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Table 2 assesses states’ adherence to the federal CMS requirement to test children receiving the Medicaid EPSDT benefit at 12 and 24 months (or notes whether they received approval for targeted testing). The table provides an indication of the level of compliance in the column entitled “% of kids receiving at least 1 test by age 2.” In addition, while CMS requires that children receiving this benefit be tested between 36 and 72 months if not tested earlier, this component of the policy is not discussed in the table because the available data did not indicate whether children received tests in this age range.[63]

In the table below, the percentages are either directly from or derived from lead screening data issued by the National Committee for Quality Assurance. For more detail, please refer to the Methodology section of this report.

Open Table 2 in a new window –State Medicaid Testing Policies Compared with Federal CMS Requirement; Testing Rates

Are Medicaid-Eligible Children at Increased Risk?

As discussed above, it is a federal CMS requirement for children enrolled in Medicaid/EPSDT to be tested for lead at 12 and 24 months, and between 36 and 72 months if not tested previously, absent approval for targeted screening. The targeted screening exception was based on CDC’s recommendation, and CDC recommended this in part because the data indicated children enrolled in Medicaid were not necessarily at a higher risk for EBLLs.

A few states have actively determined whether the disparity in EBLL risk still exists or whether other risk factors are more prominent. Arizona successfully applied for targeted screening approval.[64] Nevada and Washington State have applications pending, indicating that they believe Medicaid-enrolled children, as a group, are not at increased risk.[65] On the other hand, Pennsylvania Medicaid staff indicated the state made a conscious decision to continue universal testing of the Medicaid population.[66] Wisconsin analyzed its data and found that in 2014, “Medicaid-enrolled children in Wisconsin [were] at three times greater risk of lead poisoning than non-Medicaid-enrolled children.”[67]

Stated Compliance with CMS Requirement

As shown in Table 2 above, not all states say they adhere to the CMS requirement to test children receiving the EPSDT benefit at 12 and 24 months. Utah staff explicitly stated by email that they don’t require lead testing for Medicaid-enrolled children.[68] Since 2010, Alaska regulations have required “lead screening appropriate for age and risk factors,” but they stop short of actually requiring doctors to do testing specifically at 12 and 24 months, instead leaving this up to the doctor’s discretion.[69] Likewise, Montana requires doctors to test patients in EPSDT for lead, but only recommends the testing happen at 12 and 24 months.[70]

Two states were unclear on their compliance. Nebraska’s Medicaid regulations (implemented by the Division of Medicaid & Long-Term Care) only require testing at 12 months, but the state’s Division of Public Health is required by law to establish a lead program that requires BLL testing of Medicaid-enrolled children.[71] Public Health staff implemented this requirement in 2012.[72] Delaware Medicaid staff referred Safer Chemicals, Healthy Families (SCHF) to the lead program staff when asked to clarify the policy stated in their manual, and the lead program staff said the state only required two-year-olds to be tested based on risk factors unrelated to Medicaid enrollment status.

Impact of State Policies on Testing Rates

No state reports testing all children enrolled in Medicaid at least once by age 2, although some come close. Generally speaking, the states with higher testing rates in 2014 (higher than the national benchmark) either already aimed to test all children through universal screening laws, or tended to treat the requirement as a state requirement, instead of a solely federal requirement. For several years, a notable exception to this was Wisconsin. Although this state framed the requirement in its provider manual as the federal requirement, from 2006 through 2011, state Medicaid staff collaborated with lead program staff to send reports to providers showing them their testing rate and identifying children who needed to be tested. This program had a significant impact on testing rates. The state’s own data showed that the 2014 testing rate was still higher than the pre-2006 rate, suggesting that the reports had a lingering effect even after they were discontinued.[73]