Centers for Disease Control and Prevention (CDC)

The current federal recommendations on screening young children for lead poisoning were issued by the US Centers for Disease Control and Prevention (CDC) in a 1997 document called Screening Young Children for Lead Poisoning: Guidance for State and Local Public Health Officials. Because lead risk varies considerably by geography, CDC recommends that state and local health departments assess local data on lead risks and develop lead screening recommendations for health care providers in their jurisdictions, focusing on one- and two-year- old children. These CDC recommendations replaced a 1991 policy calling for universal screening for all children ages 6 to 72 months.

In the years since 1997, a majority of states have developed screening plans reflecting local priorities and lead risks. Some states have opted to screen all young children, while others are targeting children at higher risk. Some states have incorporated their screening policies into laws or regulations, while others have been issued as guidance from the health department. Many state screening plans can be accessed through health department web sites.

Centers for Medicare and Medicaid Services (Medicaid)

Federal Medicaid policy, which is established by the Centers for Medicare and Medicaid Services (CMS), plays a vital role in lead poisoning screening and treatment because of the consistent and important association between childhood lead poisoning and poverty. [1]

Requirement for Screening -- Federal law specifically requires lead screening "as appropriate for age and risk factors" for all children enrolled in Medicaid. [2] Thus, the CMS policy since 1989 has required a blood lead test for all young children enrolled in Medicaid. Technically, the screening provision is part of the mandatory package of preventive health services called "Early and Periodic Screening, Diagnostic and Treatment Services" (or EPSDT). [3] Current CMS policy requires that all children receive a screening blood lead test at 12 months and 24 months of age. Children between the ages of 36 months and 72 months of age must receive a screening blood lead test if they have not been previously screened for lead poisoning. Note that the policy does not require a verbal risk assessment questionnaire. It also specifically states that States may not adopt at this time a statewide plan for screening children for lead poisoning that does not require lead screening for all Medicaid-eligible children. [4]

However, performance in recent years has fallen far short of the policy requiring routine screening. A 1998 GAO report estimated that only 19 percent of young Medicaid enrollees had been screened. These low rates are confirmed by states’ self-reported data: only 8 of 42 states reported a Medicaid lead-screening rate above 20 percent for one- and two-year-olds in their FY 99 reports to the federal Medicaid agency. [5] This amount of screening means that the vast majority of lead-poisoned children served by Medicaid are never identified or treated, and that the lead hazards in their environments are likely left uncontrolled. A separate report by the CDC Advisory Committee on Childhood Lead Poisoning Prevention (ACCLPP) explores the reasons behind these low screening rates and offers recommendations. [6] As a consequence of the GAO report and many other initiatives, there has been a recent increased focus on improving Medicaid screening policies and performance. There has been encouraging progress in some places, but frustratingly little in others.

Requirement for Follow-up Care -- CMS policy on follow-up care for children with elevated blood lead levels requires that state Medicaid programs cover environmental investigation and case management services. However, state Medicaid programs vary in their compliance. [7] CDC recommendations for managing elevated blood lead levels in children were updated in 2002. [8]

Pending Policy Issues

Medicaid Reimbursement Policy for Environmental Investigation

An essential aspect of treating children with lead poisoning is identifying the source(s) of lead exposure. Current CMS policy requires that state Medicaid programs cover a one-time environmental investigation to determine the source of lead and necessary case management services. [9] Medicaid coverage is limited to the health professional's time, as well as activities during an on-site investigation of the child's home or primary residence. This policy effectively allows activities such as visual assessment of the home, interview of occupants, and on-site X-ray fluorescence (XRF) analysis of lead paint content. However, CMS will not authorize Medicaid reimbursement for lead testing of any substances (water, paint, etc.) that are sent to a laboratory for analysis. This policy precludes the use of lead dust testing, a critical and relatively inexpensive method of determining if paint is the source of lead exposure. Moreover, the lead content of water, dust, and soil can not be determined by simply looking; laboratory analysis is necessary. [10] The Alliance urges CMS to revise the State Medicaid Manual to explicitly allow reimbursement for collection and laboratory analysis of environmental samples for lead content to determine the source or sources of lead exposure for a lead-poisoned child.

Future Revisions to Medicaid Screening Policy

In September 2002, the CDC Advisory Committee on Childhood Lead Poisoning Prevention (ACCLPP) submitted recommendations to former HHS Secretary Tommy Thompson for a new process authorizing states to provide Medicaid lead screening on a targeted basis. ACCLPP’s recommendations were developed at the request of former HHS Secretary Donna Shalala, who had received requests from two states for waivers of lead screening requirements. After considering lead screening initiatives, program capacities, and the latest national and state data documenting significant variation in lead risks nationwide, ACCLPP recommended a new approach under which states that want to target lead screening within their Medicaid populations would apply for a “Lead Screening Exception” (LSE). Under the ACCLPP proposal, a state’s application would be based on analysis of risk factors and identification of highest risk areas and populations. States that do not receive an LSE would be required to provide routine screening to all Medicaid enrollees. A new Peer Review Committee, to be appointed by CDC and made up of lead poisoning prevention program experts with experience in targeted screening strategies, would review the applications. The ACCLPP’s stated goal is encouraging “smarter screening” through concerted efforts by state health departments and Medicaid agencies. To date, CMS has not made any policy changes or issued any formal response to the ACCLPP proposal.

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[1] The General Accounting Office (GAO) and CDC estimate that Medicaid enrollees account for an estimated 60 percent of all children with blood lead elevations and up to an estimated 93 percent of severely lead poisoned children. See: Kaufmann R, Clouse TL, Olson DR, Matte TD, Elevated Blood Lead Levels and Blood Lead Screening Among US Children Aged One to Five Years: 1988-1994, Pediatrics, Vol. 106 No. 6 December 2000.

[2] CMS has responsibility for interpreting the legal requirement for screening and providing program requirements for states; CMS publishes these policies in a document called the State Medicaid Manual, which is enforceable and periodically updated. Because CMS is essentially a financing agency, it looks to CDC for guidance on interpreting the phrase "appropriate for age and risk factors" as it applies to lead screening.

[3] CMS information about EPSDT.

[4] Section 5123.2, Screening Service Content.--Part D, Appropriate Laboratory Tests, Health Care Financing Administration, Transmittal No. 12, September 1998.

[5] Since fiscal year 1999, CMS has required states to report annually the number of Medicaid children receiving blood lead screening tests on the form known as HCFA “Form 416,” which is used to collect information on services provided to children under the EPSDT program. These forms provide the first self-reported data from states on their lead screening performance for children enrolled in Medicaid. The 416 forms are public data and should be available on request from CMS or your state Medicaid agency.

[6] Advisory Committee on Childhood Lead Poisoning Prevention (ACCLPP), Recommendations for Blood Lead Screening of Young Children Enrolled in Medicaid: Targeting a Group at High Risk, MMWR Recommendations and Reports, December 8, 2000 / Vol. 49 / No. RR-14

[7] For a discussion of state policies on follow-up care, see Another Link in the Chain and the Another Link in the Chain Update

[8] Centers for Disease Control and Prevention, Managing Elevated Blood Lead Levels Among Young Children: Recommendations from the Advisory Committee on Childhood Lead Poisoning Prevention, March 2002

[9] Timothy M. Westmoreland, HCFA, Letter to State Medicaid Directors, October 22, 1999.

[10] The standard of care for investigating the home of a lead-poisoned child is set out in Chapter 16 of the US Department of Housing and Urban Development’s Guidelines for the Evaluation and Control of Lead-Based Paint Hazards in Housing.