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MMCD Policy Letter 02-01

Subject: Blood Lead Screening of Young Children

Purpose

The purpose of this policy letter is to clarify the Medi-Cal managed care plans' contractual requirements to provide blood lead screening tests to all young children who are plan members. The information contained in this policy letter is in compliance with current Federal and State law and is intended to ensure that all young children in Medi-Cal managed care plans receive the blood lead screenings and appropriate follow-up services to which they are legally entitled, in accordance with the standards of care detailed herein.

Background

Lead exposure has been recognized as an environmental health hazard for a number of years. A large and growing body of evidence indicates that children are more sensitive to the neurotoxic effects of lead than are adults, and no blood lead level is recognized as safe. Low levels of lead exposure have been associated with developmental delays and decrements in intelligence, short term memory, perception integration, visual motor functioning and behavior in children. For that reason, prompt identification of children at risk is essential.

Children aged 1 through 5 who are enrolled in Medicaid are at increased risk for having elevated blood lead levels (BLLs). According to estimates from the National Health and Nutrition Examination Survey (NHANES: 1991-1994), Medicaid enrollees accounted for 83% of U.S. children aged 1-5 years who had BLLs greater than or equal to 20 micrograms of lead per deciliter of blood, the level at which referral to California Children Services is mandatory for Medi-Cal managed care plans in California.

Since 1989, Federal law has required states to screen children enrolled in Medicaid for elevated BLLs as part of required prevention services offered through the Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT). The California Childhood Lead Poisoning Prevention Act of 1991 [Health and Safety Code (HSC) sections 105275-105310] subsequently required that California establish a standard of care for the risk evaluation of all children for lead poisoning during each child's periodic health assessments. Children at risk could then receive appropriate blood lead testing and follow-up services. Many professional groups and public health programs, including the American Academy of Pediatrics (AAP), the California Childhood Health and Disability Prevention (CHDP) program and the California Childhood Lead Poisoning Prevention Branch (CLPPB), established guidelines for the performance of risk assessments, blood lead screenings and follow-up services.

Despite these requirements at the Federal and State levels, the great majority of young children enrolled in Medicaid were not receiving necessary screenings and blood lead tests into the 1990s. In California, this fact was confirmed by a report issued by the State Auditor in 1999. In light of this situation, Federal Medicaid regulations were updated in 1998 to require that all Medicaid eligible young children receive blood lead testing. California regulations that incorporated these Federal requirements were adopted in final form in November 2001. This policy letter is intended to enable plans and their providers to understand and comply with all mandated requirements for blood lead testing and follow-up of Medi-Cal enrollees.

Policy

I. Blood Lead Screening of All Young Children in Medi-Cal Managed Care Plans

California regulations, adopted in final format in November 2001 (California Code of Regulations, Title 17, Division 1, Chapter 9, Articles 1 and 2, commencing with section 37000) require that Medi-Cal managed care plan providers, i.e. physicians, nurse practitioners and physician assistants, who see children between the ages of 6 and 72 months, provide anticipatory guidance and lead screening services as described below.

1. Oral or written anticipatory guidance to a parent or guardian of the child, including, at a minimum, the information that children can be harmed by exposure to lead, especially from deteriorating or disturbed lead-based paint and the dust from it, and are particularly at risk of lead poisoning from the time the child begins to crawl until 72 months of age. Anticipatory guidance shall be performed at each periodic health assessment, starting at 6 months of age and continuing until 72 months of age.
2. Perform blood lead level (BLL) testing on all children in accordance with the following:
   
   
   1. At 12 months and at 24 months of age.
   2. When the health care provider performing a periodic health assessment becomes aware that a child 12 to 24 months of age has no documented evidence of BLL test results taken at 12 months of age or thereafter.
   3. When the health care provider performing a periodic health assessment becomes aware that a child 24 to 72 months of age has no documented evidence of BLL test results taken when the child was 24 months of age or thereafter.
   4. Whenever the health care provider performing a periodic health assessment of a child 12 to 72 months of age becomes aware that a change in circumstances has placed the child at increased risk of lead poisoning, in the professional judgement of the provider.

The health care provider is not required to perform BLL testing if:

1. A parent or guardian of the child, or other person with legal authority to withhold consent, refuses to consent to the screening.
2. If in the professional judgement of the provider, the risk of screening poses a greater risk to the child's health than the risk of lead poisoning.
   Providers will document the reasons for not screening in the child's medical record.

Screening may be conducted using either the capillary (fingerstick) or venous blood sampling methods. The venous method is preferred because of its accuracy. All screening results indicating an elevated blood lead level of 10 micrograms of lead per deciliter of blood (10mg/dL), or greater, require additional follow-up and blood lead testing, as discussed below. All confirmatory and follow-up BLLs must be on venous specimens.

All plans must have written policies and procedures describing the Plan's methods of monitoring provider compliance with the blood lead screening requirements detailed in this policy letter.

II. Follow-up, Referral and Reporting Requirements

For blood lead screening to be meaningful as a mandated prevention service, identification of a child with an elevated BLL must trigger services designed to lower the BLL. All children with BLLs > 10 µg/dL must receive appropriate follow up depending on the blood lead level, as described below.

A. Additional actions for elevated BLLs of > 10 through 14 µg/dL.

• Perform follow-up on the BLL within 3 months of the original test, using a venous blood sample.
• Members with confirmed BLLs of >10 µg/dL should be referred to the local Childhood Lead Poisoning Prevention Program (CLPPP) or, if none, to the local health department (LHD).
• Further follow-up as clinically indicated or as determined in consultation with the local CLPPP or LHD.

B. Additional actions for BLLs of 15 through19 mg/dL

• Confirm the BLL within 2 months of the original test, using a venous sample.
• Refer the member and family to the local CLPPP or if none, to the LHD.
• Retest at one-to-two months following confirmatory testing.
• Perform additional follow-up as clinically necessary, including consultation with the local CLPPP.

C. Provider Actions for BLLs > 20 mg/dL

• Confirm the BLL according to timelines in the table below. The higher the result, the more urgent the need for confirmatory testing.
  
  

  > 20 through 44 mg/dL	Confirm finger stick with venous sample in 1 week to 1 month depending on severity of BLL.
  > 45 through 59 mg/dL	Retest with venous sample within 48 hours.
  > 60-69 mg/dL	Retest with venous sample within 24 hours.
  > 70 mg/dL	Retest with venous sample immediately. This is a medical emergency.

• Children with venous BLLs 20mg/dL or higher must be referred to California Children Services (CCS) and the CLPPP or if none, the LHD.

III. Blood Lead Testing Performance Measure

The Department of Health Services (DHS) has developed a blood lead testing performance measure that is mandatory for all plans to perform on an annual basis. Blood lead screening rates are audited and reported as part of the external accountability set of performance measures, developed in satisfaction of the external quality review requirements of the Federal waivers under which Medi-Cal managed care operates. Please refer to the attached Lead Testing Performance Measure and Abstraction Tool to be used for developing the audited screening rates for this measure. DHS may modify this measure and tool in the future.

IV. Provider Education and Member Informing

A. Provider Education

Plans must ensure that all providers receive education regarding the legal requirements for the provision of blood lead testing to all young children, in compliance with the information presented in this policy letter. Plans should instruct providers in the appropriate follow-up of elevated BLLs and how to access the local CLPPP or LHD or the State CLPPB and the local CCS program to assure that appropriate follow-up, referral, case management and reporting requirements are met.

B. Member Informing

Plans must inform parents or guardians of members in need of blood lead screening services of the hazards of exposure to lead, the seriousness of the results of exposure to lead and the importance of blood lead screening to detect and ameliorate problems caused by exposure to lead. Members should be instructed of the importance of follow-up for elevated BLLs and advised of the services available both within and outside the plan for management of the elevated BLL, including an environmental assessment of the source of lead contamination and means for remediating the lead hazard.

V. Discussion

DHS does not require a memorandum of understanding (MOU) between the plan and the local CLPPP. Plans should, however, develop clear expectations as to how lead poisoning prevention issues are to be handled between the various programs involved in the management of such problems and may wish to incorporate these joint case management responsibilities [e.g. with Child Health and Disability Prevention (CHDP) Program, CCS, CLPPP] in MOUs.

The local CLPPP, if one exists, is the preferred starting point for plans and their providers as the point of contact for lead poisoning prevention and follow-up activities. Referral services provided by the CLPPP and/or the LHD are contingent upon the level of lead detected in the blood sample. Some health departments offer assistance with establishing an on-site fingerstick-sampling program. Services provided by the CLPPP or the LHD may include environmental investigation and management, case management, and health education. Educational materials for patients and families may be provided.

Plans should be aware that effective September 21, 2001, the CHDP Program implemented new service codes on the PM 160 form, to enable CHDP providers to report compliance with counseling and blood lead testing referral requirements and, if appropriate, to claim additional reimbursement for actual performance of a blood lead test. These codes are described in detail in CHDP Provider Information Notice 01-06, and CLPP Provider Information Notice 01-A, jointly distributed and dated September 21, 2001. In addition, new reimbursement codes have been implemented (retroactive to July 1, 2001) for use by Medi-Cal fee-for-service providers who are not CHDP providers.

Please note that providers cannot bill Medi-Cal for reimbursement for testing services provided to beneficiaries enrolled in plans that are financially responsible for CHDP services. However, plans are encouraged to appropriately provide incentives to providers for provision of required lead screening services and may also wish to incorporate the new data provided on the PM 160 into their methods for tracking provision of lead screening services to members, in addition to the required lead screening performance measure.

A list of County CLPPP contact phone numbers is available on the CLPPB web site listed below. Other informational Web sites, important telephone numbers and additional references are listed for your information.

Informational web sites and phone numbers:

If you have any questions regarding this policy letter, please contact your contract manager.

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