Medicaid
State and Federal Actions Have Been Taken to Improve Children's Access to Dental Services, but More Can Be Done Gao ID: GAO-10-112T October 7, 2009Dental disease remains a significant problem for children in Medicaid. Although dental services are a mandatory benefit for the 30 million children served by Medicaid, these children often experience elevated levels of dental problems and have difficulty finding dentists to treat them. In testimony before your Subcommittee last September, we reported that children in Medicaid were almost twice as likely to have untreated cavities as children with private insurance and that the percentage of children in Medicaid who received any dental care was far below the Department of Health and Human Service's (HHS) target for low-income children. Concerns about low-income children's poor oral health, inadequate access to dental services, low payment rates for dental services, and insufficient federal and state efforts to address oral health access problems are long-standing. During subcommittee hearings in May 2007 and February 2008, you raised concerns about the effectiveness of federal oversight of state Medicaid dental services by the Centers for Medicare & Medicaid Services (CMS), the agency that oversees Medicaid at the federal level. This testimony is based on our report, released at this hearing, Medicaid: State and Federal Actions Have Been Taken to Improve Children's Access to Dental Services, but Gaps Remain.
States and CMS have made concerted efforts to improve access to dental services for children in Medicaid. However, information on the oral health of and receipt of dental services by Medicaid children show that more needs to be done. Although many states have reported moderate increases in access to Medicaid dental services, states responding to our survey reported that low provider and beneficiary participation, and administrative burdens--many of the same factors that contributed to the low use of dental services in 2000--still present barriers to access today. CMS's reviews of states' efforts have identified deficiencies in several state Medicaid programs, but CMS has not required corrective actions by states or planned additional dental reviews. In our report, we are making four recommendations to CMS to strengthen the agency's monitoring of state Medicaid dental services for children and help states improve children's access to Medicaid dental services. Our recommendations include developing a plan to review dental services for Medicaid children in all states with low utilization rates, ensuring that states found to have inadequate MCO dental provider networks take action to strengthen these networks, working with stakeholders to develop needed guidance on topics of concern to states, and identifying ways to improve sharing of promising practices among states.
GAO-10-112T, Medicaid: State and Federal Actions Have Been Taken to Improve Children's Access to Dental Services, but More Can Be Done
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Testimony:
Before the Subcommittee on Domestic Policy, Committee on Oversight and
Government Reform, House of Representatives:
United States Government Accountability Office:
GAO:
For Release on Delivery:
Expected at 2:00 p.m. EDT:
Wednesday, October 7, 2009:
Medicaid:
State and Federal Actions Have Been Taken to Improve Children's Access
to Dental Services, but More Can Be Done:
Statement of Katherine M. Iritani:
Acting Director, Health Care:
GAO-10-112T:
[End of section]
Mr. Chairman and Members of the Subcommittee,
I am pleased to be here today as you examine federal and state efforts
to improve access to dental services by children in Medicaid (a joint
federal and state program that provides health care coverage, including
dental care, for low-income children). Dental disease remains a
significant problem for children in Medicaid. Although dental services
are a mandatory benefit for the 30 million children served by Medicaid,
[Footnote 1] these children often experience elevated levels of dental
problems and have difficulty finding dentists to treat them. In
testimony before your Subcommittee last September, we reported that
children in Medicaid were almost twice as likely to have untreated
cavities as children with private insurance and that the percentage of
children in Medicaid who received any dental care was far below the
Department of Health and Human Service's (HHS) target for low-income
children.[Footnote 2] Concerns about low-income children's poor oral
health, inadequate access to dental services, low payment rates for
dental services, and insufficient federal and state efforts to address
oral health access problems are long-standing. During subcommittee
hearings in May 2007 and February 2008, you raised concerns about the
effectiveness of federal oversight of state Medicaid dental services by
the Centers for Medicare & Medicaid Services (CMS), the agency that
oversees Medicaid at the federal level.
My remarks today are based on our report, released at this hearing,
Medicaid: State and Federal Actions Have Been Taken to Improve
Children's Access to Dental Services, but Gaps Remain.[Footnote 3] This
report was prepared at the request of the subcommittee and examined (1)
state strategies to monitor and improve access to dental care for
children in Medicaid and (2) CMS actions since 2007 to improve
oversight of Medicaid dental services for children. To identify state
strategies to monitor and improve children's access to Medicaid dental
services, we conducted a Web-based survey of state Medicaid directors
in all 50 states and the District of Columbia (we refer to the District
of Columbia as a state in this report)--all 51 responded to our survey.
The survey included questions on the methods states have used for
promoting and monitoring dental utilization, statewide goals for the
delivery of dental services, and the federal support provided to states
for the provision of Medicaid dental services. We also reviewed
contracts between state Medicaid programs and nine large managed care
organizations (MCO) to identify certain dental provisions concerning
network adequacy and access standards.[Footnote 4] To examine CMS's
oversight of state Medicaid dental services for children, we
interviewed CMS officials, dental associations, and key stakeholders;
reviewed federal laws, regulations, and CMS guidance; and analyzed data
used by CMS to monitor provision of Medicaid dental services. Our work
was performed in accordance with generally accepted government auditing
standards.
State Medicaid Programs Reported They Employ Multiple Strategies to
Monitor and Improve Access to Medicaid Dental Services, but Problems
Persist:
All 51 states responding to our survey reported that they monitor the
provision of dental care to Medicaid-enrolled children--often using
three or more methods. Common methods included collecting utilization
data, conducting surveys of oral health, and monitoring dental
claims.[Footnote 5] States also reported using various measures to
assess children's access to Medicaid dental services, including the
percentage of children who had a dental visit in the previous year, the
percentage of children who had not visited a dentist in the last 3
years, and the percentage of dentists in the state who treat children
in Medicaid. Forty-two states also reported that they have set at least
one statewide dental utilization goal related to the provision of
children's dental care in Medicaid. Commonly reported goals include the
percentage of children receiving any dental care in a given period
exceeding a certain threshold, the ratio of participating dental
providers to Medicaid children exceeding a certain threshold, and the
percentage of children who report difficulty finding dental care fall
below a certain threshold.
States' oversight of MCO provider networks varied. All 21 states that
provide Medicaid dental services through MCOs reported that they set
measurable access standards for MCOs, but more than half also reported
that MCOs in their state do not meet any, or only meet some, of the
state's dental access standards. Common MCO access standards include
maximum waiting times for appointments, maximum travel time or distance
to the dentist's office, and minimum provider-to-patient ratios. Twelve
of the 21 states reported that they routinely verify that MCO providers
accept new Medicaid patients. Two states did not report taking any
action to verify MCO provider networks. Although 17 states reported
that they used incentives or penalties to encourage the MCOs to meet or
exceed state standards, potential incentives or penalties did not
always produce the desired result. For example, one state reported MCOs
had not met any of the established standards even though MCOs could be
paid a bonus if they met some or all of the standards. Similarly, other
states reported that only some standards were being met, despite
potential financial penalties for MCOs that did not meet all of the
state's standards. Our review of nine MCO contracts illustrates
variations in the standards that states established for MCOs concerning
network adequacy and access measures. For example, some, but not all,
contracts specified a maximum number of Medicaid enrollees per dental
provider--one contract specified a county-level maximum of 486
enrollees per dental provider, while other contracts did not specify
such a maximum.
Nearly all states reported that they had undertaken initiatives to
improve children's access to Medicaid dental services, but persistent
barriers remain. For example, states reported simplifying claims
processing, increasing reimbursement rates, recruiting providers, and
educating beneficiaries. Although some states reported limited success,
Medicaid dental utilization rates remain low. CMS data show that the
national average Medicaid dental utilization rate for children had
improved from 27 percent in 2000 to 35 percent in 2007--but in 2007,
only 1 state reported a dental utilization rate above 50 percent and 12
states remained below 30 percent. Forty-eight states reported that the
principal barriers that contributed to the low use of dental services
by Medicaid beneficiaries in 2000--including low provider participation
rates, administrative burdens, and insufficient funding--were impeding
their current efforts. States also reported that access rates could be
affected by barriers faced by children seeking dental services, such as
finding a provider that accepts Medicaid, and barriers faced by
providers serving Medicaid beneficiaries, such as beneficiaries not
showing up for appointments (see figure 1).
Figure 1: Barriers to Children Seeking Medicaid Dental Services and
Barriers to Dental Providers Serving Medicaid Beneficiaries, as
Reported by State Medicaid Programs:
[Refer to PDF for image: illustration]
To what extent do you believe the following are barriers to children
receiving Medicaid dental services in your state?
Finding a dental provider that accepts Medicaid:
Major/moderate barrier: 43;
Minor barrier: 6;
Nor a barrier: 2.
Transportation to and from the dental provider's office:
Major/moderate barrier: 25;
Minor barrier: 16;
Nor a barrier: 10.
Distance between the dental provider's office and the family's home:
Major/moderate barrier: 34;
Minor barrier: 14;
Nor a barrier: 3.
Parents are unable to take time off work:
Major/moderate barrier: 27;
Minor barrier: 22;
Nor a barrier: 2.
Other barriers:
Major/moderate barrier: 23;
Minor barrier: 1;
Nor a barrier: 7.
To what extent do you believe the following are barriers to dental
providers beginning to serve or serving more Medicaid beneficiaries?
Low reimbursement rates: 36;
Major/moderate barrier: 9;
Minor barrier: 6.
Nor a barrier:
Administrative requirements:
Major/moderate barrier: 28;
Minor barrier: 17;
Nor a barrier: 6.
Limited capacity to accept new patients:
Major/moderate barrier: 30;
Minor barrier: 13;
Nor a barrier: 8.
Beneficiary does not show up for appointments:
Major/moderate barrier: 45;
Minor barrier: 6;
Nor a barrier: 0.
Beneficiary does not follow treatment plan as advised by the provider:
Major/moderate barrier: 30;
Minor barrier: 20;
Nor a barrier: 1.
Other barriers:
Major/moderate barrier: 14;
Minor barrier: 2;
Nor a barrier: 8.
Source: GAO (Survey of state Medicaid directors conducted between
December 2008 and January 2009).
[End of figure]
CMS Has Taken Action to Improve Federal Oversight of State Medicaid
Dental Services for Children, but Gaps Remain:
Responding to concerns expressed by your subcommittee about CMS
oversight of state Medicaid dental services, CMS has taken a number of
actions since May 2007 to strengthen its oversight of Medicaid dental
services for children, but gaps remain in the agency's efforts. CMS
actions include the following:[Footnote 6]
* Focused dental reviews in 17 states identified significant concerns,
but CMS did not plan additional reviews.[Footnote 7] Between October
2007 and May 2008, CMS conducted a series of focused dental reviews in
17 states.[Footnote 8] CMS identified concerns in all 17 states it
reviewed, including multiple findings in some states, and made
recommendations to all states. In 11 states, CMS reported concerns that
the states were not adhering to federal law or regulations. CMS also
identified several promising practices to improve the delivery of oral
health services, which it highlighted in its summary report.[Footnote
9] Although CMS reviews identified shortcomings in state practices and
identified needed improvements, CMS did not have plans at the time of
our review to conduct focused dental reviews in additional states. CMS
416 data from 2006 showed that 24 of the 34 states that CMS did not
review reported dental utilization rates between 31 and 40 percent of
eligible children having received any dental service in the prior year--
well below HHS's Healthy People 2010 goal of having 66 percent of low-
income children under age 19 receive a preventive dental service.
[Footnote 10] In addition, CMS did not require corrective action in
states found to have inadequate MCO networks. CMS's focused dental
reviews identified eight states that provided dental services through
managed care that did not ensure that MCO provider networks were
adequate to afford access to covered dental services. CMS made
recommendations to strengthen MCO provider networks in all eight
states; however, CMS did not require these states to take corrective
action--rather, agency officials indicated they would follow up with
states on the status of CMS's recommendations.
* CMS established an Oral Health Technical Advisory Group and published
a dental policy document, but states reported additional guidance was
needed. In conjunction with the National Association of State Medicaid
Directors, CMS established an Oral Health Technical Advisory Group to
address issues related to oral health services. Advisory group projects
include examining the effects of recent legislation on oral health
programs, considering improvements to the CMS 416 annual reports, and
improving materials used to inform beneficiaries of their Medicaid
dental benefits. In addition, CMS posted a 16-page document on Medicaid
dental policy issues on its Web site in September 2008. This document
covered a variety of questions from states on topics including
periodicity schedules, dental referral requirements, covered services,
and patient cost sharing.[Footnote 11] Although CMS has taken action to
provide some guidance to states, states report that additional guidance
from CMS is needed. In response to our survey, nearly all states
reported that additional CMS guidance could help them improve delivery
of Medicaid dental services. States cited a need for additional
information in several areas, including information on billing
policies, establishing appropriate dental fee schedules, improving
documentation and coding practices, and information on quality and
preventive initiatives.
* CMS has taken steps to improve communications with states and
stakeholders, including sharing promising state dental practices, but
states reported further collaboration was needed. From 2007 through
2009, CMS held several meetings and conference calls with state dental
representatives, provider associations, and other stakeholders to
discuss issues concerning Medicaid dental services for children. Groups
involved in CMS partnership activities included American Academy of
Pediatric Dentistry, the American Association of Public Health
Dentistry, the Association of State and Territorial Dental Directors,
and the American Dental Association. CMS also posted "promising
practices"--described by CMS as successful state programs that reflect
innovative approaches to meeting common problems--on its Web site. As
of May 2009, CMS had posted promising dental practices from Delaware,
South Carolina, Tennessee, and Virginia. Although CMS has taken action
to involve stakeholders and share promising dental practices, 37 states
responding to our survey indicated a need for more information on other
states' efforts to improve dental utilization. Eleven states reported
that they were unaware of the promising practices posted on CMS's Web
site and 26 states responding to our survey reported that their states
had best practices that could be shared with other states, such as
providing mobile dental vans, training and reimbursing physicians to do
oral screens and apply fluoride varnish, and establishing a dental home
for children.
In conclusion, states and CMS have made concerted efforts to improve
access to dental services for children in Medicaid. However,
information on the oral health of and receipt of dental services by
Medicaid children show that more needs to be done. Although many states
have reported moderate increases in access to Medicaid dental services,
states responding to our survey reported that low provider and
beneficiary participation, and administrative burdens--many of the same
factors that contributed to the low use of dental services in 2000--
still present barriers to access today. CMS's reviews of states'
efforts have identified deficiencies in several state Medicaid
programs, but CMS has not required corrective actions by states or
planned additional dental reviews. In our report, we are making four
recommendations to CMS to strengthen the agency's monitoring of state
Medicaid dental services for children and help states improve
children's access to Medicaid dental services. Our recommendations
include developing a plan to review dental services for Medicaid
children in all states with low utilization rates, ensuring that states
found to have inadequate MCO dental provider networks take action to
strengthen these networks, working with stakeholders to develop needed
guidance on topics of concern to states, and identifying ways to
improve sharing of promising practices among states.
In commenting on a draft of our report being released today, CMS
generally concurred with all four recommendations and described several
initiatives planned or under way that would strengthen its oversight of
state Medicaid dental services for children. CMS indicated that the
agency was developing additional guidance and technical assistance to
states on the provision of EPSDT services, with a particular focus on
access to dental services. CMS also reported that its efforts to
implement the Children's Health Insurance Program Reauthorization Act
of 2009 would include a number of activities related to dental
services, such as a new quality measure program and new reporting
requirements.
Mr. Chairman, this concludes my prepared remarks. I would be pleased to
answer any questions you or other members of the subcommittee may have.
For further information regarding this statement, please contact
Katherine Iritani at (202) 512-7114 or at iritanik@gao.gov. Contact
points for our Offices of Congressional Relations and Public Affairs
may be found on the last page of this statement. Kim Yamane, Assistant
Director; Sarah Burton; Mollie Hertel; Sarah Marshall; Terry Saiki; and
Teresa Tam also make key contributions to this statement.
[End of section]
Related GAO Products:
Medicaid: State and Federal Actions Have Been Taken to Improve
Children's Access to Dental Services, but Gaps Remain. [hyperlink,
http://www.gao.gov/products/GAO-09-723]. Washington, D.C.: September
30, 2009.
Medicaid: Extent of Dental Disease in Children Has Not Decreased, and
Millions Are Estimated to Have Untreated Tooth Decay. [hyperlink,
http://www.gao.gov/products/GAO-08-1121]. Washington, D.C.: September
23, 2008.
Medicaid: Extent of Dental Disease in Children Has Not Decreased.
[hyperlink, http://www.gao.gov/products/GAO-08-1176T]. Washington,
D.C.: September 23, 2008.
Medicaid: Concerns Remain about Sufficiency of Data for Oversight of
Children's Dental Services. [hyperlink,
http://www.gao.gov/products/GAO-07-826T]. Washington, D.C.: May 2,
2007.
Medicaid Managed Care: Access and Quality Requirements Specific to Low-
Income and Other Special Needs Enrollees. [hyperlink,
http://www.gao.gov/products/GAO-05-44R]. Washington, D.C.: December 8,
2004.
Medicaid and SCHIP: States Use Varying Approaches to Monitor Children's
Access to Care. [hyperlink, http://www.gao.gov/products/GAO-03-222].
Washington, D.C.: January 14, 2003.
Medicaid: Stronger Efforts Needed to Ensure Children's Access to Health
Screening Services. [hyperlink, http://www.gao.gov/products/GAO-01-
749]. Washington, D.C.: July 13, 2001.
Oral Health: Factors Contributing to Low Use of Dental Services by Low-
Income Populations. [hyperlink,
http://www.gao.gov/products/GAO/HEHS-00-149]. Washington, D.C.:
September 11, 2000.
Oral Health: Dental Disease Is a Chronic Problem Among Low-Income
Populations. [hyperlink, http://www.gao.gov/products/GAO/HEHS-00-72].
Washington, D.C.: April 12, 2000.
Medicaid Managed Care: Challenge of Holding Plans Accountable Requires
Greater State Effort. [hyperlink,
http://www.gao.gov/products/GAO/HEHS-97-86]. Washington, D.C.: May 16,
1997.
[End of section]
Footnotes:
[1] Low-income children eligible under a state Medicaid plan generally
are entitled to coverage of screening, diagnostic, and treatment
services--including dental services--under Medicaid's early and
periodic screening, diagnostic, and treatment (EPSDT) benefit.
[2] GAO, Medicaid: Extent of Dental Disease in Children Has Not
Decreased, [hyperlink, http://www.gao.gov/products/GAO-08-1176T]
(Washington, D.C.: Sept. 23, 2008).
[3] GAO, Medicaid: State and Federal Actions Have Been Taken to Improve
Children's Access to Dental Services, but Gaps Remain, [hyperlink,
http://www.gao.gov/products/GAO-09-723] (Washington, D.C.: Sept. 30,
2009).
[4] We obtained a non-generalizable sample of contracts from MCOs that
covered dental services and that served the most Medicaid beneficiaries
in nine states, including five states whose dental programs had been
reviewed by CMS in 2008.
[5] States are required to report annually to CMS on the provision of
EPSDT services, including dental services. The annual EPSDT
participation report, Form CMS-416, is the agency's primary tool for
gathering data on the provision of dental services to children in state
Medicaid programs.
[6] See [hyperlink, http://www.gao.gov/products/GAO-09-723] for
additional information on the actions taken by CMS to improve its
oversight of Medicaid dental services.
[7] CMS focused reviews were designed to examine state efforts to
improve children's dental utilization rates, assess state compliance
with federal Medicaid statutes and regulations, and identify promising
or notable state practices to improve the delivery of oral health
services.
[8] Fifteen of the 17 states reviewed had reported dental utilization
rates below 30 percent in fiscal year 2006: Arkansas, California,
Delaware, District of Columbia, Florida, Louisiana, Michigan, Missouri,
Montana, Nevada, New Jersey, New York, North Dakota, Pennsylvania, and
Wisconsin. In addition, Maryland was reviewed in October 2007 and
Georgia was reviewed in May 2008 at the request of the subcommittee.
[9] CMS, 2008 National Dental Summary, (January 2009) and Final Report
on Maryland's Early and Periodic Screening, Diagnostic and Treatment
(EPSDT) Program With a Focus on Dental Services for Children (Feb. 5,
2008).
[10] Recognizing the importance of good oral health, HHS in 1990
established oral health goals as part of its Healthy People 2000
initiative; and in 2000 updated these oral health goals for 2010. These
include goals related to oral health in children, for example, reducing
the proportion of children with untreated tooth decay. Another goal
relates to the Medicaid population: to increase the proportion of low-
income children and adolescents under the age of 19 who receive any
preventive dental service each year to 66 percent in 2010. See U.S.
Department of Health and Human Services, Public Health Service,
Progress Review: Oral Health (Feb. 7, 2008).
[11] HHS, Centers for Medicare & Medicaid Services, Policy Issues in
the Delivery of Dental Services to Medicaid Children and Their Families
(Sept. 22, 2008); [hyperlink,
http://www.cms.hhs.gov/medicaiddentalcoverage/] (accessed Oct. 6,
2008).
[End of section]
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