Each state administers its Medicaid program in accordance with a state  plan, which must be approved by CMS. State Medicaid programs are required to cover EPSDT services for  Medicaid beneficiaries under 21. 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. 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. 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. 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. 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. Our July 2001 report found that  states faced challenges collecting data on EPSDT services from both fee- for-service providers and managed care plans. Since 2002, according to  CMS in April 2007, the agency had conducted focused reviews in 11 states. 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. One official told us that interrupted Medicaid eligibility,  accompanied by the implementation of the State Children’s Health  Insurance Program, has also caused problems in the data on the number  of children eligible for services. 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. 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. 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.
Why GAO Did This Study

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.

What GAO Found

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.