Lead testing update:
CMS issues guidance for states seeking to end universal blood lead screening for Medicaid-eligible children

---

On June 22, 2012, the Centers for Medicare & Medicaid Services (CMS) issued a guidance following an informational bulletin announcing the end of universal blood lead testing for Medicaid eligible children. Instead, with approval from CMS and the Centers for Disease Control and Prevention (CDC), states may choose to target screening efforts by testing only those children thought to be at high risk for blood lead poisoning.

To engage in targeted screening, states must provide CMS: (1) an explanation of why it seeks to transition from universal to targeted screening; (2) sufficient evidence of current blood lead poisoning levels including survey and mapping data as well as CMS 416 reports of blood lead tests administered under Medicaid; (3) a communications plan for implementing the targeted screening approach developed with state and local agencies and community stakeholders; and (4) a timeframe and strategy, including a logic model, for evaluating the targeted screening approach.

NHeLP outlined several concerns with the proposal to switch from universal to targeted lead screening a recent letter, summarized as follows:

1. CMS should require states to develop an accurate baseline by improving blood lead testing rates as the required first step for a state to move to targeted screening. Recent studies show that blood tests are far more effective in detecting lower levels of blood lead poisoning than the risk assessment tools utilized in targeted testing approaches.
2. CMS should establish a clear standard for evaluating a state lead plan and should not permit states to end universal screening based upon insufficient, poor quality, or outdated data. An increasing number of states have lost federal funding or scaled-back their childhood lead poisoning programs which provide data for lead risk assessment planning.
3. CMS should update the State Medicaid Manual to reflect the CDC’s new lead standard which replaces the “level of concern” (10 µg/dL) with a reference value based upon the 97.5th percentile of the BLL distribution of children 1-5 years old in the United States. The reference value is currently calculated at 5 µg/dL. This change would support health professionals in the follow up and treatment of children with blood lead poisoning < 10 µg/dL.

In 2005, the CDC concluded that there is no safe level for blood lead in children. Even low levels of blood lead poisoning can cause serious mental and physical impairment, including lower IQ, long term behavioral health problems, and diminished school performance. Given these serious health consequences, for more than 20 years the federal government has required states to test the blood lead levels (BLLs) of all children enrolled in Medicaid. However, data from CMS show that most children in Medicaid still go untested and presumably untreated for blood lead poisoning.

NHeLP has long urged CMS and state Medicaid agencies to improve blood lead screening rates as part of Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services. NHeLP and other health and child welfare advocates helped formulate new strategies proposed by the CDC’s Advisory Committee for Childhood Lead Poisoning Prevention (ACCLPP) to increase BLL testing compliance, such as better education and monitoring of providers, and adequate reimbursement.. The ACCLPP also suggested that targeted screening might improve compliance rates. However, the implementation of these strategies at the federal, state, and local levels has been, at best, sporadic and unsustained.

NHeLP will continue to monitor CMS’ efforts to transition from universal to targeted screening and will work with other health advocates to ensure that all children at risk for lead exposure receive appropriate screening and treatment.