is primarily based.^6

6CMS generally agreed with the two related recommendations we made in
2001, that CMS work with states to improve EPSDT reporting and that CMS
develop a mechanism for sharing model practices among states for providing
EPSDT practices.

Background

Medicaid is one of the largest programs in federal and state budgets. In
fiscal year 2005, the most recent year for which complete information is
available, total Medicaid expenditures were an estimated $317 billion. The
estimated federal share that year was about $182 billion. States pay
qualified health providers for a broad range of covered services provided
to Medicaid beneficiaries, and the federal government reimburses states
for their share of these expenditures. The federal matching share of each
state's Medicaid expenditures for services is determined by a formula
defined under federal law and can range from 50 percent to 83 percent.
Each state administers its Medicaid program in accordance with a state
plan, which must be approved by CMS.^7 Medicaid is an open-ended
entitlement program, under which the federal government is obligated to
pay its share of expenditures for covered services provided to eligible
individuals under each state's federally approved Medicaid plan.

States have considerable flexibility in designing their Medicaid programs,
including certain aspects of eligibility, covered services, and provider
payment rates. But under federal law, states generally must meet certain
requirements for what benefits are to be provided, who is eligible for the
program, and how much these beneficiaries can be required to pay in
sharing the cost of their care. States are required, for example, to cover
certain services under their state plans, such as physician, hospital, and
nursing facility services, as well as EPSDT services for beneficiaries
under the age of 21.^8

EPSDT Services

EPSDT services are designed to target health conditions and problems for
which children are at risk, including obesity, lead poisoning, dental
disease, and iron deficiency. EPSDT services are also intended to detect
and correct conditions that can hinder a child's learning and development,
such as vision and hearing problems. For many children, particularly those
with special needs related to disabilities or chronic conditions, EPSDT
services can help to identify the need for, and make available, essential
medical and support services.

^7In order to qualify for federal matching funds, a state plan must detail
certain elements of a Medicaid program, including the populations served,
the services the program covers, and the rates of and methods for
calculating payments to providers. Any changes a state wishes to make to
the state plan must be submitted to CMS for review and approval in the
form of a state plan amendment.

^8See 42 U.S.C. SS 1396a(a)(10)(A),1396d(a).

State Medicaid programs are required to cover EPSDT services for Medicaid
beneficiaries under 21.^9 These services are defined as screenings, which
must include a comprehensive health and developmental history, a
comprehensive unclothed physical exam, appropriate immunizations,
laboratory tests (including a blood-lead assessment), and health
education. Other required EPSDT services include

           o dental services, which must include relief of pain and
           infections, restoration of teeth, and maintenance of dental
           health;

           o vision services, including diagnosis and treatment for vision
           defects, and eyeglasses;

           o hearing services, including diagnosis and treatment for hearing
           defects, and hearing aids; and

           o services necessary to correct or ameliorate physical and mental
           illness discovered through screenings, regardless of whether these
           services are covered under the state's Medicaid plan for other
           beneficiaries.^10

           Although state Medicaid programs must cover EPSDT services, states
           have some flexibility in determining the frequency and timing of
           screenings, including the provision of dental services. Federal
           law requires states to provide dental services at intervals that
           meet reasonable standards of dental practice, and each state
           determines these intervals after consulting with recognized dental
           organizations.^11 Each state must also develop dental periodicity
           schedules, which contain age-specific timetables that identify
           when dental examinations should occur.
		   
		   Medicaid Delivery and Financing

           States generally provide Medicaid services through two service
           delivery and financing systems--fee-for-service and managed care.
           Under a fee-for-service model, states pay providers for each
           covered service for which they bill the state. Under a managed
           care model, states contract with managed care plans, such as
           health maintenance organizations, and prospectively pay the plans
           a fixed monthly fee, known as a capitated fee, per Medicaid
           enrollee to provide or arrange for most medical services.^12 This
           model is intended to create an incentive for plans to provide
           preventive and primary care to reduce the chance that
           beneficiaries will require more expensive treatment services in
           the future. However, this model may also create a financial
           incentive to underserve or deny beneficiaries access to certain
           services.
		   
^942 U.S.C. S1396d(a)(4)(B).

^10See 42 U.S.C. S1396d(r).

^11See 42 U.S.C. S1396d(r)(3)(A). State Medicaid programs, however, must
also provide dental services whenever necessary to identify a suspected
illness.

           State Medicaid agencies use a variety of delivery and payment
           approaches to provide dental services under Medicaid. These
           include (1) paying managed care plans with which they have
           contracts to cover or arrange for the provision of dental
           services; (2) "carving out" or not requiring the provision of
           dental services from the group of services provided by managed
           care plans and paying dentists on a fee-for-service basis; or (3)
           carving out the dental services and paying specialized dental
           managed care plans to provide Medicaid dental benefits, giving the
           managed care dental plan flexibility in managing the program in
           exchange for a capitated payment to cover dental services.
           According to the American Dental Association, 18 states and the
           District of Columbia used one or more managed care dental plans to
           provide Medicaid dental benefits in 2004.

           Much of the Medicaid population is covered by some form of managed
           care, and consequently Medicaid managed care plans often provide
           EPSDT services. In 1991, 2.7 million beneficiaries were enrolled
           in some form of Medicaid managed care. According to CMS
           statistics, this number grew to 27 million in 2004--a tenfold
           increase--after the Balanced Budget Act of 1997 (BBA) gave states
           new authority to require certain Medicaid beneficiaries to enroll
           in managed care plans.^13 CMS estimates that in 2004, about 60
           percent of Medicaid enrollees received benefits through some form
           of managed care.^14
		   

^12Throughout our testimony, the term managed care refers to capitated
managed care arrangements and fee-for-service arrangements that include
primary care case management arrangements. In our earlier work on states'
approaches to monitoring children's access to care, we included primary
care case management arrangements as fee-for-service arrangements because
participating providers were predominately paid on a fee-for-service
basis.

^13The BBA allowed states to implement mandatory managed care through
amendments to their state plans, as opposed to obtaining CMS approval to
waive certain federal statutory provisions. The BBA also required the
establishment of consumer protections in such areas as access to and
quality of care for Medicaid managed care enrollees. See BBA, Pub. L. No.
105-33, SS 4701, 4704-4705, 111 Stat. 251, 489-501(1997) (codified, as
amended, at 42 U.S.C. S1396u-2).

^14All states except Alaska, New Hampshire, and Wyoming have all or a
portion of their Medicaid population enrolled in managed care. CMS's
statistics include the Medicaid population enrolled in capitated plans and
primary care case management models. These latter programs were not
included as part of our 2001 and 2003 reviews related to managed care. In
2001, we reported that compared to primary care case management
enrollment, about five times as many beneficiaries were enrolled in
capitated managed care plans. CMS's statistics do not define the extent
that Medicaid beneficiaries are enrolled in managed care that specifically
cover dental services.

           CMS Requires States to Report Annually on Provision of EPSDT
		   Dental Services through the CMS 416

           CMS requires states to report annually on the provision of EPSDT
           dental services through the CMS 416, the agency's primary tool for
           overseeing the provision of dental services to children in state
           Medicaid programs. The CMS 416 is used to report a range of EPSDT
           services. CMS implemented the CMS 416 to comply with the Omnibus
           Budget Reconciliation Act of 1989 (OBRA), which required that the
           Secretary of Health and Human Services establish state-specific
           annual goals for children's participation in EPSDT services. OBRA
           and implementing regulations mandated state-established
           periodicity schedules for health, dental, vision, and hearing
           screenings and related services.^15 CMS initially required states
           to provide only one type of dental-related data: the dental
           assessments provided. This requirement was expanded in 1999 to
           collect more detailed data.

           According to CMS, the CMS 416 is used to assess the effectiveness
           of state EPSDT programs in terms of the number of children who are
           provided child health screening services, referrals for corrective
           treatment, and dental services. Child health screening information
           is used to calculate the provision of health screenings and
           states' progress in meeting an 80 percent screening participation
           goal. For dental services, the CMS 416 captures, by age group, the
           total number of eligible children

           o receiving any dental services,
		   
^15OBRA also required blood-lead assessments (for lead poisoning)
appropriate for age and risk factors. OBRA also imposed new EPSDT
reporting requirements, specifically requiring states to report annually
to the Secretary of Health and Human Services, by age group and by basis
of eligibility, (1) the number of children provided child health screening
services, (2) the number of children referred for corrective treatment,
(3) the number of children receiving dental services, and (4) the state's
results in attaining defined participation goals. OBRA, Pub. L. No.
101-239, S 6403, 103 Stat. at 2263 (1989) (codified, as amended, at 42
U.S.C. S1396d(r)).

           o receiving any preventive dental services (each child is counted
           only once even if more than one preventive service is provided),
           and

           o receiving dental treatment services (each child is counted only
           once even if more than one treatment service is provided).

           CMS officials told us in April 2007 that CMS had not established a
           participation goal or other standard that states are expected to
           meet specifically for the provision of dental services. CMS
           officials told us they calculate state and national ratios only
           for child health screenings and participation.

           The CMS 416 also requires states to report the number of
           individuals eligible for EPSDT services who are enrolled in
           managed care at any time during the reporting year.^16 States are
           required to report information on all EPSDT dental services
           provided to children, regardless of whether those services are
           provided under a fee-for-service or managed care arrangement.
		   
Quality of CMS Data on EPSDT Dental Services Has Improved, but Data Have Limited
Usefulness for Oversight

           We have issued a number of reports that highlighted various
           problems in the delivery of EPSDT dental services and with the
           reporting of dental and other required EPSDT services provided.^17
           Problems we found in 2001 with the CMS 416 reporting included
           states not submitting CMS 416s on time or at all and states
           submitting reports that were not complete because of challenges
           they faced collecting accurate data. In our 2001 report, we
           recommended that CMS work with states to improve EPSDT reporting
           and the provision of EPSDT services. According to agency
           officials, CMS has taken steps to improve the CMS 416 data.^18
           However, state and national health association officials continue
           to cite concerns about the data's completeness and sufficiency for
           purposes of overseeing the provision of dental and other required
           EPSDT services.
		   
^16The CMS 416 instructions for managed care include reporting any
capitated arrangements, such as health maintenance organizations or
individuals assigned to a primary care provider or primary care case
manager, regardless of whether reimbursement is on a fee-for-service or
capitated basis (many primary care case management arrangements are paid
on a fee-for-service basis).

^17See related GAO products listed at the end of this report.

^18Our recommendation was made to the Administrator of CMS. In the same
2001 report, we recommended that CMS develop mechanisms to share
successful state, plan, and provider practices with states for reaching
children in Medicaid.

           State CMS 416s Are Not Always Submitted or Complete

           Some states have submitted their CMS 416s late, and others have
           not submitted the CMS 416s at all. Further, states that did submit
           reports may have provided incomplete data because of challenges in
           collecting the data. Therefore, the reports cannot be used to
           provide national estimates of the provision of dental and other
           required EPSDT services to children in Medicaid or to assess every
           state's progress in providing services. We first reported this
           problem in July 2001. States were required to submit their fiscal
           year 1999 CMS 416 reports by April 1, 2000. But as of January
           2001, 15 states had not submitted their reports, and another 15
           states' reports had been returned by CMS because they were
           deficient. As of April 2007, 7 states had not submitted their CMS
           416s for fiscal year 2005 (due to CMS by April 1, 2006), and
           another 2 states had submitted reports, but CMS considered them
           deficient and was working with the states to improve their
           reports. We estimate that these 9 states account for 20 percent of
           all children enrolled in Medicaid nationwide.

           Another long-standing concern with the CMS 416s submitted by
           states has been the completeness of the data on dental and other
           required EPSDT services used to compile the reports. Our July 2001
           report found that states faced challenges collecting data on EPSDT
           services from both fee-for-service providers and managed care
           plans. Under the fee-for-service approach, providers bill the
           state for each EPSDT service they deliver. Thus, data on EPSDT
           services are often collected by the state as part of the payment
           process. Most of the states we examined for our 2001 report had
           some difficulty obtaining complete and accurate data from
           fee-for-service providers--for example, due to coding or system
           issues. States faced more extensive problems obtaining data from
           capitated managed care plans. Unlike fee-for-service arrangements,
           when capitated managed care plans pay their participating
           providers a flat fee per beneficiary regardless of services
           provided, the providers do not need to submit information on each
           service provided in order to receive payment. Thus plans have had
           difficulty reporting on the provision of specific EPSDT services
           separately as required by states.
		   
		   CMS Has Taken Steps to Improve Quality of the Data, but Concerns Remain

           CMS officials have reported taking several actions in response to
           our 2001 recommendation that the Administrator of CMS improve
           EPSDT reporting.^19 CMS reported, for example, that it had started
           assessing states' CMS 416s as part of periodic focused reviews
           conducted by CMS regional offices. We reported in 2001 that CMS
           regional office reviews of states' EPSDT programs had been helpful
           in highlighting policy and process concerns, as well as innovative
           state practices. Since 2002, according to CMS in April 2007, the
           agency had conducted focused reviews in 11 states. These reviews
           have evaluated, among other things, state data collection and
           reporting, including the extent to which the state develops its
           CMS 416 in accordance with instructions and uses the data to
           measure progress and define areas for improvement. During these
           reviews, CMS found deficiencies, such as incorrect coding and
           incomplete data. CMS made specific recommendations to the states
           that would improve the reliability of the state-generated CMS 416
           data.

           Another step CMS has taken that has improved the quality and
           completeness of the data states can use to compile their 416s was
           to require states to gather encounter data from Medicaid managed
           care plans. The BBA and implementing regulations require states
           that contract with managed care plans to implement a quality
           assessment and improvement strategy that included procedures for
           monitoring and evaluating the quality and appropriateness of
           services provided under the contracts. States are also required to
           ensure that managed care plans maintain a health information
           system and report encounter data.^20 CMS also developed a protocol
           for states' use for validating encounter data. Officials from
           several states and national health associations we contacted in
           preparation for this hearing generally said that, although
           problems remain, the quality and completeness of the underlying
           data, such as managed care encounter data, that states used to
           prepare the CMS 416, had improved since 2001. CMS officials
           indicated a number of efforts were underway to evaluate other
           quality and outcome measures of dental services provided to
           children enrolled in Medicaid. For example, one measure CMS is
           considering is the Quality Compass developed by the National
           Committee for Quality Assurance that provides plan-specific,
           comparative, and descriptive information for use as a health plan
           benchmarking tool.

^19See footnote 23.

^20The BBA required states that contract with managed care plans to
implement a quality assessment and improvement strategy that includes
procedures for monitoring and evaluating the quality and appropriateness
of services provided under the contracts. Pub. L. No. 105-33, S4705, 111
Stat. 498-501 (1997) (codified, as amended, at 42 U.S.C. S1396u-2).
Implementing regulations published in 2002 required, for example, that
states ensure that managed care plans maintain a health information system
that collects, analyzes, integrates, and reports data. This health
information system must collect data on enrollee and provider
characteristics as specified by the state and on services furnished to
enrollees through an encounter data system or other methods as may be
specified by the state. See 42 C.F.R. S 438.242.

           But despite these improvements, officials from states and from
           national health associations remain concerned that the CMS 416s
           are unreliable for developing national estimates of the provision
           of dental and other required EPSDT services and therefore
           insufficient for oversight purposes. Although some officials cited
           some uses of the CMS 416, for example, as a set of basic
           indicators of the extent to which children use dental services
           over time, the officials cited several different problems.

           o Inconsistent data collection. Citing differences in how states
           collected data on dental EPSDT services, an April 2005 National
           Oral Health Policy Center report stated that comparing the number
           of children receiving services over time or examining the rate of
           dental utilization across states should be done with caution. The
           Center's director provided several examples. For instance, some
           states inappropriately reported oral health assessments conducted
           in group settings, such as those performed by nurses or other
           non-dentist health providers in schools, as dental examinations.
           Likewise, some states inappropriately reported oral health
           assessments provided by hygienists as dental examinations.
           According to the director, such assessments should not be
           considered dental examinations.

           o Coding inconsistencies and anomalies. CMS 416s may not
           accurately reflect the provision of dental and other required
           EPSDT services, according to an official from the National Academy
           for State Health Policy speaking about research she had done in
           2002 and 2004. States have reported that discrepancies exist
           between managed care plans and state Medicaid agencies in the
           definitions of ESPDT services. Similarly, we reported in 2001 that
           states faced such issues in collecting CMS 416 data for the range
           of EPSDT services that might be provided during a comprehensive
           office visit. For example, providers in Florida were required to
           use a specific EPSDT code and a claim form to document the
           components of EPSDT services they provided. However, according to
           state officials, providers often chose to use other codes instead.
           According to the officials, some providers submitted claims under
           a comprehensive office-visit code for a new patient that paid a
           higher rate than an EPSDT screening, or used other comprehensive
           office-visit codes that required less documentation. Specific to
           dental EPSDT services, the George Washington University Medical
           Center reported in December 2003 that several Medicaid program
           representatives said that it was difficult to separate specific
           provided services in EPSDT data reported by managed care plans to
           determine the provision of dental screening services because
           providers did not always bill for those services separately.^21

           o Changes in beneficiary eligibility. Gaps in children's
           eligibility for Medicaid and movement of children between Medicaid
           and other health insurance plans may also cause problems in
           accurately determining the extent that Medicaid children received
           dental and other required EPSDT services. One official told us
           that interrupted Medicaid eligibility, accompanied by the
           implementation of the State Children's Health Insurance
           Program,^22 has also caused problems in the data on the number of
           children eligible for services. As children move between health
           insurance programs as their program eligibility changes, officials
           reported that it becomes difficult to maintain an accurate count
           of Medicaid-eligible children. Without an accurate count, an
           accurate rate of the provision of the dental and other required
           EPSDT services to eligible children cannot be calculated.
		   
		   CMS 416s Have Limitations for Oversight Purposes

           The type of data collected on the CMS 416 has limited usefulness
           for purposes of oversight, as officials from states and national
           health associations have noted. Many officials from national
           health associations told us that the CMS 416 did not provide
           enough information to allow CMS to assess the effectiveness of
           states' EPSDT programs. One official who works with many state
           Medicaid agencies told us that states do not generally use the CMS
           416 to inform their monitoring and quality improvement activities,
           but instead rely on other sources of data. Some state officials
           reported using the CMS 416 data, but noted that they supplement
           the data with additional information.

^21See Accountability in Medicaid Managed Care: Implications for Pediatric
Health Care Quality, the George Washington University Medical Center
School of Public Health and Health Services, December 2003. Funded by the
David and Lucile Packard Foundation.

^22The State Children's Health Insurance Program (SCHIP) is a federal and
state program that finances health insurance for children and certain
adults whose incomes are low, but are above Medicaid's eligibility
requirements. States may implement SCHIP programs by expanding Medicaid
programs, developing separate SCHIP programs, or a combination of both. If
a state elects Medicaid expansion, it must provide EPSDT services to SCHIP
beneficiaries.

           The limitations noted generally fell into three categories. First,
           while states report the total number of children enrolled in
           managed care plans, dental and other required EPSDT services
           delivered to managed care enrollees are not reported separately
           from fee-for-service enrollees. Consequently, the data captured by
           the CMS 416 cannot be used to specifically monitor the provision
           of dental and other required EPSDT services under either
           fee-for-service or managed care arrangements.

           Second, the information captured by the CMS 416 is limited to
           summary statistics, such as age group, eligibility, state
           requirements, and services delivered, and does not provide
           information that would illuminate whether children have received
           the recommended number of visits for dental and other required
           EPSDT services. For example, a concern raised by a national health
           association official was that the CMS 416 did not provide
           information about whether eligible children had received the
           number of biannual preventive dental visits that are required by
           the state or recommended by the American Academy of Pediatric
           Dentistry. Because each child is counted only once each fiscal
           year, regardless of the number of dental services or preventive
           dental services the child received that year, the data do not
           reflect the total number of dental appointments each child had in
           any given year.

           Third, CMS 416s do not contain information that would illuminate
           any of a number of factors that may contribute to low use of
           dental and other required EPSDT services among children enrolled
           in Medicaid. Our 2001 report found that children's low utilization
           of EPSDT dental and other services could have been attributed to
           program-related matters, such as limited provider participation in
           Medicaid or inadequate methods for informing beneficiaries of
           available services. In addition, some beneficiary-related factors,
           such as changing eligibility status or language barriers, could
           have limited utilization of services. Also, our 2000 report on
           factors contributing to low utilization of dental services by
           Medicaid and other low-income populations found that the primary
           contributing factor among low-income persons with coverage for
           dental services was difficulty finding dentists to treat them.
           Dentists generally cited low payment rates, burdensome
           administrative requirements, and such patient issues as frequently
           missed appointments as the reasons why they did not treat more
           Medicaid patients.^23 Additional, more specific information would
           be needed to supplement the information collected in the CMS 416
           to further understand these factors.
		   
^23 [28]GAO/HEHS-00-149 .

           Concluding Observations

           Millions of low-income children enrolled in Medicaid should have
           access to important services to treat dental disease, as intended
           by Congress in mandating the coverage of and reporting on the
           provision of EPSDT dental services. Services to identify and treat
           tooth decay--a chronic problem among low-income populations and a
           preventable disease--are critical for ensuring that the nation's
           children and adolescents are healthy and prepared to learn.
           Unfortunately, as we reported in 2001 and 2003, data for gauging
           Medicaid's success in providing these important services to
           enrolled children are unreliable and incomplete. CMS and states
           have taken a number of steps to improve the data, but problems
           persist. Moreover, concerns have been raised that the reported
           data on EPSDT dental services have limited utility for determining
           how to improve children's access to these services. Strengthening
           the safety net for children in Medicaid will require additional
           efforts to gather more complete and reliable information on the
           delivery of dental and other ESPDT services.

           Mr. Chairman, this concludes my prepared remarks. I would be
           pleased to respond to any questions that you or other members of
           the Subcommittee may have at this time.
		   
		   GAO Contacts and Acknowledgments

           For future contacts regarding this testimony, please contact James
           C. Cosgrove at (202) 512-7118 or at [email protected]. Contact
           points for our Offices of Congressional Relations and Public
           Affairs may be found on the last page of this testimony. Katherine
           Iritani, Assistant Director; Emily Beller; Terry Saiki; and
           Timothy Walker made key contributions to this statement.
		   
		   Appendix I: CMS Form 416
		   
		   Related GAO Products

           Medicaid and SCHIP: States Use Varying Approaches to Monitor
           Children's Access to Care. [18]GAO-03-222 . Washington, D.C.:
           January 14, 2003.

           Medicaid: Stronger Efforts Needed to Ensure Children's Access to
           Health Screening Services. [19]GAO-01-749 . Washington, D.C.: July
           13, 2001.

           Oral Health: Factors Contributing to Low Use of Dental Services by
           Low-Income Populations. [20]GAO/HEHS-00-149 . Washington, D.C.:
           September 11, 2000.

           Oral Health: Dental Disease Is a Chronic Problem Among Low-Income
           Populations. [21]GAO/HEHS-00-72 . Washington, D.C.: April 12,
           2000.
		   
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www.gao.gov/cgi-bin/getrpt? [29]GAO-07-826T .

To view the full product, including the scope

and methodology, click on the link above.

For more information, contact James Cosgrove at (202) 512-7118 or
[email protected].

Highlights of [30]GAO-07-826T , a testimony before the Subcommittee on
Domestic Policy, Committee on Oversight and Government Reform, House of
Representatives

May 2, 2007

MEDICAID

Concerns Remain about Sufficiency of Data for Oversight of Children's
Dental Services

The 31 million children enrolled in Medicaid are particularly vulnerable
to tooth decay, which, if untreated, may lead to more serious health
conditions and, on rare occasion, result in death. Congress established a
comprehensive health benefit for children enrolled in Medicaid to cover
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services,
which include dental services. The Centers for Medicare & Medicaid
Services (CMS) is responsible for oversight of these services. States are
responsible for administering their state Medicaid programs in accordance
with federal requirements, including requirements to report certain data
on the provision of EPSDT services.

GAO was asked to address the data that CMS requires states to submit on
the provision of EPSDT dental services and the extent to which these data
are sufficient for CMS oversight of the provision of these services.

This testimony is based on reports GAO issued from 2000 through 2003. GAO
updated relevant portions of its earlier work through interviews conducted
in April 2007 with officials from CMS; state Medicaid programs in
California, Illinois, Minnesota, New York, and Washington (states
contacted for GAO's 2001 study or referred to GAO by another official);
and national health associations. GAO also reviewed relevant literature
provided by officials from CMS and other organizations.

CMS requires states to report annually on the provision of certain EPSDT
dental services through form CMS 416. The CMS 416 is designed to provide
information on state EPSDT programs in terms of the number of children who
receive child health screening services, referrals for corrective
treatment, and dental services from fee-for-service providers and under
managed care plans. Data captured on dental services include the number of
children receiving any services, any preventive services, and any
treatment services.

The CMS 416s, however, are not sufficient for overseeing the provision of
dental and other required EPSDT services in state Medicaid programs. We
reported in 2001 that not all states submitted the required CMS 416s on
time or at all. CMS 416s that states did submit were often based on
incomplete and unreliable data. States faced challenges getting complete
and accurate data, however, particularly for children in managed care.
According to agency officials, CMS has taken steps since our 2001 report
to improve the data. For example, CMS has conducted reviews of some
states' EPSDT programs that included assessments of states' CMS 416 data.
CMS officials said that 11 states' EPSDT programs had been reviewed since
2002. CMS has also required since 2002 that states collect data on
utilization of dental and other required EPSDT services from managed care
plans. State and national health association officials told us that these
data have improved over time. But concerns about the CMS 416 remain.
Concerns cited by state and national health association officials we
contacted included inconsistencies in how states report data, data
inaccuracies, and problems with the data captured that preclude
calculating accurate rates of the provision of dental and other required
EPSDT services. Further, the usefulness of the CMS 416 for federal
oversight purposes is limited by the type of data currently requested.
First, rates of dental services delivered to children in managed care
cannot be identified from the data. Second, the data captured do not
address whether children have received the recommended number of dental
visits. And third, the data do not illuminate factors, such as the
inability of beneficiaries to find dentists to treat them, which
contribute to low use of dental services among Medicaid children.

References

Visible links

  14. http://www.gao.gov/cgi-bin/getrpt?GAO-03-222
  15. http://www.gao.gov/cgi-bin/getrpt?GAO-01-749
  16. http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-00-149
  17. http://www.gao.gov/cgi-bin/getrpt?GAO-01-749
  18. http://www.gao.gov/cgi-bin/getrpt?GAO-03-222
  19. http://www.gao.gov/cgi-bin/getrpt?GAO-01-749
  20. http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-00-149
  21. http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-00-72
  28. http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-00-149
  29. http://www.gao.gov/cgi-bin/getrpt?GAO-07-826T
  30. http://www.gao.gov/cgi-bin/getrpt?GAO-07-826T
*** End of document. ***