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Recommendations to Governor Frank O'Bannon by IKE's Lead Poisoning Prevention Task Force
Finalized on April 25, 2000
Recommendation #1
Enforce federal mandate that all Medicaid eligible children are tested.
Action: Through aggressive education efforts, ensure that all Medicaid-eligible and CHIPS-participating children who see a healthcare professional have blood lead tests when they are twelve-months and twenty-four months old. Require that all children between two- and six-years of age be tested if not previously tested.
Medicaid-eligible children represent about 80% of all children with lead poisoning – nearly five times the rate for children not in the Medicaid program. To address this problem, the federal Medicaid Act requires blood lead testing and treatment to be part of the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program. This program is required for all Medicaid-eligible children.
However, many healthcare professionals interpret the provision only to require screening instead of an actual laboratory test. There is a widespread belief among healthcare professionals that lead exposure is no longer a problem in their communities. Therefore, they often only give a questionnaire to the parent to complete. Lab tests are often not done despite the fact that they would be reimbursed for the lab test as part of the EPSDT package. In addition, many parents of Medicaid-eligible children do not see a healthcare professional or do not actually get a lab test as directed by a healthcare professional.
In January 1999, the US General Accounting Office published a report determining that 81% of children younger than six and 79% of the children at greatest risk – 1- and 2-year-old children – who were eligible for Medicaid were not being tested. Many children may have gotten lead poisoning despite a federal mandate to protect them and despite the fact that a payment was provided to ensure they were tested.
On October 22, 1999, the Health Care Financing Administration reinforced its EPSDT annual reporting requirements to require states to report the number of screening blood lead tests provided to children starting with calendar year 1999.
Indiana’s Family and Social Services Administration released its results using the revised form for 1999. A test could be confirmed for only 1 out of more than 22,000 of our most at-risk children.
Table 1 - Lead Testing Information Reported by Indiana’s Medicaid Program for 1999
Category | Age of Children | |||
< 1 | 1 to 2 | 3 to 5 | Total | |
Number of Medicaid-eligible children. | 31,944 | 61,306 | 69,905 | 163,155 |
Number of those children receiving at least one initial or periodic screen. | 22,012 | 37,674 | 22,340 | 82,026 |
Number of those children with confirmed negative blood lead tests. | 1 | 140 | 171 | 312 |
Percentage of children that screened that received blood lead test. | 0.005% | 0.37% | 0.77% | 0.38% |
IKE is confident that more tests were done but not confirmed either because the doctor did not submit a claim for reimbursement or the health maintenance organization did not report it. Several local health departments have commented that they have requested reimbursement for testing, but Medicaid was unable to pay for it because the doctor’s authorization number was not provided.
Even if all tests were recorded, the data strongly suggests that Indiana’s testing rate is well below the national estimated average of 20%.
This problem is not unique to Indiana, though. On November 30, 1999, the Missouri Attorney General took action to address concerns in the St. Louis area. He sued five health-maintenance organizations operating in that area for breach of contract and Medicaid fraud because they were alleged to have accepted payment for lead lab tests never performed. Nationally, 42% of Medicaid-eligible children receive medical care through health maintenance organizations.
The IKE Task Force believes that Indiana needs to:
- Update the Indiana Medicaid Handbook so that the required referrals for lead screening follow, at a minimum, the federally mandated schedule and stated as mandatory expectations not suggestions;
- Evaluate the potential inaccuracies in the testing numbers and take steps to address them;
- Ensure that testing done by local health departments and other groups is included in the testing numbers after doctors are notified of the test results;
- Aggressively implement this federal testing mandate through significantly improved educational programs to more effectively reach doctors;
- Effectively educate parents of Medicaid-eligible children so that they are aware that they have a legal right to have the tests done as part of Medicaid and that it is important that they get the results from their doctor;
- Test all Medicaid-eligible children younger than age six if they were missed before; and
- Extend coverage equivalent to Medicaid to Indiana’s Children Health Insurance Program.
The IKE Task Force does not believe that Indiana’s Attorney General needs to take legal action against health maintenance organizations that failed to test Medicaid-eligible children while accepting EPSDT payment. Given the current dynamics of the system, education is a better approach than litigation at this time, especially with health maintenance organizations. However, if the results don’t improve more forceful efforts may be needed.
See also article in IKE's April 2000 Newsletter on Medicaid testing.