The Health Care Financing Administration has issued a Dear State Medicaid Director letter revising EPSDT (Early and Periodic Screening, Diagnosis, and Treatment) reporting on the Form HCFA-416. Although the new form includes some new and helpful elements, the overall effect is to reduce the ability to track trends in preventive services for children.
On the positive side, the revised form contains some new elements:
- expanded reporting on dental services;
- new and more appropriate age groupings; and
- a new reporting element on lead blood tests.
On the negative side, the revised form, among other problems:
- allows states to use their own periodicity schedules for purposes of reporting, which prevents comparisons across states and across time;
- still does not distinguish managed care enrollees from fee-for-service enrollees;
- no longer collects separate information on vision and hearing screens;
- still does not include a separate line item for mental health referrals; and
- does not update the EPSDT participation goals, which have been stalled at 80 percent since fiscal year 1995.
States are to use the revised form for the current fiscal year (October 1, 1998 through September 30, 1999), and the report is due on April 1, 2000. The revised reporting requirements will eventually be published in the HCFA State Medicaid Manual, § 2700.4. We are asking HCFA to review our concerns with the new form prior to issuing the new State Medicaid Manual provisions.
Purpose of the Form
Congress requires states annually to report to HCFA on the extent to which their EPSDT programs are reaching poor children. 42 U.S.C. §§ 1396a(a)(43)(D), 1396d(r). In addition, the Medicaid Act requires HCFA to set participation goals for each state's EPSDT program.(1) HCFA requires states to report the EPSDT information on the Form 416. According to HCFA, the information on this form serves dual purposes, to:
- demonstrate the state's attainment of participant and screening goals; and
- show trend patterns and projections "from which decisions and recommendations can be made to ensure that eligible children are given the best possible health care."
Thus, the Form 416 is the state's self-reported record of EPSDT compliance for a certain year. In the study, Children's Health Under Medicaid: A National Review of Early and Periodic Screening, Diagnosis, and Treatment, the National Health Law Program used the Form 416 to document that few children are getting the preventive medical services they need through EPSDT. The data contained in the Form 416 is critical in assessing the state's record of compliance over time, as well as in identifying areas needing targeted efforts. Clearly, the Form 416 is an essential document for child health advocates.
Discussion of the Changes
Age groupings
To date, the Form 416 has required states to use the following four age groupings when reporting EPSDT information: <1 year, 1-5 years, 6-14 years, and 15-20 years. The new form requires states to use seven age groupings:
<1
1-2
3-5
6-9
10-14
15-18
19-20
These additional age groupings are welcome and could be of great benefit. For example, such reporting can assist states with better targeting age-appropriate outreach activities to improve screening rates.
Determining a child's age group
Under the old form, the child's age grouping was determined by the child's age on March 31st of the federal fiscal year being reported. The new form instructs states to report the child's age as of September 30th of the fiscal year.
This is a very significant difference with negative ramifications for the accuracy of reporting. With the exception of children born on October 1st, all children and adolescents are two different ages during any one fiscal year. The reporting form, however, only allows for a child to be reported in one age category. If the child's advance in age causes the child to change age groups (e.g., from ages 15-18 to ages 19-20), then the state must assign the child to one of the two potential age groupings.
Under the old form, the method was to split the difference and to look at how old the child was on March 31st, the halfway point in the fiscal year. This meant that if a child were eligible for the full fiscal year, she would be placed in the age grouping in which she spent the majority of the year. The new form, however, looks at how old the child is on September 30th, the last day of the fiscal year. As a result, all children will be placed in the higher age group, even if they spent the majority of the year in the younger age grouping.
The ramifications will be significant. Suppose, for example, that an infant is born on August 1st and remains Medicaid-eligible for ten months. During the first fiscal year, the infant will be counted in the under age one group. However, beginning October 1st, the start of the new fiscal year, the infant will be counted in the age 1-2 group, even though he will be less than one during his entire period of eligibility. This is because the state looks not to how old the child actually is at the time of eligibility, but to how old the child will be on September 30th, the last day of the fiscal year.
This change will not only make it impossible to compare data collected before and after fiscal year 1999, but it also will overinflate the results. Because the recommended number of screens per year typically decreases as the child ages, the change in calculating age groupings will create an artificial increase in screening rates. For example, under the federal periodicity schedule, a child under age one is expected to receive a screen six times during one year. In contrast, a child between the ages of one and five (the old age grouping), is expected to receive 1.2 screens during one year. Thus, by placing the child in an older age grouping, the state can provide substantially fewer screens while still increasing its screening rates. The state thus increases its screening rates, but only at the expense of the child.
Exclusion of certain children
The old Form instructed states to exclude medically needy children from their reporting if the state did not offer EPSDT to the medically needy. The revised Form tells states to exclude the following additional groups: (1) children eligible only under an 1115 demonstration waiver as part of an expanded group for which the full complement of EPSDT services is not available; (2) undocumented aliens eligible only for emergency services; and (3) other groups "eligible for only limited services as part of their Medicaid eligibility (i.e., pregnancy-related services)." The revised form also points states to the instructions of the Form 2082 for determining the basis of eligibility.
We can envision some problems with this section, and advocates should obtain clarification from their states on which groups of eligible children are being counted. For instance, a state with an 1115 demonstration waiver should not be able to exclude any of the expansion groups of children unless there is an explicit waiver of EPSDT (e.g. Oregon). Also, the "other groups" catch-all could be abused. If an adolescent is pregnant, the federal law does not authorize the state to limit her to pregnancy-related services; rather, as an individual under age 21, she would be entitled to the full package of EPSDT benefits. In addition, HCFA should clarify the circumstances where children enrolled in state Children's Health Insurance Programs should be included on the reporting form. State CHIP programs need to be notified by HCFA of reporting requirements.
State periodicity schedules
The previous Form 416 used the screening schedule recommended by the American Academy of Pediatrics for measuring screening rates. On the revised form, states will report according to their own state-developed periodicity schedules.
This is one of the most troubling changes in the Form. First, the form does not acknowledge that, for immunizations, the state must use the schedule established by the Advisory Committee on Immunization Practices. More importantly, the change frustrates the very purpose of the form — tracking patterns and projections for the nation, individual states, and geographic regions. Because each state can use a different periodicity schedule, comparison among states obviously is made more difficult. In addition, comparisons over time cannot be made. Since states may choose not to use the same periodicity schedule in and after fiscal year 1999 as in previous years, it will be difficult to determine the extent to which performance has improved or deteriorated. Individuals interested in comparing state and national performance over time will have to make their own separate calculations.
Unfortunately, this break down comes at a time when accurate comparisons are crucial. A number of studies have reported that EPSDT screening has declined in some Medicaid managed care programs, and advocates have repeatedly voiced concerns that managed care is creating a financial incentive to underserve. By eliminating the ability to track trends over time and across states, this change also impairs the ability to determine the effect of managed care on EPSDT screening.
When it amended EPSDT in 1989, Congress explicitly pointed states to the screening schedule set by the American Academy of Pediatrics. Advocates should be wary lest states and managed care organizations use the occasion of their Form 416 revision to press for periodicity schedules that do not reflect current child health practice as recommended by the AAP.
Reporting using CPT codes
The revised form adds a provision allowing states to use certain listed CPT codes or state-specific EPSDT codes as a proxy for the EPSDT screen. The listed codes are CPT-4 codes for preventive medical services; thus, sick visits or episodic visits are not to be reported unless an initial or periodic exam also was performed during the visit.
We assume this change was made to accommodate managed care organizations and states which are using the HCFA 1500 claim form. This claim form bases reporting on CPT codes and, along with its commercial counterpart, is increasingly being used by insurance companies. Managed care organizations have complained that EPSDT reporting asks them to submit data they do not ordinarily collect and adds to the cost of providing services.
Unfortunately, nothing in the CPT codes or on the Form 1500 reveals whether all five of the mandatory components of the EPSDT medical screen have been provided. (Federal law defines the medical screen to include: developmental assessment, unclothed physical examination, immunizations, laboratory tests, and health education).
With the change in the Form 416, the industry has won an important concession. HCFA has included the following proviso in the instructions for completing the revised Form: "Use of these proxy codes is for reporting purposes only. States must continue to ensure that all five age-appropriate elements of an EPSDT screen, as defined by law, are provided to EPSDT recipients." However, the literature is replete with examples of the inability of government purchasers to collect data, their failure to collect data, and their failure to use the data they have collected. Advocates should contact their states now (and repeatedly) to learn what steps will be taken to assure effective and routine monitoring of the five screening elements.
Screening ratio
The screening ratio indicates the extent to which EPSDT eligibles receive the number of initial and periodic screening services required by the state's periodicity schedule, adjusted by the proportion of the year for which they are Medicaid eligible. Using the previous reporting form, some states showed screening ratios in excess of 100 percent. The revised form says this should not happen: "Any data submitted which exceeds 100% will be reflected as 100% on the final report."
This change will certainly minimize the appearance of faulty data. Capping rates, however, is a poor substitute for careful verification. First, if reported rates of greater than 100 percent are inaccurate (as many undoubtedly are), there is no reason to presume that the actual rate is 100 percent. Instead, states should verify the accuracy of their data. And, second, there should be recognition that rates higher than 100 percent are possible.
For example, states may attempt to screen all children regardless of their length of eligibility. This type of effort recognizes that many EPSDT-eligible children have undiagnosed conditions and may not have been screened as frequently as they should have been in the past. In addition to aggressive screening, these states may seek to address the on-again, off-again eligibility of many Medicaid children which allows children to fall through the cracks. These states have the potential to achieve screening rates of greater than 100 percent. Consider the following hypothetical: a state's periodicity schedule calls for screenings once every two years for adolescents 19-20 years of age. Eight such adolescents are enrolled in a managed care plan in the state. Suppose the average period of eligibility for this age group is three months. Under the screening rate formula, eight adolescents each enrolled for three months is considered the equivalent of one teenager enrolled for twenty-four months. [8 teenagers × 3 months = 1 teenager × 24 months]. As a result, the plan would only need to screen one of the eight teenagers to achieve a s
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