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Recommendations to Governor Frank O'Bannon by IKE's Lead Poisoning Prevention Task Force

Finalized April 26, 2000

Recommendation #2

Implement federal mandate that treatment services are reimbursed.

Action: Implement the Medicaid mandate to reimburse health departments and other healthcare organizations for case management and environmental investigations. Extend the reimbursement program to the State’s Children’s Health Insurance Program.

Since lead poisoning is an environmentally caused condition and the Medicaid-eligible children are often transient, the State needs to closely manage their cases to ensure lead poisoned children recover. Effective case management must be complemented with at least one or more environmental investigations at the child’s home to help identify the sources of lead and educate the family on methods to reduce exposure. Usually, but not always, the lead is from the paint in the house. This effort takes significant resources.

The Indiana State Health Department and Marion County Health Department currently have a grant from the Centers for Disease Control and Prevention to do this work. But the resources are not enough to adequately reach the entire State – even though less than 20% of the Medicaid-eligible children actually get tested for lead and the rate is even lower for other children. In addition, it is inefficient for the ISDH to cover the entire state when local health departments could provide the support if they received funding for the work.

Yet, Federal Medicaid law requires that Medicaid’s Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program cover treatment or other forms of medical assistance necessary to correct or ameliorate conditions identified through screens. In its September 1998 revision to the State Medicaid Manual, the Health Care Financing Administration made this requirement explicit.

However, according to a January 1999 report by the U.S. General Accounting Office, less than half the state Medicaid programs have policies to pay for such services. Indiana is one of those states.

In response to the GAO report, most states in Region 5 provided for reimbursement of the services. Reimbursement rates to health departments are grouped around $300 per home visit but go much higher in some states.

On October 22, 1999, the Health Care Financing Authority reinforced and clarified its requirements. HCFA made it clear that state Medicaid programs must cover any follow-up service, including:

  • Diagnostic and treatment services
  • Case management
  • One-time environmental investigations where a health professional visits the child’s home and conducts a risk assessment.

Despite this directive, Indiana is the only state in Region 5 that still provides no reimbursement for the services. As a result, many local health departments refuse to provide the case management and environmental investigations to support the Medicaid-eligible children. Several health departments provide the services, but the program must compete for limited resources and follow-up is not done often.

ISDH strives to fill the gap and use its limited CDC grant funds for case management and environmental investigations. If Medicaid funds were provided to ISDH and local health departments, more follow-up would be done and it would be done more efficiently. In addition, the State would be able to leverage more federal money. ISDH currently receives no State funds for the program and relies 100% on federal funds.

Because of the delays, children in Indiana known to have lead poisoning (blood lead levels greater than 10 ug/dL) may receive incomplete or delayed treatment services. During this time, the damage can become more severe and lasting.

An additional benefit of providing adequate reimbursement is to protect both the state and local health departments from liability for failing to followup on a child with lead poisoning. According to an article in the New York Law Journal on November 4, 1999, an Albany, New York, court held a municipality liable for $1,800,000 for failing to properly manage a lead poisoning case as well as the subsequent abatement.

The IKE Task Force believes that Indiana needs to:

  • Immediately adopt a reimbursement program that is consistent with other Region 5 states for both case management and environmental investigations;
  • Extend the reimbursement to include children participating in the CHIP’s Package C; and
  • Aggressively educate local health departments about the reimbursement option and help them quickly enter the program.