Medicaid
State and Federal Actions Have Been Taken to Improve Children's Access to Dental Services, but Gaps Remain Gao ID: GAO-09-723 September 30, 2009Children's access to Medicaid dental services is a long-standing concern. The tragic case of a 12-year-old boy who died from an untreated infected tooth that led to a fatal brain infection renewed attention to this issue. He was enrolled in Medicaid--a joint federal and state program that provides health care coverage, including dental care, for 30 million low-income children--but, like many children in Medicaid, he experienced difficulty finding a dentist who would treat him. At the federal level, the Centers for Medicare & Medicaid Services (CMS), an agency within the Department of Health and Human Services (HHS), oversees Medicaid. In this report, GAO 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. GAO surveyed all state Medicaid programs and interviewed state and federal officials, and dental researchers and associations
State Medicaid programs reported that they use multiple strategies to monitor and improve access to dental services for children, but problems persist. Most states responding to our survey use a variety of tools, such as examining claims and utilization data, to monitor the provision of dental services to children in Medicaid. Although all 21 states that provide Medicaid dental services through managed care organizations (MCO) reported that they set measurable access standards for MCOs, 14 states reported that MCOs do not meet all of the state's dental access standards. Almost all states described initiatives to improve access to dental services, including simplifying claims processing, increasing reimbursement rates, recruiting providers, and educating beneficiaries. Nonetheless, access rates remain low and states reported that long-standing barriers hinder further improvement. Since May 2007, CMS has taken steps to strengthen its oversight of Medicaid dental services for children, but gaps remain. For example, CMS reviews of Medicaid dental services in 17 states identified a number of concerns and made recommendations for improvement. Nonetheless, at the time of our review CMS did not plan to perform more reviews, even though other states had utilization rates well below HHS's 2010 target for low-income children receiving a preventive dental service. CMS also provided guidance to states and facilitated collaboration among stakeholders, but states reported needing more CMS support, including guidance on setting dental payment rates, on quality initiatives, and on promoting outreach. States also reported wanting more information on other states' efforts to improve dental utilization.
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Director: Team: Phone:GAO-09-723, Medicaid: State and Federal Actions Have Been Taken to Improve Children's Access to Dental Services, but Gaps Remain
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Report to Congressional Requesters:
United States Government Accountability Office:
GAO:
September 2009:
Medicaid:
State and Federal Actions Have Been Taken to Improve Children's Access
to Dental Services, but Gaps Remain:
GAO-09-723:
GAO Highlights:
Highlights of GAO-09-723, a report to congressional requesters.
Why GAO Did This Study:
Children‘s access to Medicaid dental services is a long-standing
concern. The tragic case of a 12-year-old boy who died from an
untreated infected tooth that led to a fatal brain infection renewed
attention to this issue. He was enrolled in Medicaid”a joint federal
and state program that provides health care coverage, including dental
care, for 30 million low-income children”but, like many children in
Medicaid, he experienced difficulty finding a dentist who would treat
him. At the federal level, the Centers for Medicare & Medicaid Services
(CMS), an agency within the Department of Health and Human Services
(HHS), oversees Medicaid.
In this report, GAO 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. GAO surveyed all state Medicaid programs and interviewed
state and federal officials, and dental researchers and associations.
What GAO Found:
State Medicaid programs reported that they use multiple strategies to
monitor and improve access to dental services for children, but
problems persist. Most states responding to our survey use a variety of
tools, such as examining claims and utilization data, to monitor the
provision of dental services to children in Medicaid. Although all 21
states that provide Medicaid dental services through managed care
organizations (MCO) reported that they set measurable access standards
for MCOs, 14 states reported that MCOs do not meet all of the state‘s
dental access standards. Almost all states described initiatives to
improve access to dental services, including simplifying claims
processing, increasing reimbursement rates, recruiting providers, and
educating beneficiaries. Nonetheless, access rates remain low and
states reported that long-standing barriers hinder further improvement.
Figure: Number of States Reporting Barriers to Children Receiving
Medicaid Dental Services and Barriers to Dental Providers Serving
Medicaid Beneficiaries:
[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]
Since May 2007, CMS has taken steps to strengthen its oversight of
Medicaid dental services for children, but gaps remain. For example,
CMS reviews of Medicaid dental services in 17 states identified a
number of concerns and made recommendations for improvement.
Nonetheless, at the time of our review CMS did not plan to perform more
reviews, even though other states had utilization rates well below HHS‘
s 2010 target for low-income children receiving a preventive dental
service. CMS also provided guidance to states and facilitated
collaboration among stakeholders, but states reported needing more CMS
support, including guidance on setting dental payment rates, on quality
initiatives, and on promoting outreach. States also reported wanting
more information on other states‘ efforts to improve dental
utilization.
What GAO Recommends:
GAO recommends that CMS develop a plan to review dental services in
states with low utilization rates, ensure that states found to have
inadequate managed care provider networks strengthen their networks,
develop additional guidance, and identify ways to improve sharing of
promising practices among states. CMS generally concurred with GAO‘s
recommendations.
View [hyperlink, http://www.gao.gov/products/GAO-09-723] or key
components. For more information, contact Alicia Puente Cackley, (202)
512-7114, cackleya@gao.gov.
[End of section]
Contents:
Letter:
Background:
State Medicaid Programs Reported They Employ Multiple Strategies to
Monitor and Improve Access to Medicaid Dental Services, but Problems
Persist:
CMS Has Taken Action to Improve Federal Oversight of State Medicaid
Dental Services for Children, but Gaps Remain:
Conclusions:
Recommendations for Executive Action:
Agency Comments:
Appendix I: Methods Used by State Medicaid Programs to Monitor the
Statewide Provision of Dental Care to Children:
Appendix II: Statewide Utilization Goals for the Provision of Dental
Care to Children in State Medicaid Programs:
Appendix III: Access Standards Set by the 21 States That Provide Dental
Services through Managed Care Organizations (MCOs):
Appendix IV: Extent to Which Managed Care Organizations (MCO) Meet
State Standards and State Verification of MCO Networks:
Appendix V: CMS Promising Practices and State Reported Best Practices:
Appendix VI: Comments from the Department of Health and Human Services:
Appendix VII: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Tables:
Table 1: Number of State Medicaid Programs Employing Certain Methods to
Monitor the Provision of Medicaid Dental Services to Children:
Table 2: Number of State Medicaid Programs Employing Certain Measures
to Monitor Children's Access to Dental Services, by Service Delivery
Method:
Table 3: Number of State Medicaid Programs That Reported Setting
Statewide Utilization Goals for the Provision of Dental Services to
Children:
Table 4: MCO Access Standards Set by the 21 State Medicaid Programs
That Provide Dental Services to Children under Managed Care:
Table 5: Outreach Actions Taken to Educate Families on the Importance
of Dental Care, as Reported by State Medicaid Programs:
Table 6: Actions to Recruit Dental Providers since 2000, as Reported by
State Medicaid Programs:
Table 7: Barriers That Hinder State Initiatives to Improve Access to
Medicaid Dental Services, as Reported by State Medicaid Programs:
Table 8: Description of State-Reported Best Practices for Improving
Dental Care for Children in Medicaid:
Figure:
Figure 1: Barriers to Children Seeking Medicaid Dental Services and
Barriers to Dental Providers Serving Medicaid Beneficiaries, as
Reported by State Medicaid Programs:
Abbreviations:
AAPD: American Academy of Pediatric Dentistry:
CMS: Centers for Medicare & Medicaid Services:
EPSDT: Early and Periodic Screening, Diagnostic, and Treatment:
HHS: Department of Health and Human Services:
MCO: managed care organization:
NASMD: National Association of State Medicaid Directors:
SCHIP: State Children's Health Insurance Program:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
September 30, 2009:
The Honorable Dennis Kucinich:
Chairman:
Subcommittee on Domestic Policy:
Committee on Oversight and Government Reform:
House of Representatives:
The Honorable Elijah Cummings:
House of Representatives:
Dental disease is a significant problem for children in Medicaid, a
joint federal and state program that provides health care coverage,
including dental care, for low-income children. 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.
Attention to this subject became more acute after the widely publicized
case of a 12-year-old boy who died in 2007 as a result of an untreated
infected tooth, even though he was entitled to dental coverage under
Medicaid. In testimony before the Subcommittee on Domestic Policy of
the Committee on Oversight and Government Reform[Footnote 2] last year,
we reported that children in Medicaid were almost twice as likely to
have untreated cavities as children with private insurance.[Footnote 3]
We also reported that the percentage of children in Medicaid ages 2
through 18 who received any dental care--37 percent according to
national survey data--was far below the Department of Health and Human
Services' (HHS) target of having 66 percent of low-income children
under age 19 receive a preventive dental service.
Concerns about low-income children's poor oral health and 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. Our reports dating back to 2000 highlight
the problem of chronic dental disease and the factors that contribute
to low use of dental services by low-income populations, including
children in Medicaid.[Footnote 4] A major concern has been the adequacy
of the network of dental providers who serve low-income populations,
particularly for children who receive Medicaid dental services under
managed care. This concern stems in part from investigations by the
Subcommittee that found that some managed care organizations (MCO) did
not have adequate provider networks--that is, a sufficient number and
mix of dental providers--to provide timely access to covered Medicaid
dental services. In September 2000, we reported that while several
factors contributed to the low use of dental services among low-income
persons who had coverage, the major factor was difficulty finding
dentists to treat them.[Footnote 5] During a Subcommittee hearing in
May 2007, concerns were raised about federal oversight of state
Medicaid dental services for children by the Centers for Medicare &
Medicaid Services (CMS), the agency that oversees Medicaid at the
federal level.
You expressed concern about the state and federal actions taken to
ensure children in Medicaid receive recommended dental services. This
report examines (1) the strategies that state Medicaid programs employ
to monitor and improve access to dental services for children in
Medicaid and (2) CMS actions since 2007 to improve oversight of state
Medicaid dental services for children. To identify state strategies to
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.[Footnote 6] The survey included both closed-ended
and open-ended questions regarding dental services for children, the
methods states have used for promoting and monitoring dental
utilization (the use of dental services), statewide goals for the
delivery of dental services, and the federal support provided to states
for the provision of dental services. To establish the reliability of
our survey data, we consulted with knowledgeable state officials in
developing the survey and pre-tested the survey questions with Medicaid
officials from two states. The survey was conducted from December 8,
2008, through January 30, 2009. We received responses from all 50
states and the District of Columbia. We reviewed survey responses for
internal consistency and in certain cases where responses were absent,
unclear, or inconsistent, we contacted state officials for
clarification. We did not independently verify specific aspects of
responses or the effectiveness of programs reported through the survey.
We determined that the data submitted by states were sufficiently
reliable for the purposes of our engagement. In addition to the Web-
based survey, we reviewed studies and reports on state Medicaid dental-
related initiatives and conducted a review of current literature to
obtain information on these initiatives and on barriers to providing
dental care in Medicaid. To describe contractual provisions between
states and MCOs concerning network adequacy and timely access standards
related to dental services for children, we obtained and reviewed a non-
generalizable sample of contracts from the MCOs that covered dental
services and that served the most Medicaid beneficiaries in 9 states,
including 5 states whose dental programs had been reviewed by CMS in
2008.[Footnote 7]
To examine CMS's oversight of state Medicaid dental services for
children, we interviewed CMS officials; reviewed federal laws,
regulations, and guidance that CMS provides to states; and interviewed
key stakeholders, including the Medicaid/SCHIP Dental
Association,[Footnote 8] the National Association of State Medicaid
Directors (NASMD), and experts involved with pediatric dental issues.
We also reviewed data used by CMS to monitor provision of dental
services to children in state Medicaid programs, including information
in annual reports submitted by states on the provision of dental and
other services provided under Medicaid's early and periodic screening,
diagnostic, and treatment (EPSDT) benefit. We also examined CMS's
reviews of Medicaid dental programs in 17 states. To obtain states'
perspectives of CMS oversight, we included several questions about
CMS's guidance and activities in our survey of state Medicaid programs.
We conducted this performance audit from July 2008 through August 2009
in accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
Background:
In 2000, the Surgeon General noted that tooth decay is the most common
chronic disease among children.[Footnote 9] Left untreated, the pain
and infections caused by tooth decay can lead to problems in eating,
speaking, and learning. Proper dental care can prevent tooth decay and
associated problems that can lead to dental disease and even death.
Research has shown that preventive dental care is cost effective and
can make a significant difference in health outcomes. For example, a
2004 study found that, over a 5-year period, low-income children who
had their first preventive dental visit by age 1 had average dental-
related costs of $262, compared to $546 for children who received their
first preventive visit at age 4 through 5.[Footnote 10]
The American Academy of Pediatric Dentistry (AAPD) recommends that each
child see a dentist when the child's first tooth erupts and no later
than the child's first birthday, with subsequent visits occurring at 6-
month intervals or more frequently if recommended by a dentist. The
early initial visit establishes a "dental home" for the child, creating
an opportunity to build an ongoing relationship with a dental provider
who can ensure comprehensive, continuously accessible care.
Comprehensive dental visits can include both clinical assessments, such
as for tooth decay and the need for sealants,[Footnote 11] and
appropriate discussion and counseling for oral hygiene, injury
prevention, and speech and language development, among other topics.
Because resistance to tooth decay is determined partly by genetics and
partly by behavior, delaying the onset of tooth decay may also reduce
long-term risk for decay.
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.[Footnote 12]
At the federal level, CMS oversees Medicaid, which provides health care
coverage for low-income families and aged, blind, and disabled people.
CMS oversight includes monitoring state Medicaid programs, issuing
guidance to states, and facilitating communication and collaboration
among stakeholders. Medicaid provided health coverage for over 30
million children under 21 in fiscal year 2008.[Footnote 13] The states
operate their Medicaid programs within broad federal requirements and
may contract with MCOs to provide Medicaid benefits. CMS estimated that
in 2006 about 65 percent of Medicaid beneficiaries received benefits
through some form of managed care.[Footnote 14] State Medicaid programs
are required to cover certain populations and services under federal
law. For instance, under the Medicaid EPSDT benefit, state Medicaid
programs generally must provide coverage of dental screening,
diagnostic, and related treatment services for all eligible Medicaid
beneficiaries under the age of 21. Other federal requirements for the
EPSDT benefit that are related to dental services include the
following:
* Developing dental periodicity schedules. State Medicaid programs have
some flexibility in determining the frequency and timing of dental
screenings covered for children under the EPSDT benefit. Under federal
law, however, state Medicaid programs must provide these dental
services at intervals that meet reasonable standards of dental practice
as determined by the state after consultation with recognized dental
organizations involved in children's health care.[Footnote 15]
According to CMS guidance, as an alternative to developing a state-
specific periodicity schedule, a state may adopt a nationally
recognized dental periodicity standard, such as the schedule
recommended by AAPD. CMS considers AAPD's periodicity schedule a model
for comparison and it is published in CMS's Guide to Children's Dental
Care in Medicaid.[Footnote 16]
* Reporting on delivery of EPSDT services. Federal law requires states
to report annually on the provision of EPSDT services, including dental
services.[Footnote 17] The annual EPSDT participation report, Form CMS-
416 (hereafter called the CMS 416), is the agency's primary tool for
gathering data on the provision of dental services to children in state
Medicaid programs. It captures data on the number of children who
received a preventive dental service, a dental treatment service, or
any dental service each year. Information on the CMS 416 report is used
to calculate a state's dental utilization rate--the percentage of
children eligible for EPSDT that received any dental service in a given
year.
Inadequate access to dental services for low-income children has been a
longstanding concern. In April 2000, we reported that Medicaid
beneficiaries and other low-income people had low rates of dental
visits and high rates of dental disease relative to the rest of the
population.[Footnote 18] In a September 2000 report, we identified
factors influencing the access that low-income groups have to dental
care: a primary factor was limited dentist participation in
Medicaid.[Footnote 19] As part of its oversight of state Medicaid
dental services for children, in January 2001 CMS issued a letter to
state Medicaid directors indicating that, through a series of state
reviews, CMS would increase its oversight activities and assess state
compliance with statutory requirements. CMS highlighted four areas for
review: outreach and administrative case management, adequacy of
Medicaid reimbursement rates, increasing provider participation, and
claims reporting and processing. CMS did not complete this initiative.
In September 2008, we reported that the extent of dental disease in
Medicaid-enrolled children had not decreased between 1988 through 1994
and 1999 through 2004.[Footnote 20] We also reported that millions of
Medicaid-enrolled children were estimated to have untreated tooth
decay, and that children in Medicaid were often not receiving dental
services.
The American Recovery and Reinvestment Act of 2009 (Recovery Act)
authorized an estimated $87 billion in additional federal Medicaid
funding for states in the form of a temporary increase in the funds
that the federal government contributes toward state Medicaid programs,
including the provision of Medicaid dental services for children. The
Recovery Act provides this money to states through a temporary, 27-
month increase in the federal medical assistance percentage formula--
the formula that determines the federal share of a state's Medicaid
service expenditures.[Footnote 21] In July 2009, we reported that the
receipt of an increased federal share may reduce the states' share of
expenditures for their Medicaid program, and states have reported using
these available funds for a variety of purposes, such as maintaining
program eligibility, covering increased Medicaid caseloads, and
maintaining local health care reform initiatives.[Footnote 22]
State Medicaid Programs Reported They Employ Multiple Strategies to
Monitor and Improve Access to Medicaid Dental Services, but Problems
Persist:
In response to our survey, most states reported using multiple
strategies to monitor and improve access to Medicaid dental services,
but they also reported that persistent barriers hinder improvements.
All 21 states that provided Medicaid dental services under managed care
arrangements reported that they set measurable access standards for
MCOs, however 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. Further, some states reported that they do not routinely
verify the adequacy of MCO provider networks. Almost all states
described initiatives to recruit dental providers and enhance outreach
to beneficiaries' families, but barriers persist and access rates
remain low.
State Medicaid Programs Reported They Use a Variety of Methods to
Monitor Dental Services:
In response to our survey, all 51 states reported that they monitor the
provision of dental care to Medicaid-enrolled children, but how they do
so varies. The majority (39 states) reported that they use multiple
methods--often three or more--to monitor the provision of dental care.
These methods included surveys of oral health, monitoring dental
claims, and collecting utilization data (see table 1). See appendix I
for a list of the monitoring methods reported by each state.
Table 1: Number of State Medicaid Programs Employing Certain Methods to
Monitor the Provision of Medicaid Dental Services to Children:
Monitoring method: Track utilization by collecting CMS 416 data;
Number of states (51 states): 50.
Monitoring method: Use claims data and/or encounter data provided by
MCOs;
Number of states (51 states): 23.
Monitoring method: Collect and analyze data from phone calls to the
state or MCOs regarding concerns with dental care;
Number of states (51 states): 16.
Monitoring method: Collect and analyze data from beneficiary
satisfaction surveys;
Number of states (51 states): 16.
Monitoring method: Use survey data to monitor problems obtaining needed
dental services;
Number of states (51 states): 11.
Monitoring method: Use survey data to monitor oral health of children;
Number of states (51 states): 7.
Monitoring method: Other monitoring methods[A];
Number of states (51 states): 19.
Source: GAO (Survey of state Medicaid directors conducted between
December 2008 and January 2009).
Note: States could select more than one monitoring method and may be
counted in more than one category.
[A] States reported using other methods to monitor the provision of
Medicaid dental services, including generating ad hoc reports on
various dental procedures and analyzing monthly budget reports by
procedure code to monitor utilization trends.
[End of table]
States also reported using various measures to monitor children's
access to Medicaid dental services. The most common reported measure--
used by 40 (of 51) states for their fee-for-service programs and by 18
(of 21) states that also used managed care[Footnote 23]--was the
percentage of children who had a dental visit in the previous year (see
table 2). In the 21 states where both fee-for-service and managed care
programs are used to provide dental services to Medicaid-enrolled
children, state monitoring can vary by service delivery method. For
example, one state reported that it monitors the percentage of dentists
who treat children through its managed care program, but does not
monitor the percentage of dentists who treat children through its fee-
for-service program. Conversely, another state reported the opposite--
that it monitors this percentage for its fee-for-service program, but
not for managed care.
Table 2: Number of State Medicaid Programs Employing Certain Measures
to Monitor Children's Access to Dental Services, by Service Delivery
Method:
Measure: The percentage of children who had a dental visit in the
previous year;
Fee-for-service (51 states): 40;
Managed care (21 states)[A]: 18.
Measure: The percentage of dentists who treat children in Medicaid;
Fee-for-service (51 states): 36;
Managed care (21 states)[A]: 14.
Measure: The extent to which provision of dental services is
concentrated among a small number of providers;
Fee-for-service (51 states): 27;
Managed care (21 states)[A]: 7.
Measure: The percentage of children who did not visit a dentist in the
last three years;
Fee-for-service (51 states): 12;
Managed care (21 states)[A]: 5.
Measure: Other analyses of claims data, utilization data, or both;
Fee-for-service (51 states): 19;
Managed care (21 states)[A]: 8.
Measure: Other monitoring efforts;
Fee-for-service (51 states): 6;
Managed care (21 states)[A]: 4.
Source: GAO (Survey of state Medicaid directors conducted between
December 2008 and January 2009).
Note: States could select more than one monitoring measure and may be
counted in more than one category.
[A] Twenty-one of the 51 state Medicaid programs reported using both
managed care and fee-for-service to deliver dental services to Medicaid
beneficiaries in their state.
[End of table]
States reported setting statewide dental utilization goals related to
the provision of children's dental services. In response to our survey,
42 states reported that they have set at least one statewide
utilization goal related to the provision of children's dental care in
Medicaid and about half of these 42 states (20 states) have set three
or more statewide goals (see table 3). Nine states reported they had no
goals related to children's dental care. See appendix II for a list of
the utilization goals reported by each state.
Table 3: Number of State Medicaid Programs That Reported Setting
Statewide Utilization Goals for the Provision of Dental Services to
Children:
Statewide dental utilization goal: The percentage of children receiving
any dental care in a given time period exceeds a certain threshold;
Number of states (51 states): 31.
Statewide dental utilization goal: The percentage of children receiving
dental preventive services, such as sealants, exceeds a certain
threshold;
Number of states (51 states): 25.
Statewide dental utilization goal: The ratio of participating dental
providers to Medicaid children (provider to beneficiary ratio) exceeds
a certain threshold;
Number of states (51 states): 17.
Statewide dental utilization goal: The percentage of children receiving
restorative procedures for oral health problems, such as tooth decay,
exceeds a certain threshold; Number of states (51 states): 14.
Statewide dental utilization goal: The percentage of children who
report difficulty finding dental care falls below a certain threshold;
Number of states (51 states): 11.
Statewide dental utilization goal: Other state goals[A];
Number of states (51 states): 16.
Total number of states that set at least one statewide utilization
goal:
Number of states (51 states): 42.
Source: GAO (Survey of state Medicaid directors conducted between
December 2008 and January 2009).
Note: States could select more than one statewide dental utilization
goal and may be counted in more than one category.
[A] States reported other goals, including a target percent of children
who are continually enrolled in Medicaid and receive appropriate follow-
up care, and increasing levels of provider participation.
[End of table]
All States with Managed Care Programs Reported They Set Measurable MCO
Access Standards and about Half Routinely Verified Provider Networks:
All of the 21 states that reported using managed care programs to
deliver Medicaid dental services reported that they had established one
or more measurable MCO access standards specific to each MCO dental
network, such as specifying maximum waiting times for scheduling
appointments or a minimum ratio of available providers to Medicaid
beneficiaries (see table 4). However, more than half--14 of the 21
states--reported that the MCOs either did not meet any, or only met
some, of their standards. Seventeen states reported that they used
incentives or penalties to encourage the MCOs to meet or exceed state
standards. However, 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 if MCOs did not meet all of the state's
standards.
Table 4: MCO Access Standards Set by the 21 State Medicaid Programs
That Provide Dental Services to Children under Managed Care:
Dental access standards specific to MCO provider networks: Maximum
waiting times when scheduling dental appointments; States using MCOs
(21 states): 17.
Dental access standards specific to MCO provider networks: Maximum
waiting times when scheduling emergency dental appointments;
States using MCOs (21 states): 16.
Dental access standards specific to MCO provider networks: Maximum
travel distances from beneficiaries' residences to the dental
provider's office;
States using MCOs (21 states): 15.
Dental access standards specific to MCO provider networks: Maximum
travel times from beneficiaries' residences to the dental provider's
office;
States using MCOs (21 states): 11.
Dental access standards specific to MCO provider networks: Minimum
provider to patient ratios (minimum number of dental providers for a
given enrollment);
States using MCOs (21 states): 6.
Dental access standards specific to MCO provider networks: Other state
standards[A]; States using MCOs (21 states): 10.
Dental access standards specific to MCO provider networks: Total number
of states that established one or more MCO dental access standard;
States using MCOs (21 states): 21.
Source: GAO (Survey of state Medicaid directors conducted between
December 2008 and January 2009).
Note: States could select more than one MCO access standard and may be
counted in more than one category.
[A] States reported other standards, such as identifying and managing
beneficiaries who use emergency room facilities to obtain dental
services.
[End of table]
State oversight of MCO provider networks varied. Approximately half of
the states using managed care--12 of 21 states--reported contacting a
selection of providers in their MCO provider networks on a regular
basis to determine if they accept new Medicaid patients. Eighteen
states using managed care reported that they examined the adequacy of
their dental networks in response to a complaint or concern.[Footnote
24] Two of the 21 states using managed care did not report taking any
action to verify MCO provider networks in their state. See appendix III
for a list of MCO standards set by states and appendix IV for a
description of the extent to which MCOs meet state standards and the
methods states use to verify that MCO dental providers accept children
in Medicaid.
State Medicaid agencies also set expectations for MCOs related to
provider networks and access to services through the contracts they
establish with the MCOs. We reported in 2001 that specific and
comprehensive contract language helps ensure that MCOs know their
responsibilities and that they can be held accountable for delivering
covered services.[Footnote 25] Our review of contracts between states
and nine large MCOs that provide Medicaid dental services illustrate
variations in the specificity of the standards that states established
in their contracts concerning network adequacy and access measures.
Regarding one measure of network adequacy--the maximum number of
beneficiaries per dental provider--some, but not all, contracts
specified a maximum allowed number of Medicaid enrollees per dental
provider. One contract, for example, specified a county-level maximum
of 486 enrollees per dental provider, while other contracts did not
specify any maximum. Standards related to timely access also varied;
for example, one contract required that routine dental appointments be
scheduled within 30 calendar days, or sooner if possible, while another
contract required that routine dental appointments be scheduled within
90 days of a formal request. Finally, the specificity of the contracts
with regard to standards for the proximity of dental providers to
beneficiaries varied. One contract, for example, specified a maximum
travel time of 30 minutes to a provider, while another contract had no
proximity standards.
State Medicaid Programs Reported Efforts to Improve Access, but Also
Reported That Persistent Barriers Hinder Further Improvement in
Children's Access to Dental Care:
Many of the 51 states we surveyed reported efforts to improve
children's access to dental care, including efforts to provide outreach
to the families of children in Medicaid and recruit dental providers.
Forty-eight states reported that they have taken one or more actions to
facilitate or encourage parents to take their children to a dentist,
including publishing literature about the importance of oral health and
establishing a hotline that families can call for help in finding a
dentist (see table 5). Studies in the published literature have
reported some successes in outreach programs. One such study reported
on a state program where dental hygienist services provided in three
schools resulted in an increase in the percentage of children who had
seen a dentist at least once a year from 59 percent to 78 percent in
the first year of the program.[Footnote 26]
Table 5: Outreach Actions Taken to Educate Families on the Importance
of Dental Care, as Reported by State Medicaid Programs:
State actions to provide outreach to families: Issued literature to
Medicaid families discussing the importance of oral health;
States responding (51 states): 39.
State actions to provide outreach to families: Established a hotline
that families in Medicaid can call for help in finding a dental
provider;
States responding (51 states): 35.
State actions to provide outreach to families: Translated literature
about the importance of oral health into other languages;
States responding (51 states): 29.
State actions to provide outreach to families: Distributed an up-to-
date list of dental providers who accept children in Medicaid;
States responding (51 states): 24.
State actions to provide outreach to families: Required MCOs to assist
families in finding a dental provider for their children;
States responding (51 states): 20.
State actions to provide outreach to families: Launched a Web site for
Medicaid families providing information about oral health care;
States responding (51 states): 18.
State actions to provide outreach to families: Required MCOs to provide
literature to their beneficiaries about the importance of oral health;
States responding (51 states): 18.
State actions to provide outreach to families: Provided incentives to
Medicaid families to bring their children to dental providers;
States responding (51 states): 5.
State actions to provide outreach to families: Paid for advertisements
aimed at Medicaid families that promote the importance of oral health;
States responding (51 states): 5.
State actions to provide outreach to families: Other state actions[A];
States responding (51 states): 17.
Total number of states that have taken one or more outreach action:
States responding (51 states): 48.
Source: GAO (Survey of state Medicaid directors conducted between
December 2008 and January 2009).
Note: States could select more than one action to provide outreach to
families and may be counted in more than one category.
[A] States reported other actions, such as outreach to families with
children who have not received a dental service in the past year and
free dental screening programs.
[End of table]
All but one of the 51 state Medicaid programs reported they have taken
at least one action since 2000 to recruit Medicaid dental providers
(see table 6), and some states provided evidence that their initiatives
have enhanced their Medicaid dental provider networks. For example, one
state Medicaid program implemented an initiative that included
simplifying claims processing, increasing reimbursement rates,
educating and recruiting providers, and educating beneficiaries.
According to a study of this program published in the Journal of Rural
Health, from fiscal year 1999 to 2002, this state Medicaid program saw
a 39 percent increase in the number of dentists accepting Medicaid and
a 57 percent increase in the number of Medicaid-enrolled children
receiving dental services after implementing this initiative.[Footnote
27]
Table 6: Actions to Recruit Dental Providers since 2000, as Reported by
State Medicaid Programs:
State actions to recruit dental providers: Met with dental provider
groups to encourage them to see more children in Medicaid;
States responding (51 states): 45.
State actions to recruit dental providers: Increased dental fee-for-
service reimbursement rates;
States responding (51 states): 44.
State actions to recruit dental providers: Streamlined fee-for-service
claims processing;
States responding (51 states): 36.
State actions to recruit dental providers: Reduced or eliminated
administrative burdens, such as prior authorization requirements;
States responding (51 states): 35.
State actions to recruit dental providers: Action by other state
agencies, such as providing scholarships, loan repayment, or other
funding to dental providers for serving low-income communities;
States responding (51 states): 34.
State actions to recruit dental providers: Encouraged non-dental
providers, such as pediatricians, to provide basic oral health care;
States responding (51 states): 31.
State actions to recruit dental providers: Sent literature to dental
providers to encourage them to see more children in Medicaid;
States responding (51 states): 21.
State actions to recruit dental providers: Increased funding to clinics
serving Medicaid children for hiring more dental providers;
States responding (51 states): 14.
State actions to recruit dental providers: Increased dental managed
care capitation payments to MCOs;
States responding (51 states): 11.
State actions to recruit dental providers: Paid for advertisements
aimed at dental providers to encourage them to see more children in
Medicaid;
States responding (51 states): 5.
State actions to recruit dental providers: Invested in health
information technology that allows rural dental providers to consult
with dentists in other areas on high risk cases;
States responding (51 states): 2.
State actions to recruit dental providers: Other actions taken by the
state Medicaid agency[A];
States responding (51 states): 22.
State actions to recruit dental providers: Total number of states that
have taken one or more actions to recruit dental providers;
States responding (51 states): 50.
Source: GAO (Survey of state Medicaid directors conducted between
December 2008 and January 2009).
Note: States could select more than one action to recruit dental
providers and may be counted in more than one category.
[A] States reported other actions by the state Medicaid agency,
including investing in telemedicine, producing a guide of program
procedure codes with descriptions of services and prior authorization
requirements, and introducing eligibility verification systems with
free online access.
[End of table]
Although nearly all states reported that since 2000 they have
undertaken initiatives to improve children's access to dental care, CMS
416 data on children's access to dental care show that access rates
remain low, and states report facing the same barriers they faced in
2000. CMS 416 data show dental utilization rates have improved since
2000, from a national average of 27 percent to 35 percent in 2007--but
in 2007 only 1 state reported a dental utilization rate above 50
percent and 12 states' utilization rates remained below 30 percent.
Less than half of the states that reported undertaking initiatives to
improve children's access to dental care (21 states) reported that all
their initiatives met their expectations. Nearly all (48 of 51 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--continue to impede their current efforts. Apart from funding
concerns, states most often reported that a lack of provider and
beneficiary participation hindered their efforts to improve access to
Medicaid dental services in their state (see table 7). Twenty-six
states reported these and other barriers resulted in one or more of
their improvement initiatives not being implemented or their
expectations not being met.
Table 7: Barriers That Hinder State Initiatives to Improve Access to
Medicaid Dental Services, as Reported by State Medicaid Programs:
Barriers to state initiatives: Lack of available funding;
States responding (51 states): 44.
Barriers to state initiatives: Lack of provider participation;
States responding (51 states): 40.
Barriers to state initiatives: Lack of beneficiary participation;
States responding (51 states): 38.
Barriers to state initiatives: Administrative burden on providers;
States responding (51 states): 31.
Barriers to state initiatives: Difficulty coordinating with other state
agencies;
States responding (51 states): 13.
Barriers to state initiatives: Lack of CMS approval for state
initiatives;
States responding (51 states): 5.
Barriers to state initiatives: Other barriers[A];
States responding (51 states): 6.
Source: GAO (Survey of state Medicaid directors conducted between
December 2008 and January 2009).
Note: States could select more than one barrier and may be counted in
more than one category.
[A] States reported other barriers, including staffing shortages that
limit the agencies' ability to take on additional projects and cultural
competency barriers, such as translating oral health information into
other languages.
[End of table]
When asked to describe the extent to which state goals were being met,
some states reported that successes in increasing the numbers of
providers enrolled in the Medicaid program have resulted in increasing
rates of utilization by children, but that more needs to be done to
increase the percentage of children receiving dental services beyond
current levels. States also described other challenges to meeting their
goals and improving children's access to dental care, such as
fluctuations in eligibility for services, lack of beneficiary
compliance, low oral health awareness among beneficiaries, and a lack
of demand for routine dental care by beneficiaries.
In addition to barriers that hinder state initiatives, states report
that access rates could also be affected by two other types of
barriers: those faced by children seeking dental services and those
faced by providers serving Medicaid beneficiaries. For children seeking
dental services, most states reported that finding a provider that
accepts Medicaid is a moderate or major barrier. Comparatively fewer
states reported that obtaining transportation to and from the
provider's office or the ability of parents to take time off work are
moderate or major barriers for children seeking dental care. For
providers, most states also reported that beneficiaries not showing up
for appointments and a limited capacity to accept new patients
(reported by 45 and 30 states, respectively) are moderate to major
barriers. One state noted that these issues are particularly
significant when they are combined together, at which point they can
become moderate to major barriers for dental providers. See figure 1
for barriers faced by children and providers.
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 congressional concern 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 Has Taken Steps toward Improving Oversight of State Medicaid Dental
Services for Children:
In February 2008 and September 2008 Subcommittee hearings, CMS
officials described several initiatives under way by CMS to improve
monitoring of state programs and to provide guidance and facilitate
collaboration. At the time of our review, some of these initiatives had
been completed, while others were still under way. CMS initiatives
include the following:
* Focused dental reviews in 17 states. Between October 2007 and May
2008, CMS conducted a series of focused dental reviews in 17 states.
[Footnote 28] The 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. In January 2009, CMS published a summary report of its
findings and recommendations in 16 states (in February 2008, CMS had
published a separate report on Maryland).[Footnote 29] CMS had concerns
that 11 of the 17 states were not adhering to federal law or
regulation, including multiple findings in some states. For example,
CMS found that 6 states had inadequate dental networks in MCOs that
provided Medicaid dental services, 2 states had not ensured that all
medically necessary dental services were provided, and 1 state had
inappropriately limited reimbursement for out-of-state emergency dental
services, leaving the remainder of the costs to the beneficiaries.
[Footnote 30] CMS also made recommendations to all 17 states it
reviewed and identified several promising practices, which it
highlighted in its summary report.[Footnote 31]
* Improved collection of CMS 416 reports. In June 2007, CMS began an
initiative to improve reporting by states that had not submitted timely
or reliable dental utilization data in their annual CMS 416 reports.
CMS sent formal requests to 22 states that had failed to submit
complete CMS 416 reports for one or more years. CMS also contacted the
states and provided technical assistance on problems with data
collection methodology. As of March 2009, all 51 states had submitted
their 2007 CMS 416 reports to CMS. CMS 416 reports for 2008 were due to
CMS in April 2009, however, as of early June 2009, only 42 states had
submitted their 2008 reports.
* Review of state periodicity schedules. In 2008, CMS examined dental-
related periodicity schedules from all states. CMS found that all but
three states reported having some type of periodicity schedule, but not
all schedules were in compliance with CMS requirements. For example,
some schedules indicated when a primary care provider should refer a
child to a dentist, but the schedule did not specify how often dental
services should occur. CMS also found that periodicity schedules in
several states were not readily accessible by providers or
beneficiaries. For states that had not submitted separate dental
periodicity schedules as required by CMS, CMS recommended that the
states adopt AAPD's periodicity schedule for children.
* Publication of a dental policy document. 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 32] For example,
one question asked if the state could allow providers to bill patients
for missed appointments. CMS responded that Medicaid policy did not
permit such billing, in part because no service was delivered. Further,
missed appointments are not a distinct, reimbursable Medicaid service,
but are instead considered part of a provider's overall cost of doing
business.
* Communications with states and stakeholders. 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. For
example, CMS presented information on Medicaid dental issues at the
April 2008 National Oral Health Conference sponsored by the American
Association of Public Health Dentistry and the Association of State and
Territorial Dental Directors. Other groups involved in CMS partnership
activities included AAPD, the American Dental Association, and the
Association of Community Affiliated Plans.
* Establishment of an Oral Health Technical Advisory Group. In
conjunction with NASMD, CMS established an Oral Health Technical
Advisory Group to address issues related to oral health services,
including access and quality. A NASMD member chairs the advisory group
and, as of January 2009, other members included CMS representatives,
state representatives from different regions of the country, and other
NASMD staff. Advisory group projects include examining the effects on
oral health programs of recent legislation, such as the Recovery Act
and the Children's Health Insurance Program Reauthorization Act of
2009, considering improvements to the CMS 416 annual reports, and
improving materials used to inform beneficiaries of their Medicaid
dental benefits.
* Sharing of promising state practices related to dental services. CMS
posted "promising practices"--described by CMS as successful state
programs that reflect innovative approaches to meeting common problems--
on its Web site.[Footnote 33] As of May 2009, CMS had posted promising
practices from 4 states related to Medicaid dental services:
Delaware increased reimbursement, reduced administrative burden on
providers, and increased provider outreach.
South Carolina increased reimbursement rates, reduced administrative
barriers, and began an outreach campaign to encourage dentists to
participate in Medicaid.
Tennessee increased reimbursement, separated (or "carved out") the
dental benefit from Medicaid managed care contracts, and hired a
contractor to administer the dental benefit.
Virginia increased reimbursement, carved out the dental benefit from
Medicaid managed care contracts, and adopted incentives to increase
provider participation, such as establishment of a dedicated call
center, new billing options and quicker payment, streamlined prior
authorization for care, and simplified provider credentialing.
Gaps Remain in CMS Efforts to Monitor Provision of Dental Services to
Children in Medicaid, Provide Guidance, and Facilitate Collaboration
among States:
Although CMS has taken a number of important steps, gaps in CMS
oversight point to opportunities for further action to improve access
to dental services for children in Medicaid. Remaining gaps in CMS
oversight include the following:
* CMS does not have plans to conduct focused dental reviews in
additional states. CMS's focused dental reviews targeted 15 states with
the lowest dental utilization rates, but 2006 CMS 416 reports showed
that in 24 additional states (including Georgia and Maryland) in that
year, between 31 and 40 percent of eligible children received any
dental service--well below HHS's Healthy People 2010 goal of having 66
percent of low-income children under age 19 receive a preventive dental
service. According to CMS officials, CMS, at the time or our review,
did not plan to conduct focused dental reviews in these states,
potentially missing an opportunity to identify important areas for
improvement.[Footnote 34] When asked what additional assistance CMS
could provide, 6 states responding to our survey reported that they
believed that an independent review of dental services would be helpful
to their Medicaid programs.
* CMS did not require corrective action in states found to have
inadequate MCO networks. CMS's focused dental reviews identified 8
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. In 6 states, CMS presented its concerns as a
"finding," that is, a concern that the state is not adhering to federal
law or regulation. In the remaining 2 states, CMS cited deficiencies in
MCO provider networks, but did not report its concerns as findings. CMS
made recommendations to strengthen MCO provider networks in all 8
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 416 reports provide limited information on dental service
utilization. The CMS 416 report only gathers data on the number of
children who received a preventive dental service, a dental treatment
service, or any dental service. We have reported in the past that these
data are limited in their usefulness for oversight of Medicaid dental
services for children.[Footnote 35] For example, because dental
services delivered to managed care enrollees are not reported
separately from services to fee-for-service enrollees, the CMS 416 data
does not provide information that could be used to flag problems with a
specific service delivery method. Further, it is not possible to
determine how many children in a state received all of the recommended
dental services included in the state's periodicity schedule. According
to the CMS Deputy Administrator, the Oral Health Technical Advisory
Group has a project under way to consider improvements to the CMS 416.
* States report that additional guidance from CMS is needed. In
response to our survey, 2 states reported that CMS's September 2008
policy paper on Medicaid dental issues was helpful, but nearly all
states (49 of 51) reported that additional CMS guidance could help them
improve delivery of Medicaid dental services. States cited a need for
additional information in several areas: for example, guidance on
standards for dental care, information on billing policies, better
definitions for outreach and transportation services in Medicaid
programs, establishing appropriate dental fee schedules, improving
documentation and coding practices, and information on quality and
preventive initiatives.
* CMS has posted relatively few promising practices on its Web site.
When asked what CMS assistance would be helpful to their state Medicaid
program, the most common answer (other than increasing the federal
medical assistance percentage), cited by 37 states, was information on
other states' efforts to improve dental utilization. Although CMS
maintains a Web site to publicize promising state Medicaid dental
practices, 11 states reported that they were unaware of the promising
practices posted on CMS's Web site. The 4 promising practices posted as
of May 2009 are just a few of the practices that could be shared with
other states. For example, during its focused dental reviews, CMS
identified 17 additional promising and notable practices, none of which
were included on the CMS promising practice Web site. Further, 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 (see appendix V for brief descriptions of these practices).
Conclusions:
CMS has begun several initiatives to strengthen its oversight of state
Medicaid dental services for children, but information on the oral
health of and receipt of dental services by Medicaid children show that
much more needs to be done. Although many states have reported moderate
increases in access to Medicaid dental services, we reported in
September 2008 that the extent of dental disease in children had not
decreased and that millions of children were estimated to have
untreated tooth decay. States responding to our survey reported that a
lack of available funding, low provider 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. Through a series of focused reviews of states' efforts to
provide dental services to children in Medicaid, CMS has identified
deficiencies in several state Medicaid programs. Although CMS made
recommendations for improvement to the states, it required no
corrective actions. Moreover, not all states with low rates of
children's dental utilization have been reviewed, nor are such reviews
planned. These reviews have not only identified problem areas, but have
also helped identify information on promising state dental practices
that could be useful to other states seeking to improve their own
programs. Finally, for Medicaid-enrolled children who receive dental
services through managed care programs, CMS has found that certain
states have not ensured that MCOs have adequate provider networks to
provide covered dental services to their enrollees. Although CMS and
states have taken steps to address long-standing barriers, continued
attention and action is needed to ensure children's access to Medicaid
dental services.
Recommendations for Executive Action:
To strengthen monitoring of state Medicaid dental services for children
and help states improve children's access to Medicaid dental services,
we are recommending that the Administrator of CMS take the following
four actions:
* Develop a plan to review dental services for Medicaid children in all
states with low utilization rates, such as those not meeting HHS's
Healthy People 2010 targets.
* Ensure that states found to have inadequate MCO dental provider
networks take action to strengthen these networks.
* Work with stakeholders to develop needed guidance on topics of
concern to states.
* Identify ways to improve sharing of promising practices among states.
Agency Comments:
We provided a draft of this report for comment to HHS. Responding for
HHS, CMS provided written comments. In summary, CMS concurred with
three of our recommendations--specifically, to ensure that states found
to have inadequate MCO provider networks take corrective action, to
develop additional guidance on topics of concern to states, and to
improve sharing of promising practices among states and other
stakeholders. CMS described several initiatives planned or under way
that would strengthen its oversight of state Medicaid dental services
for children. CMS concurred in part with our fourth recommendation, to
develop a plan to review Medicaid dental services in states with low
utilization rates. In following up with CMS, an official clarified that
CMS agreed with the need to review Medicaid dental services in these
states but wanted this plan to be part of the agency's broader plan to
review all EPSDT services. As part of this broader plan, CMS would
consider additional focused dental reviews as well as comprehensive
EPSDT service reviews.[Footnote 36] We believe that CMS's action will
meet the intent of our recommendation. CMS also noted that the
Children's Health Insurance Program Reauthorization Act of 2009
included a number of provisions related to dental services that the
agency was in the process of implementing, including requirements for
states to post a listing of participating Medicaid and CHIP dental
providers on HHS's [hyperlink, http://www.insurekidsnow.gov] Web site,
to publish new quality measures for Medicaid and CHIP children, and to
report additional information on children receiving dental care under
Medicaid.[Footnote 37] Finally, CMS provided one technical comment,
which we incorporated into the report. CMS's letter is reprinted in
appendix VI.
As agreed with your offices, unless you publicly announce the contents
of this report earlier, we plan no further distribution until 30 days
from the report date. At that time, we will send copies of this report
to the Secretary of HHS and other interested parties.
In addition, the report will be available at no charge on GAO's Web
site at [hyperlink, http://www.gao.gov]. If you or your staffs have any
questions about this report, please contact me at (202) 512-7114 or
cackleya@gao.gov. Contact points for our Offices of Congressional
Relations and Public Affairs may be found on the last page of this
report. GAO staff that made major contributions to this report are
listed in appendix VII.
Signed by:
Alicia Puente Cackley:
Director, Health Care:
[End of section]
Appendix I: Methods Used by State Medicaid Programs to Monitor the
Statewide Provision of Dental Care to Children:
Yes: State did have this method of monitoring children's dental care.
No: State did not have this method of monitoring children's dental
care.
State: Alaska;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: No;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: Yes.
State: Alabama;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: No;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: Yes.
State: Arkansas;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: No;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: Yes;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: Yes.
State: Arizona;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: Yes;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: Yes;
Survey for problems obtaining services: Yes;
Survey to monitor oral health of children: No;
Other methods[A]: Yes.
State: California;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: Yes;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: No.
State: Colorado;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: Yes;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: Yes.
State: Connecticut;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: Yes;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: No.
State: District of Columbia;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: Yes;
Phone calls to state and/or MCOs on concerns: Yes;
Beneficiary satisfaction surveys: Yes;
Survey for problems obtaining services: Yes;
Survey to monitor oral health of children: Yes;
Other methods[A]: No.
State: Delaware;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: No;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: Yes.
State: Florida;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: No;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: No.
State: Georgia;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: Yes;
Phone calls to state and/or MCOs on concerns: Yes;
Beneficiary satisfaction surveys: Yes;
Survey for problems obtaining services: Yes;
Survey to monitor oral health of children: No;
Other methods[A]: No.
State: Hawaii;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: No;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: No.
State: Iowa;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: No;
Phone calls to state and/or MCOs on concerns: Yes;
Beneficiary satisfaction surveys: Yes;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: No.
State: Idaho;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: No;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: No.
State: Illinois;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: No;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: Yes;
Survey for problems obtaining services: Yes;
Survey to monitor oral health of children: No;
Other methods[A]: Yes.
State: Indiana;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: No;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: No.
State: Kansas;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: No;
Phone calls to state and/or MCOs on concerns: Yes;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: No.
State: Kentucky;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: No;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: No.
State: Louisiana;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: Yes;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: Yes.
State: Massachusetts;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: Yes;
Phone calls to state and/or MCOs on concerns: Yes;
Beneficiary satisfaction surveys: Yes;
Survey for problems obtaining services: Yes;
Survey to monitor oral health of children: No;
Other methods[A]: No.
State: Maryland;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: Yes;
Phone calls to state and/or MCOs on concerns: Yes;
Beneficiary satisfaction surveys: Yes;
Survey for problems obtaining services: Yes;
Survey to monitor oral health of children: Yes;
Other methods[A]: Yes.
State: Maine;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: No;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: No.
State: Michigan;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: Yes;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: No.
State: Minnesota;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: No;
Phone calls to state and/or MCOs on concerns: Yes;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: No.
State: Missouri;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: No;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: No.
State: Mississippi;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: No;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: Yes.
State: Montana;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: Yes;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: No.
State: North Carolina;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: Yes;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: Yes;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: No.
State: North Dakota;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: No;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: Yes.
State: Nebraska;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: No;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: No.
State: New Hampshire;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: No;
Phone calls to state and/or MCOs on concerns: Yes;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: Yes;
Survey to monitor oral health of children: No;
Other methods[A]: Yes.
State: New Jersey;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: Yes;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: Yes;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: No.
State: New Mexico;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: Yes;
Phone calls to state and/or MCOs on concerns: Yes;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: No.
State: Nevada;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: Yes;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: Yes;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: No.
State: New York;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: Yes;
Phone calls to state and/or MCOs on concerns: Yes;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: No.
State: Ohio;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: Yes;
Phone calls to state and/or MCOs on concerns: Yes;
Beneficiary satisfaction surveys: Yes;
Survey for problems obtaining services: Yes;
Survey to monitor oral health of children: Yes;
Other methods[A]: No.
State: Oklahoma;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: No;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: No.
State: Oregon;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: Yes;
Phone calls to state and/or MCOs on concerns: Yes;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: Yes.
State: Pennsylvania;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: Yes;
Phone calls to state and/or MCOs on concerns: Yes;
Beneficiary satisfaction surveys: Yes;
Survey for problems obtaining services: Yes;
Survey to monitor oral health of children: Yes;
Other methods[A]: No.
State: Rhode Island;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: Yes;
Phone calls to state and/or MCOs on concerns: Yes;
Beneficiary satisfaction surveys: Yes;
Survey for problems obtaining services: Yes;
Survey to monitor oral health of children: No;
Other methods[A]: No.
State: South Carolina;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: No;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: Yes;
Survey to monitor oral health of children: Yes;
Other methods[A]: Yes.
State: South Dakota;
CMS 416 data: No;
Claims and/or encounter data from MCOs: No;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: Yes.
State: Tennessee;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: Yes;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: Yes;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: No.
State: Texas;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: No;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: Yes;
Other methods[A]: No.
State: Utah;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: Yes;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: No.
State: Virginia;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: No;
Phone calls to state and/or MCOs on concerns: Yes;
Beneficiary satisfaction surveys: Yes;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: Yes.
State: Vermont;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: No;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: No.
State: Washington;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: No;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: Yes.
State: Wisconsin;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: Yes;
Phone calls to state and/or MCOs on concerns: Yes;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: Yes;
Other methods[A]: Yes.
State: West Virginia;
CMS 416 data: Yes;
Claims and/or encounter data from MCOs: No;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: No.
State: Wyoming;
CMS 416 data: v;
Claims and/or encounter data from MCOs: No;
Phone calls to state and/or MCOs on concerns: No;
Beneficiary satisfaction surveys: No;
Survey for problems obtaining services: No;
Survey to monitor oral health of children: No;
Other methods[A]: Yes.
Source: GAO (Survey of state Medicaid directors conducted between
December 2008 and January 2009).
[A] States reported using other methods to monitor the provision of
Medicaid dental services, including generating ad hoc reports on
various dental procedures and analyzing monthly budget reports by
procedure code to monitor utilization trends.
[End of table]
[End of section]
Appendix II: Statewide Utilization Goals for the Provision of Dental
Care to Children in State Medicaid Programs:
Yes: State did have this access goal for children's dental care.
No: State did not have this access goal for children's dental care.
State: Alaska[B];
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: No;
Percentage of children who received dental preventive services is to
exceed a certain threshold: No;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: No;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: No.
State: Alabama;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: Yes;
Percentage of children who received dental preventive services is to
exceed a certain threshold: Yes;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: No;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: No.
State: Arkansas;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: Yes;
Percentage of children who received dental preventive services is to
exceed a certain threshold: No;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: Yes;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: Yes;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: No.
State: Arizona;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: Yes;
Percentage of children who received dental preventive services is to
exceed a certain threshold: No;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: No;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: Yes.
State: California;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: No;
Percentage of children who received dental preventive services is to
exceed a certain threshold: No;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: No;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: Yes.
State: Colorado;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: Yes;
Percentage of children who received dental preventive services is to
exceed a certain threshold: Yes;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: No;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: Yes.
State: Connecticut;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: Yes;
Percentage of children who received dental preventive services is to
exceed a certain threshold: Yes;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: Yes;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: Yes;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: Yes.
State: District of Columbia;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: Yes;
Percentage of children who received dental preventive services is to
exceed a certain threshold: Yes;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: No;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: Yes;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: Yes;
Other state goals[A]: No.
State: Delaware;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: Yes;
Percentage of children who received dental preventive services is to
exceed a certain threshold: No;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: Yes;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: Yes;
Other state goals[A]: No.
State: Florida;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: No;
Percentage of children who received dental preventive services is to
exceed a certain threshold: Yes;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: Yes;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: Yes;
Other state goals[A]: No.
State: Georgia;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: Yes;
Percentage of children who received dental preventive services is to
exceed a certain threshold: Yes;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: Yes;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: Yes;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: Yes;
Other state goals[A]: No.
State: Hawaii;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: Yes;
Percentage of children who received dental preventive services is to
exceed a certain threshold: No;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: Yes;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: No.
State: Iowa;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: Yes;
Percentage of children who received dental preventive services is to
exceed a certain threshold: Yes;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: No;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: Yes;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: No.
State: Idaho;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: No;
Percentage of children who received dental preventive services is to
exceed a certain threshold: Yes;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: Yes;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: Yes;
Other state goals[A]: No.
State: Illinois;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: Yes;
Percentage of children who received dental preventive services is to
exceed a certain threshold: Yes;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: No;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: No.
State: Indiana[B];
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: No;
Percentage of children who received dental preventive services is to
exceed a certain threshold: No;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: No;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: No.
State: Kansas;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: No;
Percentage of children who received dental preventive services is to
exceed a certain threshold: No;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: No;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: Yes.
State: Kentucky[B];
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: No;
Percentage of children who received dental preventive services is to
exceed a certain threshold: No;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: No;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: No.
State: Louisiana;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: No;
Percentage of children who received dental preventive services is to
exceed a certain threshold: No;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: Yes;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: No.
State: Massachusetts;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: Yes;
Percentage of children who received dental preventive services is to
exceed a certain threshold: Yes;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: Yes;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: Yes;
Other state goals[A]: Yes.
State: Maryland;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: Yes;
Percentage of children who received dental preventive services is to
exceed a certain threshold: Yes;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: Yes;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: Yes;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: Yes.
State: Maine;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: Yes;
Percentage of children who received dental preventive services is to
exceed a certain threshold: Yes;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: No;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: No.
State: Michigan;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: Yes;
Percentage of children who received dental preventive services is to
exceed a certain threshold: Yes;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: No;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: Yes;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: No.
State: Minnesota[B];
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: No;
Percentage of children who received dental preventive services is to
exceed a certain threshold: No;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: No;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: No.
State: Missouri[B];
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: No;
Percentage of children who received dental preventive services is to
exceed a certain threshold: No;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: No;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: No.
State: Mississippi[B];
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: No;
Percentage of children who received dental preventive services is to
exceed a certain threshold: No;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: No;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: No.
State: Montana;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: Yes;
Percentage of children who received dental preventive services is to
exceed a certain threshold: No;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: No;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: No.
State: North Carolina;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: Yes;
Percentage of children who received dental preventive services is to
exceed a certain threshold: Yes;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: Yes;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: Yes.
State: North Dakota;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: Yes;
Percentage of children who received dental preventive services is to
exceed a certain threshold: Yes;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: Yes;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: Yes;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: Yes;
Other state goals[A]: No.
State: Nebraska[B];
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: No;
Percentage of children who received dental preventive services is to
exceed a certain threshold: No;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: No;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: No.
State: New Hampshire;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: Yes;
Percentage of children who received dental preventive services is to
exceed a certain threshold: Yes;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: No;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: Yes;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: Yes;
Other state goals[A]: Yes.
State: New Jersey;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: Yes;
Percentage of children who received dental preventive services is to
exceed a certain threshold: Yes;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: Yes;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: Yes;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: No.
State: New Mexico;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: Yes;
Percentage of children who received dental preventive services is to
exceed a certain threshold: Yes;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: Yes;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: Yes;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: Yes;
Other state goals[A]: No.
State: Nevada;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: No;
Percentage of children who received dental preventive services is to
exceed a certain threshold: No;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: No;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: Yes.
State: New York;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: Yes;
Percentage of children who received dental preventive services is to
exceed a certain threshold: No;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: No;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: No.
State: Ohio;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: Yes;
Percentage of children who received dental preventive services is to
exceed a certain threshold: No;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: No;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: Yes.
State: Oklahoma;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: Yes;
Percentage of children who received dental preventive services is to
exceed a certain threshold: Yes;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: Yes;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: Yes;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: Yes.
State: Oregon;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: No;
Percentage of children who received dental preventive services is to
exceed a certain threshold: No;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: No;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: Yes.
State: Pennsylvania;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: Yes;
Percentage of children who received dental preventive services is to
exceed a certain threshold: Yes;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: No;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: No.
State: Rhode Island;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: No;
Percentage of children who received dental preventive services is to
exceed a certain threshold: No;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: No;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: Yes.
State: South Carolina;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: Yes;
Percentage of children who received dental preventive services is to
exceed a certain threshold: No;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: No;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: Yes;
Other state goals[A]: No.
State: South Dakota;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: Yes;
Percentage of children who received dental preventive services is to
exceed a certain threshold: Yes;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: No;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: No.
State: Tennessee;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: Yes;
Percentage of children who received dental preventive services is to
exceed a certain threshold: No;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: Yes;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: No.
State: Texas;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: No;
Percentage of children who received dental preventive services is to
exceed a certain threshold: Yes;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: No;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: No.
State: Utah;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: No;
Percentage of children who received dental preventive services is to
exceed a certain threshold: Yes;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: No;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: Yes;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: No.
State: Virginia;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: Yes;
Percentage of children who received dental preventive services is to
exceed a certain threshold: No;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: No;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: Yes.
State: Vermont[B];
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: No;
Percentage of children who received dental preventive services is to
exceed a certain threshold: No;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: No;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: No.
State: Washington;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: No;
Percentage of children who received dental preventive services is to
exceed a certain threshold: No;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: No;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: Yes.
State: Wisconsin;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: Yes;
Percentage of children who received dental preventive services is to
exceed a certain threshold: Yes;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: Yes;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: No.
State: West Virginia[B];
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: No;
Percentage of children who received dental preventive services is to
exceed a certain threshold: No;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: No;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: No;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: No;
Other state goals[A]: No.
State: Wyoming;
Percentage of children who receive any dental care in a given time
period is to exceed a certain threshold: Yes;
Percentage of children who received dental preventive services is to
exceed a certain threshold: Yes;
Ratio of participating dental providers in Medicaid exceeds a certain
threshold: No;
Percentage of children who received restorative procedures for oral
health problems exceeds a certain threshold: Yes;
Percentage of children who report difficulty finding dental care is to
fall below a certain threshold: Yes;
Other state goals[A]: No.
Source: GAO (Survey of state Medicaid directors conducted between
December 2008 and January 2009).
[A] States reported other goals, including the percentage of children
who are continually enrolled and receive appropriate follow-up or
increasing levels of provider participation.
[B] These states reported they do not have goals related to the
provision of dental care for children in state Medicaid programs.
[End of table]
[End of section]
Appendix III: Access Standards Set by the 21 States That Provide Dental
Services through Managed Care Organizations (MCOs):
Yes: State did have this standard for MCO networks in their state.
No: State did not have this standard for MCO networks in their state.
Access Standards States Set For MCOs:
State: Arizona;
Percentage of children who should receive a dental visit: Yes;
Minimum payment rates for dental services: No;
Beneficiary satisfaction scores or ratings: No;
Minimum provider to patient ratios: No;
Maximum travel times: No;
Maximum travel distances: No;
Maximum waiting times when scheduling dental appointments: Yes;
Maximum waiting times when scheduling emergency dental appointments:
Yes;
Other standards[A]: Yes.
State: California;
Percentage of children who should receive a dental visit: No;
Minimum payment rates for dental services: Yes;
Beneficiary satisfaction scores or ratings: Yes;
Minimum provider to patient ratios: Yes;
Maximum travel times: Yes;
Maximum travel distances: Yes;
Maximum waiting times when scheduling dental appointments: Yes;
Maximum waiting times when scheduling emergency dental appointments:
Yes;
Other standards[A]: Yes.
State: District of Columbia;
Percentage of children who should receive a dental visit: Yes;
Minimum payment rates for dental services: Yes;
Beneficiary satisfaction scores or ratings: No;
Minimum provider to patient ratios: No;
Maximum travel times: Yes;
Maximum travel distances: Yes;
Maximum waiting times when scheduling dental appointments: Yes;
Maximum waiting times when scheduling emergency dental appointments:
Yes;
Other standards[A]: No.
State: Florida;
Percentage of children who should receive a dental visit: Yes;
Minimum payment rates for dental services: No;
Beneficiary satisfaction scores or ratings: No;
Minimum provider to patient ratios: Yes;
Maximum travel times: Yes;
Maximum travel distances: Yes;
Maximum waiting times when scheduling dental appointments: Yes;
Maximum waiting times when scheduling emergency dental appointments:
Yes;
Other standards[A]: No.
State: Georgia;
Percentage of children who should receive a dental visit: Yes;
Minimum payment rates for dental services: No;
Beneficiary satisfaction scores or ratings: No;
Minimum provider to patient ratios: No;
Maximum travel times: Yes;
Maximum travel distances: Yes;
Maximum waiting times when scheduling dental appointments: Yes;
Maximum waiting times when scheduling emergency dental appointments:
No;
Other standards[A]: Yes.
State: Idaho;
Percentage of children who should receive a dental visit: No;
Minimum payment rates for dental services: Yes;
Beneficiary satisfaction scores or ratings: No;
Minimum provider to patient ratios: No;
Maximum travel times: No;
Maximum travel distances: Yes;
Maximum waiting times when scheduling dental appointments: No;
Maximum waiting times when scheduling emergency dental appointments:
No;
Other standards[A]: No.
State: Kentucky;
Percentage of children who should receive a dental visit: No;
Minimum payment rates for dental services: Yes;
Beneficiary satisfaction scores or ratings: Yes;
Minimum provider to patient ratios: No;
Maximum travel times: Yes;
Maximum travel distances: Yes;
Maximum waiting times when scheduling dental appointments: No;
Maximum waiting times when scheduling emergency dental appointments:
No;
Other standards[A]: No.
State: Maryland;
Percentage of children who should receive a dental visit: Yes;
Minimum payment rates for dental services: Yes;
Beneficiary satisfaction scores or ratings: Yes;
Minimum provider to patient ratios: Yes;
Maximum travel times: Yes;
Maximum travel distances: Yes;
Maximum waiting times when scheduling dental appointments: Yes;
Maximum waiting times when scheduling emergency dental appointments:
Yes;
Other standards[A]: No.
State: Michigan;
Percentage of children who should receive a dental visit: No;
Minimum payment rates for dental services: No;
Beneficiary satisfaction scores or ratings: No;
Minimum provider to patient ratios: No;
Maximum travel times: No;
Maximum travel distances: No;
Maximum waiting times when scheduling dental appointments: Yes;
Maximum waiting times when scheduling emergency dental appointments:
Yes;
Other standards[A]: No.
State: Minnesota;
Percentage of children who should receive a dental visit: No;
Minimum payment rates for dental services: No;
Beneficiary satisfaction scores or ratings: No;
Minimum provider to patient ratios: No;
Maximum travel times: Yes;
Maximum travel distances: Yes;
Maximum waiting times when scheduling dental appointments: Yes;
Maximum waiting times when scheduling emergency dental appointments:
Yes;
Other standards[A]: Yes.
State: Missouri;
Percentage of children who should receive a dental visit: No;
Minimum payment rates for dental services: No;
Beneficiary satisfaction scores or ratings: No;
Minimum provider to patient ratios: No;
Maximum travel times: No;
Maximum travel distances: Yes;
Maximum waiting times when scheduling dental appointments: Yes;
Maximum waiting times when scheduling emergency dental appointments:
Yes;
Other standards[A]: Yes.
State: New Jersey;
Percentage of children who should receive a dental visit: Yes;
Minimum payment rates for dental services: No;
Beneficiary satisfaction scores or ratings: Yes;
Minimum provider to patient ratios: Yes;
Maximum travel times: Yes;
Maximum travel distances: Yes;
Maximum waiting times when scheduling dental appointments: Yes;
Maximum waiting times when scheduling emergency dental appointments:
Yes;
Other standards[A]: Yes.
State: New Mexico;
Percentage of children who should receive a dental visit: No;
Minimum payment rates for dental services: No;
Beneficiary satisfaction scores or ratings: No;
Minimum provider to patient ratios: No;
Maximum travel times: No;
Maximum travel distances: No;
Maximum waiting times when scheduling dental appointments: Yes;
Maximum waiting times when scheduling emergency dental appointments:
Yes;
Other standards[A]: No.
State: Nevada;
Percentage of children who should receive a dental visit: Yes;
Minimum payment rates for dental services: No;
Beneficiary satisfaction scores or ratings: No;
Minimum provider to patient ratios: Yes;
Maximum travel times: No;
Maximum travel distances: No;
Maximum waiting times when scheduling dental appointments: Yes;
Maximum waiting times when scheduling emergency dental appointments:
Yes;
Other standards[A]: No.
State: New York;
Percentage of children who should receive a dental visit: Yes;
Minimum payment rates for dental services: No;
Beneficiary satisfaction scores or ratings: No;
Minimum provider to patient ratios: Yes;
Maximum travel times: Yes;
Maximum travel distances: Yes;
Maximum waiting times when scheduling dental appointments: Yes;
Maximum waiting times when scheduling emergency dental appointments:
Yes;
Other standards[A]: No.
State: Ohio;
Percentage of children who should receive a dental visit: Yes;
Minimum payment rates for dental services: No;
Beneficiary satisfaction scores or ratings: Yes;
Minimum provider to patient ratios: No;
Maximum travel times: No;
Maximum travel distances: Yes;
Maximum waiting times when scheduling dental appointments: No;
Maximum waiting times when scheduling emergency dental appointments:
No;
Other standards[A]: Yes.
State: Oregon;
Percentage of children who should receive a dental visit: No;
Minimum payment rates for dental services: No;
Beneficiary satisfaction scores or ratings: No;
Minimum provider to patient ratios: No;
Maximum travel times: Yes;
Maximum travel distances: Yes;
Maximum waiting times when scheduling dental appointments: No;
Maximum waiting times when scheduling emergency dental appointments:
No;
Other standards[A]: Yes.
State: Pennsylvania;
Percentage of children who should receive a dental visit: Yes;
Minimum payment rates for dental services: No;
Beneficiary satisfaction scores or ratings: Yes;
Minimum provider to patient ratios: No;
Maximum travel times: Yes;
Maximum travel distances: No;
Maximum waiting times when scheduling dental appointments: Yes;
Maximum waiting times when scheduling emergency dental appointments:
Yes;
Other standards[A]: No.
State: Rhode Island;
Percentage of children who should receive a dental visit: Yes;
Minimum payment rates for dental services: Yes;
Beneficiary satisfaction scores or ratings: No;
Minimum provider to patient ratios: No;
Maximum travel times: No;
Maximum travel distances: Yes;
Maximum waiting times when scheduling dental appointments: Yes;
Maximum waiting times when scheduling emergency dental appointments:
Yes;
Other standards[A]: Yes.
State: Texas;
Percentage of children who should receive a dental visit: No;
Minimum payment rates for dental services: No;
Beneficiary satisfaction scores or ratings: No;
Minimum provider to patient ratios: No;
Maximum travel times: No;
Maximum travel distances: Yes;
Maximum waiting times when scheduling dental appointments: Yes;
Maximum waiting times when scheduling emergency dental appointments:
Yes;
Other standards[A]: Yes.
State: Wisconsin;
Percentage of children who should receive a dental visit: Yes;
Minimum payment rates for dental services: No;
Beneficiary satisfaction scores or ratings: No;
Minimum provider to patient ratios: No;
Maximum travel times: No;
Maximum travel distances: No;
Maximum waiting times when scheduling dental appointments: Yes;
Maximum waiting times when scheduling emergency dental appointments:
Yes;
Other standards[A]: No.
Source: GAO (Survey of state Medicaid directors conducted between
December 2008 and January 2009).
[A] States reported other standards, such as identifying and managing
beneficiaries who use emergency room facilities to obtain dental
services.
[End of table]
[End of section]
Appendix IV: Extent to Which Managed Care Organizations (MCO) Meet
State Standards and State Verification of MCO Networks:
Yes: State did report using this method to verify MCO provider
networks.
No: State did not report using this method to verify MCO provider
networks.
State: Arizona;
Extent to which MCOs meet established standards: Meet some;
Method used to verify that dental providers are accepting children in
Medicaid:
Routinely contact a selection of providers to determine if they accept
new Medicaid patients: No;
Examine networks in responses to complaints or other concerns on an ad
hoc basis: Yes;
Other verification[A]: Yes.
State: California;
Extent to which MCOs meet established standards: Meet some;
Method used to verify that dental providers are accepting children in
Medicaid:
Routinely contact a selection of providers to determine if they accept
new Medicaid patients: Yes;
Examine networks in responses to complaints or other concerns on an ad
hoc basis: Yes;
Other verification[A]: Yes.
State: District of Columbia;
Extent to which MCOs meet established standards: Meet all;
Method used to verify that dental providers are accepting children in
Medicaid:
Routinely contact a selection of providers to determine if they accept
new Medicaid patients: Yes;
Examine networks in responses to complaints or other concerns on an ad
hoc basis: Yes;
Other verification[A]: No.
State: Florida;
Extent to which MCOs meet established standards: Meet some;
Method used to verify that dental providers are accepting children in
Medicaid:
Routinely contact a selection of providers to determine if they accept
new Medicaid patients: Yes;
Examine networks in responses to complaints or other concerns on an ad
hoc basis: No;
Other verification[A]: No.
State: Georgia;
Extent to which MCOs meet established standards: Meet all;
Method used to verify that dental providers are accepting children in
Medicaid:
Routinely contact a selection of providers to determine if they accept
new Medicaid patients: Yes;
Examine networks in responses to complaints or other concerns on an ad
hoc basis: Yes;
Other verification[A]: No.
State: Idaho;
Extent to which MCOs meet established standards: Meet all;
Method used to verify that dental providers are accepting children in
Medicaid:
Routinely contact a selection of providers to determine if they accept
new Medicaid patients: No;
Examine networks in responses to complaints or other concerns on an ad
hoc basis: Yes;
Other verification[A]: No.
State: Kentucky;
Extent to which MCOs meet established standards: Meet all;
Method used to verify that dental providers are accepting children in
Medicaid:
Routinely contact a selection of providers to determine if they accept
new Medicaid patients: No;
Examine networks in responses to complaints or other concerns on an ad
hoc basis: No;
Other verification[A]: No.
State: Maryland;
Extent to which MCOs meet established standards: Meet some;
Method used to verify that dental providers are accepting children in
Medicaid:
Routinely contact a selection of providers to determine if they accept
new Medicaid patients: Yes;
Examine networks in responses to complaints or other concerns on an ad
hoc basis: Yes;
Other verification[A]: No.
State: Michigan;
Extent to which MCOs meet established standards: Meet some;
Method used to verify that dental providers are accepting children in
Medicaid:
Routinely contact a selection of providers to determine if they accept
new Medicaid patients: No;
Examine networks in responses to complaints or other concerns on an ad
hoc basis: No;
Other verification[A]: No.
State: Minnesota;
Extent to which MCOs meet established standards: Meet some;
Method used to verify that dental providers are accepting children in
Medicaid:
Routinely contact a selection of providers to determine if they accept
new Medicaid patients: No;
Examine networks in responses to complaints or other concerns on an ad
hoc basis: Yes;
Other verification[A]: No.
State: Missouri;
Extent to which MCOs meet established standards: Meet some;
Method used to verify that dental providers are accepting children in
Medicaid:
Routinely contact a selection of providers to determine if they accept
new Medicaid patients: No;
Examine networks in responses to complaints or other concerns on an ad
hoc basis: Yes;
Other verification[A]: No.
State: New Jersey;
Extent to which MCOs meet established standards: Meet some;
Method used to verify that dental providers are accepting children in
Medicaid:
Routinely contact a selection of providers to determine if they accept
new Medicaid patients: No;
Examine networks in responses to complaints or other concerns on an ad
hoc basis: Yes;
Other verification[A]: Yes.
State: New Mexico;
Extent to which MCOs meet established standards: Meet some;
Method used to verify that dental providers are accepting children in
Medicaid:
Routinely contact a selection of providers to determine if they accept
new Medicaid patients: Yes;
Examine networks in responses to complaints or other concerns on an ad
hoc basis: Yes;
Other verification[A]: No.
State: Nevada;
Extent to which MCOs meet established standards: Meet all;
Method used to verify that dental providers are accepting children in
Medicaid:
Routinely contact a selection of providers to determine if they accept
new Medicaid patients: Yes;
Examine networks in responses to complaints or other concerns on an ad
hoc basis: Yes;
Other verification[A]: No.
State: New York;
Extent to which MCOs meet established standards: Meet none;
Method used to verify that dental providers are accepting children in
Medicaid:
Routinely contact a selection of providers to determine if they accept
new Medicaid patients: Yes;
Examine networks in responses to complaints or other concerns on an ad
hoc basis: Yes;
Other verification[A]: No.
State: Ohio;
Extent to which MCOs meet established standards: Meet some;
Method used to verify that dental providers are accepting children in
Medicaid:
Routinely contact a selection of providers to determine if they accept
new Medicaid patients: Yes;
Examine networks in responses to complaints or other concerns on an ad
hoc basis: Yes;
Other verification[A]: No.
State: Oregon;
Extent to which MCOs meet established standards: Meet some;
Method used to verify that dental providers are accepting children in
Medicaid:
Routinely contact a selection of providers to determine if they accept
new Medicaid patients: No;
Examine networks in responses to complaints or other concerns on an ad
hoc basis: Yes;
Other verification[A]: No.
State: Pennsylvania;
Extent to which MCOs meet established standards: Meet all;
Method used to verify that dental providers are accepting children in
Medicaid:
Routinely contact a selection of providers to determine if they accept
new Medicaid patients: Yes;
Examine networks in responses to complaints or other concerns on an ad
hoc basis: Yes;
Other verification[A]: No.
State: Rhode Island;
Extent to which MCOs meet established standards: Meet all;
Method used to verify that dental providers are accepting children in
Medicaid:
Routinely contact a selection of providers to determine if they accept
new Medicaid patients: Yes;
Examine networks in responses to complaints or other concerns on an ad
hoc basis: Yes;
Other verification[A]: No.
State: Texas;
Extent to which MCOs meet established standards: Meet some;
Method used to verify that dental providers are accepting children in
Medicaid:
Routinely contact a selection of providers to determine if they accept
new Medicaid patients: Yes;
Examine networks in responses to complaints or other concerns on an ad
hoc basis: Yes;
Other verification[A]: No.
State: Wisconsin;
Extent to which MCOs meet established standards: Meet none;
Method used to verify that dental providers are accepting children in
Medicaid:
Routinely contact a selection of providers to determine if they accept
new Medicaid patients: No;
Examine networks in responses to complaints or other concerns on an ad
hoc basis: Yes;
Other verification[A]: No.
Source: GAO (Survey of state Medicaid directors conducted between
December 2008 and January 2009).
[A] States reported using other methods to verify MCO networks,
including monthly spot checks, monitoring provider registration, and
requiring annual network development plans.
[End of table]
[End of section]
Appendix V: CMS Promising Practices and State Reported Best Practices:
To promote information sharing and collaboration among states, the
Centers for Medicare & Medicaid Services (CMS) has created a Web site
in which it publishes notable "Promising Practices" related to Medicaid
and the State Children's Health Insurance Program (SCHIP). Dental care
is one of the subject areas covered on this Web site. To nominate a
promising practice, a state must complete an application describing the
underlying problem, the approach taken, and the results obtained. A
promising practice is defined by CMS as an approach to meeting a
challenge related to Medicaid/SCHIP program operations, clinical
practice, or functional level that serves to enhance quality of care
and/or life and may be of interest to other states. Specifically, the
practice must:
* Be related to the improvement of quality of care and/or life for
Medicaid and/or SCHIP beneficiaries.
* Address a significant problem in health status or functioning based
on trends in mortality, morbidity, quality of life, utilization, and/or
costs.
* Reflect an innovative approach to meeting a common problem.
* Have been in operation for a sufficient period of time to demonstrate
effectiveness (e.g., minimum 12 months).
* Have demonstrated success through tangible results (e.g.,
improvements in beneficiary physical or mental well-being, savings).
* Comply with federal Medicaid statute and regulations and CMS policy
direction.
As of May 2009, there were five dental practices listed on CMS's
"Promising Practices" Web site, four of which pertained to Medicaid.
[Footnote 38] Each of the 4 states cited as having promising practices
also indicated on our survey of state Medicaid programs that they
consider their state to have a dental best practice.
In addition to these 4 states, 22 states responding to our survey
reported that they had best practices that could be shared with other
states. See table 12 for brief descriptions of all 26 state-reported
best practices.
Table 8: Description of State-Reported Best Practices for Improving
Dental Care for Children in Medicaid:
State: Alabama;
State-reported best practice: The "Smile Alabama!" initiative
encompassed administrative reforms, implemented a case management
system, increased outreach to patients and dentists, and set
reimbursement rates equal to rates paid by commercial insurers.
State: Arkansas;
State-reported best practice: The state contracted with an organization
to assist with outreach, scheduling, reminders, and transportation for
Medicaid beneficiaries needing dental care.
State: Arizona;
State-reported best practice: The Oral Health Performance Improvement
Project assists health plans identify gaps in quality-improvement
strategies and address those areas. Examples include collaboration with
programs such as Head Start and using health plan staff or dental
providers to make presentations in schools or at community health
fairs.
State: Connecticut;
State-reported best practice: The state established dental health care
specialists who interact with the community to stress the importance of
a dental home and regular dental care. Specialists interact with
dentists to ensure families and children make their 6-month checkups,
and act as a point of contact for the dentists. Specialists also
provide oral health counseling and assistance, such as obtaining
transportation and addressing language barriers. The state also created
a member outreach handbook, including information on office etiquette
and making appointments.
State: Delaware[A];
State-reported best practice: The state reimburses providers at 85
percent of usual and customary rates, which has encouraged dentists to
participate in the state Medicaid program.
State: Florida;
State-reported best practice: The state provides coverage of fluoride
varnish applications by non-dentists.
State: Georgia;
State-reported best practice: A managed care organization implemented a
program that transferred a significant percentage of patients receiving
intravenous sedation from outpatient hospital settings to dental
offices.
State: Iowa;
State-reported best practice: As part of the I Smile Dental Home Plan,
Oral Health Care Coordinators, who are dental hygienists employed by
the Department of Public Health, work with counties to strengthen the
public health dental system, link with local boards of health, provide
training and oversight of health agency staff, and coordinate services
for children ages 12 and under.
State: Illinois;
State-reported best practice: The state implemented several
initiatives; (1) the Dental Champions Program, a peer-to-peer provider
recruitment/retention effort to enroll providers, particularly in
underserved areas, and to encourage increased participation among
enrolled providers; (2) dental administrators and Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) program outreach; (3)
dental grants to build infrastructure in the public delivery system;
and (4) fluoride varnish application in pediatric practices to promote
a focus on oral health and appropriate referrals.
State: Michigan;
State-reported best practice: In its Healthy Kids Dental Program, the
state contracted with one dental insurer so that all beneficiaries have
access to the insurer's dental network. Beneficiaries carry the
insurer's card, so they are treated the same as other employer-
sponsored subscribers.
State: North Carolina;
State-reported best practice: The state described two initiatives: (1)
The Physician Fluoride Varnish Program, known as Into the Mouth of
Babes, in which Medicaid recipients ages 6-42 months receive oral
health services from participating primary care physicians; and (2)
Carolina Dental Home Program, which is a pilot project that seeks to
identify high-risk preschool Medicaid recipients and facilitates care
coordination and referrals to general and pediatric dentists.
State: New Hampshire;
State-reported best practice: The Statewide Sealant Project is a school
based program in which volunteer dentists and dental hygienists provide
examinations and sealant applications. Other initiatives include
raising dental rates, promoting access through partnership building,
reducing administrative burdens, hiring a dental director, educating
primary care physicians and caregivers, working to reduce broken
appointments, and establishing a liaison between the state Medicaid
program and Medicaid providers.
State: New Jersey;
State-reported best practice: The state reported three dental
initiatives: (1) the Pediatric Oral Health Forum and Committee, which
developed and is implementing the Pediatric Oral Health Action Plan;
(2) a Collaborative to Improve Birth Outcomes and Health Status of
Children, which facilitates coordination of care between medical
providers and dentists; and (3) the New Jersey Smiles initiative, which
aims to increase the percentage of children up to age 6 who have a
dental home and who receive annual dental visits.
State: New Mexico;
State-reported best practice: The state created a special needs code, a
reimbursement strategy that allows for dental practitioners to be
eligible for an encounter fee of $90 (in addition to other billable
services) when providing dental care to a person with developmental
disabilities, if the practitioner has been through the program training
and has become certified.
State: Nevada;
State-reported best practice: The Pay for Performance Program provides
bonuses to health plans based on high performance and plan improvement,
and has been incorporated into managed care contracts.
State: Ohio;
State-reported best practice: The state reported two initiatives; (1)
reimbursement of physicians for application of fluoride varnish for
children from first tooth eruption to age 3; and (2) use of mobile
dental vans to improve access in underserved areas.
State: Oklahoma;
State-reported best practice: The state has implemented a student loan
repayment program for dentists who agree to practice in identified
areas and have at least 30 percent of their practice composed of
Medicaid beneficiaries.
State: Oregon;
State-reported best practice: The Early Childhood Cavities Prevention
Program trains general medical practitioners to perform oral screenings
and apply fluoride.
State: Pennsylvania;
State-reported best practice: The state described two initiatives: (1)
the Dental Disease Management Program, which encourages dental
practices to provide comprehensive preventive, routine, and follow-up
dental care; and (2) a requirement that providers notify the
Department's Intensive Care Management Unit or Access Plus contractor
when a child is referred to a dentist in order to be reimbursed. Follow
up is made to confirm that the recommended visit has occurred. For
children in MCOs, the provider must notify the MCO that the child is
due for a dental referral as part of a complete EPSDT screen.
State: Rhode Island;
State-reported best practice: The Dental Benefits Manager Program is
charged (among other things) with increasing reimbursement rates,
ensuring there are sufficient dentists participating in the network,
and assisting beneficiaries with finding dentists, securing
transportation, and providing interpretation services.
State: South Carolina[A];
State-reported best practice: The state increased fees to the 75th
percentile of private-sector reimbursement rates and reduced
administrative barriers for providers. The South Carolina Dental
Association began an outreach campaign to encourage dentists to
participate in Medicaid.
State: South Dakota;
State-reported best practice: The Accessing Better Children's Dentistry
is an initiative in which certified dentists receive an enhanced
reimbursement for certain procedures.
State: Tennessee[A];
State-reported best practice: The state carved out the dental benefit
in a Medicaid managed care environment and selected a benefit manager
to administer dental benefits and establish reasonable provider
reimbursement rates. Other activities include gathering input through a
dental advisory committee, recruiting community-based dentists, and
additional education and outreach.
State: Texas;
State-reported best practice: The First Dental Home initiative expands
preventive dental services to children 6 through 35 months of age by
providing risk assessments, anticipatory guidance, and more frequent
dental checkup visits, based on the child's risk of developing caries.
State: Virginia[A];
State-reported best practice: The Smiles for Children Program includes
an increase in dental fees, streamlined administration, and the
reduction of prior authorization requirements. The program also
includes a Broken Appointment initiative, which tracks broken
appointments and provides assistance, such as transportation, to help
families keep their appointments.
State: Washington;
State-reported best practice: The Access to Baby and Child Dentistry
program focuses on providing dental benefits to children up to age 5 by
conducting outreach to organizations in which Medicaid-eligible
children receive services, identifying and enrolling children in the
program, educating families and caregivers, and matching each child
with a program-certified dentist.
Source: GAO (Survey of state Medicaid directors conducted between
December 2008 and January 2009).
[A] Posted on CMS's Web site as a promising practice as of May 2009.
[End of table]
[End of section]
Appendix VI: Comments from the Department of Health and Human Services:
Department Of Health & Human Services:
Office Of The Secretary:
Assistant Secretary for Legislation:
Washington, DC 20201:
August 19, 2009:
Alicia Puente Cackley:
Director, Health Care:
U.S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Ms. Cackley:
Enclosed are the Department's comments on the U.S. Government
Accountability Office's draft report entitled, "Medicaid: State and
Federal Actions Have Been Taken to Improve Children's Access to Dental
Services but Gaps Remain" (GAO-09-723).
The Department appreciates the opportunity to review and comment on
this draft report before its publication.
Sincerely,
Signed by:
Barbara Pisaro Clark:
Acting Assistant Secretary for Legislation:
Enclosure:
[End of letter]
DEPARTMENT OF HEALTH & HUMAN SERVICES:
Centers for Medicare & Medicaid Services:
Administrator:
Washington, DC 20201:
Date: August 14, 2009:
To: Alicia Puente Cackley:
Director, Health Care:
Government Accountability Office:
From: [Signed by] Charlene Frizzera:
Acting Administrator:
Subject: Government Accountability Office (GAO) Draft Report:
"Medicaid: State and Federal Actions Have Been Taken to Improve
Children's Access to Dental Services but Gaps Remain" (GAO-09-723):
Thank you for the opportunity to review and comment on the GAO Draft
Report entitled, "Medicaid: State and Federal Actions Have Been Taken
to Improve Children's Access to Dental Services but Gaps Remain" (GAO-
09-723). The report was prepared at the request of Congressman Dennis
Kucinich, Chairman of the Subcommittee on Domestic Policy, and
Congressman Elijah Cummings The purpose of the report was to examine:
1) State strategies to monitor and improve access to dental care for
children in Medicaid; and;
2) The Centers for Medicare & Medicaid Services (CMS) actions since
2007 to improve oversight of Medicaid dental services for children.
The GAO Draft Report includes the following four recommendations for
CMS:
1. Develop a plan to review dental services for Medicaid children in
all States with low utilization rates, such as those not meeting HHS's
Healthy People 2010 targets;
2. Ensure that States found to have inadequate managed care
organization (MCO) dental provider networks take action to strengthen
those networks;
3. Work with stakeholders to develop needed guidance on topics of
concerns to States; and;
4. Identify ways to improve sharing of promising practices among
States.
CMS Response to Recommendation 1:
The CMS agrees in part with the GAO recommendation to develop a plan to
review Medicaid dental services. CMS recognizes the need to continue
and increase our focus on improving access to dental services for
Medicaid-eligible children and to ensure that children receive the full
scope of services available under the Early and Periodic Screening,
Diagnostic and Treatment (EPSDT) benefit. As noted in the draft report,
CMS has undertaken a number of activities related to improving access
to dental services, such as focused dental reviews in 16 States, the
release of the National Dental Summary in January 2009, and the
National Medicaid Dental Town Hall Forum held on April 6, 2009. The
purpose of the Town Hall Forum was to begin a dialogue between the
interested stakeholders to discuss what steps can be taken to address
issues related to and improve the delivery of dental services to
Medicaid-eligible children. The National Association of State Medicaid
Directors and the American Dental Association partnered with CMS for
this event. A portion of the forum was devoted to presentations by
States that provided examples of different approaches States have used
to solve issues confronted by State Medicaid dental programs. CMS is in
the process of preparing a summary of the Town Hall Forum that will be
available to the public. The summary, including several best practices
that have been identified, will be posted on the CMS Website when it
has been completed.
In the larger context of the provision of EPSDT services, CMS has
convened an internal workgroup to review the policies and procedures
related to EPSDT, including the provision of dental services. Based on
this review, we are developing a workplan in which we will solicit
input and obtain recommendations from various stakeholders to provide
updated, comprehensive guidance for State Medicaid programs. CMS is
committed to releasing this guidance to States through State Medicaid
Director letters by the end of this calendar year. As part of this
review, the workgroup will consider additional focused reviews of State
Dental programs, as well as comprehensive EPSDT service reviews.
The CMS is also in the process of implementing the Children's Health
Insurance Program Reauthorization Act of 2009 (CHIPRA) legislation,
which includes a number of provisions related to dental services for
both Medicaid and the Children's Health Insurance Program (CHIP). In
regards to the Medicaid program, CHIPRA requires additional reporting
information and requires that the Secretary work with States and others
to provide a current list of all dentists and providers that provide
dental services to children under Medicaid or CHIP State plans or
waivers. The Secretary is also required to work with States to provide
a description of the dental services that each State provides under its
Medicaid or CHIP State plan or waiver. CI IIPRA requires that this
information be reported on the Insure Kids Now (IKN) website. CMS is
currently working with the Health Resources and Services Administration
(HRSA) on these provisions to include this information on the website.
CMS will also ensure that dental quality measures are built into the
quality measures program as required under CHIPRA.
In terms of CHIP, CHIPRA requires the development of a dental education
program for new parents of targeted low-income children. It also
requires that targeted low-income children receive dental coverage;
allows States to provide dental services through benchmark plans; and
allows States with separate CHIP programs to provide dental-only
supplemental coverage.
CMS Response to Recommendation 2:
The CMS agrees that States found to have inadequate MCO dental networks
should be required to address this problem. Implementing regulations
found at 42 CFR 438.206(6)(1) requires States to ensure through their
contracts with managed care entities that the entity "maintains and
monitors a network of appropriate providers that is supported by
written agreements and is sufficient to provide adequate access to all
services covered under the contract." Section 438207(a) of Federal
regulations further requires States to obtain supporting documentation
of the adequacy of a managed care entity's provider networks. CMS
cannot approve contracts without these requirements being met. As GAO
indicates, each of the 21 States reviewed applies measurable access
standards to their MCO's dental networks.
However, once a network is verified for purposes of contract approval,
previously open panels may become filled or providers may drop out of a
network which could create an issue with ongoing provider availability.
In order to address this issue CMS is working with States to implement
the requirement that was included in CHIPRA that all States post a
listing of participating Medicaid and CHIP dental providers on the
Insure Kids Now (IKN) Website at [hyperlink,
http://www.insurekidsnow.gov]. States' MCO dental networks will also be
included on the Website as appropriate. This information became
available on the IKN website beginning August 4, 2009, as required by
CHIPRA.
Although making the lists of dental providers more publicly available
will not necessarily address the problem of network inadequacy, it will
give beneficiaries more accurate and updated information for the
purpose of finding available providers. It will also give CMS the
opportunity to assess where network adequacy problems may be occurring.
In cases where an inadequate network is identified, CMS requires the
State to impose a corrective action plan on the managed care entity to
require an expansion of its dental network. If the problem is not
corrected within a reasonable time frame, CMS could require the State
to permit enrollees to access dental services outside of the managed
care network.
With respect to the 16 State dental reviews in the CMS National Dental
Summary, GAO notes that 6 States found that they were not ensuring that
MCO provider networks were adequate to afford access to covered dental
services. As noted in the Summary, CMS is following up with each State
to address issues noted during the reviews and to ensure that the State
is in compliance with Federal laws.
CMS Response to Recommendation 3:
The CMS agrees with the recommendation to work with stakeholders to
develop needed guidance on topics of concerns to States. As noted in
our response to Recommendation 1, CMS is forming a workgroup on EPSDT
services. The workgroup will provide an opportunity for CMS to involve
interested stakeholders such as State Medicaid Agencies and
organizations that work on child health care issues to assist us in
this endeavor. We believe that input from these entities will be
helpful in focusing the workgroup in areas of the most importance.
While EPSDT will be the focus of the workgroup, access to dental
services will continue to remain a high priority. As previously
mentioned, guidance will be shared with the States as a result of the
activities of this workgroup. We anticipate the workgroup will also
focus on data reporting including dental reporting, as well as quality
measurement. We will also issue guidance on the dental provisions of
CHIPRA as we move forward with CHIPRA implementation.
CMS Response to Recommendation 4:
The CMS agrees with, and is committed to, the recommendation to improve
sharing of promising practices among States and other stakeholders. The
CMS Promising Practice. Webpage contains information on the process for
submitting a promising practice for consideration, as well as a list of
promising practices that have been vetted for publication.
The CMS routinely requests that States submit information on promising
practices through various avenues, such as our Technical Advisory
Groups (TAGs) and calls our regional offices have with State EPSDT
coordinators. CMS held a National Quality Call on Pediatric Oral Health
on April 3, 2008, highlighting several State oral health initiatives.
At that time we requested that the presenters and others in the
audience submit any oral health promising practices to be shared with
other States via our Webpage. In addition, in the National Medicaid
Dental Summary of the 16 state dental reviews, CMS noted various
promising or notable practices; some of these efforts were statewide
and others were performed on the local level. We also used that
opportunity to request those practices be submitted to us formally.
We will continue to highlight Promising Practices on our website and
solicit additional input whenever opportunities arise. The Webpage is
located at: [hyperlink,
http://www.cms.hhs.gov/MedicaidCHIPQualPrac/MCPPDL/list.asp#Top0fPage].
In addition, as required under title IV of the CHIPRA legislation on
Quality of Care, CMS is responsible for identifying and disseminating
information to States regarding best practices with respect to
"measuring and reporting on the quality of health care for children."
CMS is also responsible for facilitating the adoption of such best
practices. CMS is currently developing a work plan for identification,
dissemination, and technical assistance related to Medicaid promising
practices.
Summary:
In response to the ongoing problems related to access to dental care
identified in this report, CMS is in the process of developing
additional guidance and technical assistance to States on the provision
of EPSDT services, with a particular focus on access to dental
services. As part of our larger EPSDT initiative, CMS has undertaken a
review of our policy guidance, policies and procedures and has convened
an internal workgroup tasked with evaluating opportunities for working
with States to improve access to and the consistent provision of EPSDT
services.
The CMS expects to increase our efforts to reach out to States and
other interested parties and stakeholders through a variety of
mechanisms such as Websites, TAG (including the Oral Health TAG),
public meetings, and focused reviews.
The CMS is working to implement the CHIPRA legislation, which includes
a number of activities related to dental services. Dental measures will
be included in the new quality measures program, and there will also be
new reporting requirements. In addition, a list of dental providers
will be available on the IKN Website. Finally, CMS will continue to
focus our efforts on collecting and disseminating promising practices
related to child health issues including oral health services. We will
continue to use every opportunity to solicit input from States
including a reminder in our guidance to States in State Medicaid
Director letters on EPSDT services.
[End of section]
Appendix VII: GAO Contact and Staff Acknowledgments:
GAO Contact:
Alicia Puente Cackley, (202) 512-7114 or cackleya@gao.gov:
Staff Acknowledgments:
In addition to the contact named above, Katherine Iritani, Acting
Director; Susannah Bloch; Sarah Burton; Martha Kelly; Ba Lin; Sarah
Marshall; Terry Saiki; Jessica Cobert Smith; Teresa Tam; and Hemi
Tewarson made key contributions to this report.
[End of section]
Related GAO Products:
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] We refer to the Subcommittee on Domestic Policy, Committee on
Oversight and Government Reform, House of Representatives, as the
Subcommittee throughout this report.
[3] 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).
[4] A list of related GAO products can be found at the end of this
report.
[5] GAO, 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.: Sept.
11, 2000).
[6] We refer to the District of Columbia as a state and refer to the
Medicaid director's survey response as the state Medicaid program's
response or as the state's response throughout this report.
[7] We reviewed only those dental provisions that were specified in the
contracts under sections titled network adequacy, covered services,
access standards, or similar. We also searched each contract using key
terms, such as network and access, to identify additional related
provisions.
[8] The State Children's Health Insurance Program (SCHIP) provides
health care coverage to children in low-income families who are not
eligible for traditional Medicaid programs. CMS now refers to SCHIP as
the Children's Health Insurance Program (CHIP).
[9] U.S. Department of Health and Human Services, National Institute of
Dental and Craniofacial Research, National Institutes of Health, Oral
Health in America: A Report of the Surgeon General (Rockville, Md.:
2000).
[10] Matthew F. Savage, Jessica Y. Lee, Jonathan B. Kotch, and William
F. Vann Jr., "Early Preventive Dental Visits: Effects on Subsequent
Utilization and Costs," Pediatrics, 114 (2004).
[11] Dental sealants, a plastic material put on the chewing surfaces of
back teeth, have been shown to prevent decay on tooth surfaces where
food and bacteria can build up. AAPD recommends sealants for 6-year and
12-year molars as soon as possible after eruption.
[12] The Healthy People 2010 goal was increased from 57 percent when it
was first established in 2000 to 66 percent during a mid-course review
in the mid-2000s. The goal defines preventive dental care to include
examination, x-ray, fluoride treatment, cleaning, or sealant
application. See U.S. Department of Health and Human Services, Public
Health Service, Progress Review: Oral Health (Feb. 7, 2008).
[13] The 30 million children represent the 2008 unduplicated annual
enrollment (the total number of children, each child counted once, who
were enrolled in Medicaid at any point in federal fiscal year 2008)
reported by CMS. See [hyperlink,
http://www.cms.hhs.gov/CapMarketUpdates/02_CMSStatistics.asp#TopOfPage]
(accessed May 18, 2009).
[14] CMS's statistics include the Medicaid population enrolled in
capitated plans (typically defined as plans that contract with states
to receive a prepaid payment per enrollee for coverage of Medicaid
services) and primary care case management models.
[15] Dental services must also be provided as medically necessary to
identify a suspected illness or condition and must include, at a
minimum, relief of pain and infections, restoration of teeth, and
maintenance of dental health. 42 U.S.C. § 1396d(r)(3).
[16] CMS, Guide to Children's Dental Care in Medicaid (Washington,
D.C.: October 2004). Under contract with CMS, AAPD developed the guide
as a resource for states on clinical practice, evolving technologies,
and recommendations in dental care.
[17] State Medicaid programs must annually report to the Secretary of
HHS information on EPSDT services, including the number of children
provided EPSDT screenings, the number of children referred for
corrective treatment as a result of the screenings, the number of
children receiving dental services, and the states' results in meeting
annual goals for children's receipt of EPSDT services established by
HHS. 42 U.S.C. § 1396a(a)(43).
[18] GAO, 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.: Apr. 12,
2000).
[19] [hyperlink, http://www.gao.gov/products/GAO/HEHS-00-149].
[20] Although dental disease in the overall Medicaid population aged 2
through 18 did not decrease, the trends vary somewhat among different
age groups. Younger children--those aged 2 through 5--had statistically
significant higher rates of dental disease in the more recent time
period examined as compared to earlier surveys. By contrast, data for
adolescents--children in Medicaid aged 16 through 18--show declining
rates of tooth decay, although the change was not statistically
significant. GAO, 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.: Sept. 23, 2008).
[21] See Pub. L. No. 111-5, div. B, tit. V § 5001, 123 Stat. 115, 496
(Feb. 17, 2009) (codified at 42 U.S.C. § 1396d note).
[22] GAO, Recovery Act: States' and Localities' Current and Planned
Uses of Funds While Facing Fiscal Stresses, [hyperlink,
http://www.gao.gov/products/GAO-09-829] (Washington, D.C.: July 8,
2009).
[23] Twenty-one of the 51 state Medicaid programs reported using both
managed care and fee-for-service to deliver dental services to Medicaid
beneficiaries in their state. For our survey, we defined managed care
as arrangements where the state pays an MCO a capitated (per member per
month) payment and the MCO uses this payment to provide care. We
defined dental care organizations as managed care organizations that
provide only dental benefits.
[24] Five of the 18 states reported that examining MCO networks in
response to a complaint or concern was their only method to verify MCO
networks, 13 states do so in combination with other verification
methods.
[25] GAO, 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).
[26] Christina Melvin, "A Collaborative Community-based Oral Care
Program for School-age Children," Clinical Nurse Specialist, vol. 20,
no. 1 (2006): 18-22.
[27] Mary Greene-McIntyre, Mary Hayes Finch, and John Searcy, "Smile
Alabama! Initiative: Interim Results from a Program To Increase
Children's Access to Dental Care," Journal of Rural Health, vol. 19
suppl. (2003): 407-15.
[28] 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.
[29] 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).
[30] CMS regional offices noted deficiencies for some states with
respect to certain Medicaid requirements such as: (i) states must
ensure, through their contracts, that MCOs maintain and monitor a
network of appropriate providers that is supported by written
agreements and is sufficient to provide adequate access to covered
services (see 42 C.F.R. 438.206(b)(1)); (ii) states must ensure that
all covered services are available and accessible to MCO enrollees (see
42 C.F.R. § 438.206(a)); and (iii) Medicaid beneficiaries cannot be
charged cost-sharing for EPSDT or emergency services (see 42 C.F.R.
447.53(b)).
[31] Provider reimbursement rates were not a specific part of CMS's
focused dental reviews, even though some providers and others
interviewed by CMS noted that low payment rates contributed to low
provider participation in Medicaid. A CMS official indicated that the
issue of low reimbursement rates would likely be part of ongoing
discussions involving Medicaid dental topics such as delivery systems
and administrative issues, but would not be the focus of its oversight
efforts. The official reported that the agency plans to continue
working with states and the American Dental Association on
reimbursement issues.
[32] 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).
[33] See [hyperlink,
http://www.cms.hhs.gov/MedicaidCHIPQualPrac/MCPPDL/list.asp] (accessed
May 20, 2009).
[34] In commenting on a draft of this report, CMS indicated that it
would consider additional focused dental reviews as part of a broader
planning effort to review all EPSDT services.
[35] GAO, 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).
[36] In July 2009, CMS reported that it was developing a comprehensive
workplan that included establishing a regular schedule for reviewing
state EPSDT policy and implementation efforts. See Medicaid Preventive
Services: Concerted Efforts Needed to Ensure Beneficiaries Receive
Services, [hyperlink, http://www.gao.gov/products/GAO-09-578]
(Washington, D.C.: August 14, 2009).
[37] The Children's Health Insurance Program Reauthorization Act of
2009 also mandates that GAO conduct a study on certain dental workforce
and other Medicaid and CHIP dental issues and submit a report to
Congress by August 2010. See Pub. L. No. 111-3, § 501(h), 123 Stat. 8,
88 (Feb. 4, 2009).
[38] The additional promising practice was related to dental benefits
under the SCHIP program.
[End of section]
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