Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
CHILDRENS DENTAL SERVICES 
UNDER MEDICAID 
ACCESS AND UTILIZATION 
JUNE GIBBS BROWN 
Inspector General 
APRIL 1996 
OEI-09-93-00240  OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department of Health and Human Services (HHS) 
programs as well as the health and welfare of beneficiaries served by those programs.  This statutory 
mission is carried out through a nationwide network of audits, investigations, and inspections 
conducted by three OIG operating components:  the Office of Audit Services, the Office of 
Investigations, and the Office of Evaluation and Inspections.  The OIG also informs the Secretary of 
HHS of program and management problems and recommends courses to correct them. 
OFFICE OF AUDIT SERVICES 
The OIGs Office of Audit Services (OAS) provides all auditing services for HHS, either by 
conducting audits with its own audit resources or by overseeing audit work done by others.  Audits 
examine the performance of HHS programs and/or its grantees and contractors in carrying out their 
respective responsibilities and are intended to provide independent assessments of HHS programs and 
operations in order to reduce waste, abuse, and mismanagement and to promote economy and 
efficiency throughout the Department. 
OFFICE OF INVESTIGATIONS 
The OIGs Office of Investigations (OI) conducts criminal, civil, and administrative investigations of 
allegations of wrongdoing in HHS programs or to HHS beneficiaries and of unjust enrichment by 
providers.  The investigative efforts of OI lead to criminal convictions, administrative sanctions, or 
civil money penalties.  The OI also oversees State Medicaid fraud control units which investigate and 
prosecute fraud and patient abuse in the Medicaid program. 
OFFICE OF EVALUATION AND INSPECTIONS 
The OIGs Office of Evaluation and Inspections (OEI) conducts short-term management and program 
evaluations (called inspections) that focus on issues of concern to the Department, the Congress, and 
the public.  The findings and recommendations contained in these inspection reports generate rapid, 
accurate, and up-to-date information on the efficiency, vulnerability, and effectiveness of 
departmental programs.  This report was prepared in the San Francisco regional office under the 
direction of Kaye D. Kidwell, Regional Inspector General, and Paul A. Gottlober, Deputy Regional 
Inspector General.  Project staff included: 
SAN FRANCISCO  HEADQUARTERS 
Elizabeth Celniker  Winnie Walker, Program Specialist 
Thomas Purvis 
For additional copies of this report, please contact the San Francisco office at (415) 437-7900.  E X E C U T I V E   S U M M A R Y 

PURPOSE 
This inspection (1) identifies the reasons why many children are not receiving Early and 
Periodic Screening, Diagnostic, and Treatment (EPSDT) dental services and (2) describes 
State activities to improve access and utilization. 
BACKGROUND 
Medicaids EPSDT is a comprehensive health program that provides for initial and 
periodic examinations and medically necessary follow-up care.  Federal law requires that 
States provide EPSDT services to eligible children from birth through age 20.  The two 
primary operational premises of EPSDT are access and utilization.  That is, States must (1) 
assure that health care providers are available and accessible and (2) teach Medicaid 
families how to use available resources effectively. 
Specifically, States must (1) recruit physicians, dentists, and other providers to participate 
in EPSDT; (2) assure that these providers perform the medical and dental examinations, 
diagnoses, and treatments; (3) locate eligible families and inform them about EPSDT; 
(4) issue schedules specifying the desired frequency of medical, dental, vision, and hearing 
screenings, based on professional practice standards; (5) report information on use of 
EPSDT services to the Health Care Financing Administration (HCFA); and (6) provide all 
services needed to treat any condition identified by a screen even if the State does not 
include this service in its Medicaid plan. 
In recent years, a number of States, as well as HCFA, the Administration for Children and 
Families (ACF), the Public Health Service (PHS), and the Office of the Assistant Secretary 
for Planning and Evaluation (ASPE) have expressed concern about the number of dentists 
who are willing to see EPSDT enrollees.  (As a result of a recent Departmental 
reorganization, responsibilities for oral health within the former PHS have been transferred 
to both the Office of Public Health and Science [OPHS] within the Office of the Secretary 
and the Health Resources and Services Administration [HRSA].) 
We interviewed Medicaid and dental public health officials in all 50 States and the District 
of Columbia.  We also contacted a sample of Head Start health directors, State and 
national dental society representatives, private practice dentists, advocates, and other 
experts. 
FINDINGS 
Few eligible children receive preventive dental services 
Our interviews confirmed what the HCFA data show--few children receive EPSDT dental 
services, and the extent of the problem varies significantly from State to State.  In fact, 
i  HCFA data show that only 1 in 5 (4.2 million out of 21.2 million) eligible Medicaid 
children received preventive dental services in 1993, a slight decrease from the 22 percent 
who received services in 1992.  Also in 1993, three-fourths of the States provided 
preventive services to fewer than 30 percent, and none of the States provided them to more 
than 50 percent, of all eligible children.  The States statistics of children participating in 
the EPSDT program are unreliable, because States vary in what data they collect and 
report to HCFA. 
The reasons few children receive dental care are complex 
Approximately 80 percent of the States attribute the low utilization rate to a shortage of

dentists who are willing to accept Medicaid patients.  Head Start grantees also report

increasing difficulty in obtaining dental services for their children.  States report that

inadequate reimbursement is the most significant reason why dentists dont accept

Medicaid patients.  However, preliminary data from a few States that have raised fees

show that, at least initially, access and utilization do not increase proportionally.  Dentists

also are dissatisfied with slow Medicaid payments, arbitrary denials, and prior

authorization requirements for routine services.  Many dentists have difficulty treating

Medicaid families, and many non-pediatric dentists are unwilling to treat young children.

Medicaid families give dental services a low priority.  Respondents report that Medicaid

families have competing family priorities, and many of them are unaware of the

importance of good oral health.  Families often are unwilling to wait for appointments or

make necessary travel or child care arrangements which increases the likelihood of missed

appointments and failure to seek services.

The youngest children are the most difficult to serve and frequently are not screened at all.

Although the American Academy of Pediatric Dentists (AAPD) recommends that dentists

examine all children before their first birthday, only a small fraction of Medicaid children

receive these services.  Twenty States have adopted the AAPD standard, another 12 States

recommend screening beginning during the second year, and the rest start at

age 3.

State, local, and private agencies are experimenting to improve access and utilization 
In the past few years, State, local, and private agencies have begun initiatives to improve 
the participation of dentists in Medicaid and to encourage children and families to use 
dental services.  State initiatives include: (1) increased reimbursement, (2) managed care 
arrangements, (3) streamlined claims processing, (4) outreach and beneficiary education, 
(5) mandated provider participation, (6) training general dentists and non-dental health 
providers, (7) clinics for dental care, and (8) voluntary efforts by dentists.  While some 
States are planning to evaluate their projects, most do not yet have data to show whether 
they are effective. 
ii  RECOMMENDATION 
We recognize that there is significant legislation before Congress and the Administration 
that would alter the relationship between the Federal government and the States on matters 
discussed in this report.  Nonetheless, we believe the following recommendation and the 
options discussed for implementing it remain relevant under the current or future Federal-
State relationship. 
The Department should convene a work group that, at a minimum, would include 
HCFA, HRSA, ACF, OPHS, and ASPE to develop an integrated approach to improve 
dental access and utilization for EPSDT eligible children. 
With expanded membership, the existing PHS Oral Health Coordinating Committee 
Working Group could fulfill this need.  We suggest that the work group consider the 
following issues: 
Should a special conference with State participants be convened to facilitate an 
exchange of ideas on existing and possible demonstrations, evaluation strategies, 
and dissemination protocols? 
Can a coordinated approach be developed to identify demonstration projects, grants, 
and other activities that would improve access and utilization? 
Are there ways to encourage professional volunteerism that would increase the 
availability of dentists to this underserved population? 
How can the Department support, promote, and improve education and outreach to 
Medicaid beneficiaries, their families, and the dental community? 
What incentives and demonstration projects can be developed or promoted at the 
State and local levels to increase provider participation? 
How can existing community organizations, many of which are supported by the 
Department, become involved in providing access to childrens dental services? 
AGENCY COMMENTS 
We received comments on the draft report from the Assistant Secretary for Health, the 
Centers for Disease Control and Prevention, the National Institutes of Health (NIH), 
HRSA, and HCFA.  Both the Assistant Secretary for Health and NIH suggested that the 
existing PHS Oral Health Coordinating Committee Working Group, with expanded 
membership, could adequately address our recommendation and obviate the need for a new 
Departmental work group.  We agree that this is a viable alternative and have amended our 
recommendation accordingly.  The full text of the comments is contained in appendix C. 
iii  T A B L E   O F   C O N T E N T S 

PAGE

EXECUTIVE SUMMARY 
INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1

FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  6

Few eligible children served  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  6

Complex reasons  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  7

Experimental projects to improve access and utilization  . . . . . . . . . . . . . . . . . . . . .  9

RECOMMENDATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   13

AGENCY COMMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   14

APPENDIX A: Number and percent of children who received EPSDT 
preventive dental services in 1993, by State 
APPENDIX B: State initiatives to improve access and utilization 
of childrens dental services 
APPENDIX C:  Agency Comments  I N T R O D U C T I O N 

PURPOSE 
This inspection (1) identifies the reasons why many children are not receiving Early and 
Periodic Screening, Diagnostic, and Treatment (EPSDT) dental services and (2) describes 
State activities to improve access and utilization. 
BACKGROUND 
The EPSDT Program 
Enacted by Congress in 1967, Medicaids EPSDT is a comprehensive health program that 
provides for initial and periodic examinations and medically necessary follow-up care. 
Federal law requires that States provide EPSDT services to eligible children from birth 
through age 20. 
The two primary operational premises of EPSDT are access and utilization.  That is, States 
must (1) assure that health care providers are available and accessible and (2) teach 
Medicaid families how to use available resources effectively.  Specifically, States must 
recruit physicians, dentists, and other providers to participate in EPSDT;

locate eligible families and inform them about EPSDT services; and

assure that Medicaid-certified physicians, dentists, or other providers perform the

medical and dental examinations, diagnoses, and treatments.

In other words, States are required to (1) inform all persons who are Medicaid eligible 
about EPSDT services, (2) provide or arrange for the provision of screening services, and 
(3) arrange for all corrective treatment needed as a result of the screening. 
Congress significantly amended EPSDT as part of the Omnibus Reconciliation Act of 1989 
(OBRA 1989).  The amendments require States to: 
issue schedules specifying the desired frequency of medical, dental, vision, and

hearing screenings, based on professional practice standards (i.e., schedules

developed in consultation with recognized professional associations such as the

American Dental Association);

report more detailed information on use of EPSDT services to the Health Care

Financing Administration (HCFA); and

provide all services needed to treat any condition identified by a screen even if the

State does not include this service in its Medicaid plan.

Another OBRA 1989 amendment, which applies to the Medicaid program in general, 
requires States to set reimbursement rates at a level sufficient to assure that Medicaid 
1
 beneficiaries have access to providers equal to that of the general population in the same 
geographic area.  Prior to OBRA 1989, this requirement existed only in regulation. 
Frequency and Content of EPSDT Dental Screening 
States must establish and maintain schedules that specify how frequently children should 
be screened.  A physician or nurse practitioner usually conducts a general medical 
examination when a child is born or when the family enrolls in Medicaid.  The general 
examination includes an oral health assessment.  This oral assessment cannot substitute for 
an examination by a dentist.  Furthermore, States must assure that dentists examine 
children at least as often as their dental screening schedules require. 
States must establish the screening schedules in consultation with a recognized dental 
association.  For example, they may choose to follow the American Academy of Pediatric 
Dentists (AAPD) screening guidelines that call for an initial examination by a dentist 
during the first year of life and subsequently at least twice a year.  The AAPD schedule 
specifies that the initial screening should include a clinical oral examination and cleaning 
for the child plus dental health counseling for the family.  This initial screening also may 
include fluoride treatments and the application of dental sealants.  According to the AAPD, 
early screening and education can prevent "baby bottle tooth decay" and other causes of 
later childhood caries.  Untreated, the conditions can produce severe tooth decay and gum 
infection that may require specialized treatment or hospitalization. 
EPSDT and the Head Start Program 
Head Start requires that enrolled children receive dental examinations and treatment.  Most 
Head Start children are eligible for EPSDT services.  The initial Head Start screening 
usually is conducted by dental hygienists or trained paraprofessionals rather than dentists. 
In addition, all Head Start children must receive an examination by a dentist at least once 
during the school year and must be treated for any problems found. 
In a previous study, the Office of Inspector General (OIG) reviewed a random sample of 
80 Head Start grantees for the 1991-92 program year and found that approximately 
85 percent received the required dental examination.  Of the children requiring follow-up 
dental treatment, the OIG found that 67 percent had all their dental needs met, 7 percent 
had only some needs met, and 26 percent received no treatment.1  Nevertheless, these 
figures are substantially higher than States report for all of their EPSDT enrollees. 
Access to EPSDT Childrens Dental Services 
In recent years, a number of States, as well as HCFA, the Administration for Children and 
Families, the Public Health Service (PHS), and the Office of the Assistant Secretary for 
Planning and Evaluation have expressed concern about the number of dentists who are 
1Office of Inspector General, Evaluating Head Start Expansion Through Performance Indicators (OEI-09-
91-00762), May 1993 
2  willing to serve EPSDT enrollees.  (As a result of a recent Departmental reorganization, 
responsibilities for oral health within the former PHS have been transferred to both the 
Office of Public Health and Science [OPHS] within the Office of the Secretary and the 
Health Resources and Services Administration [HRSA].)  Several recent studies have 
focused on access problems and identified some of the reasons why few Medicaid children 
receive dental services.  For example: 
The Congressional Office of Technology Assessment reported in 1990 that none of

the State Medicaid programs adequately covered childrens basic dental services

and that a variety of barriers, identified by both dentists and State staff, restrict

access.2

A 1990 California Policy Seminar report found that most California county EPSDT

programs were having trouble finding any dentists who were willing to see eligible

children.3

A series of oral health workshops sponsored in 1990 and 1991 by the PHS

Maternal and Child Health Bureau described regulatory, administrative, and

economic barriers that inhibit the delivery of dental services to children.

These studies identified inadequate reimbursement rates, complicated claims processing, 
prior authorization requirements, and dentists actual or perceived problems with 
beneficiaries as the reasons why so few dentists are willing to serve Medicaid children. 
Data concerning provider participation are not available 
National reporting requirements that would provide data concerning the number of dentists 
participating in Medicaid do not exist.  Also, adequate access has not been defined.  Many 
States look at only how quickly families or staff can find a dentist, rather than the number 
who are getting services.  Some States consider dentists to be participating if they file at 
least one Medicaid claim during the year.  This is misleading because many of these 
dentists may refuse to take new Medicaid patients.  Most States also lack data to track 
referrals from EPSDT screenings to determine if needed diagnoses and treatment were 
completed.  A few States are beginning to compare the ratio of dentists willing to take 
Medicaid patients to the Medicaid-eligible population, but most lack access data or 
common measures. 
The HCFA plans to collect and analyze data from selected States to provide information on 
the participation rate among dentists and the impact this has on Medicaid childrens use of 
dental services. 
2Congress of the United States, Office of Technology Assessment, Childrens Dental Services Under the 
Medicaid Program, September 1990 
3California Policy Seminar, Access to Dental Care for Medi-Cal Recipients, Research Report, University 
of California, Berkeley, 1990 
3  Federal Oral Health 2000 Goals 
Although approximately 21.2 million children were eligible for EPSDT services in 1993 
(the last year for which data are available), only 1 in 5 received the required preventive 
dental services.4  As part of its efforts to mitigate this problem, PHS launched the Oral 
Health 2000 project in 1991 as a collaborative effort with a number of private and 
voluntary health agencies.  (The Office of Public Health and Science now has oversight 
responsibilities for this project.)  The primary goal of Oral Health 2000 is to raise public 
awareness and improve access to oral health care services.  Specific objectives are 
designed to: 
reduce the occurrence and severity of oral diseases,

reduce the unnecessary loss of teeth from disease, neglect, or trauma, and

alleviate barriers that prevent individuals from achieving oral health.

Oral Health 2000 addresses the 16 oral health objectives that PHS developed as part of 
"Healthy People 2000," a broader national health promotion initiative.  One objective 
specifically related to EPSDT is "to increase to at least 90 percent the proportion of all 
children entering school programs for the first time who have received an oral health 
screening, referral, and follow up for necessary diagnostic, preventive, and treatment 
services."  Other issues concern increased use of fluorides, cessation of tobacco use, and 
the oral health of handicapped and minority populations. 
METHODOLOGY 
Our study methodology was four-fold.  Basically, we: 
gathered existing EPSDT data from HCFA records, 
conducted telephone and in-person interviews to gather new information about the 
status of EPSDT dental services in the States, 
conducted telephone and in-person interviews to gather new information about State 
and local initiates to improve access and utilization, and 
presented the existing and new information in a single document.  . 
We interviewed officials in all 50 States and the District of Columbia.  In most States, we 
interviewed EPSDT coordinators and Medicaid dental consultants as well as the States 
chief dental officer.  We also contacted a sample of Head Start health directors, State 
dental society representatives, private practice dentists, advocates, and other experts.  The 
4Health Care Financing Administration, EPSDT Program Indicators, Fiscal Year 1993, HCFA-416 
Performance Reports, Early and Periodic Screening, Diagnostic and Treatment Program, 50 States and 
District of Columbia 
4  American Dental Association and the American Academy of Pediatric Dentists helped 
facilitate contacts with State organizations and provided other information and assistance. 
We conducted our review in accordance with the Quality Standards for Inspections issued 
by the Presidents Council on Integrity and Efficiency. 
5
 F I N D I N G S 

FEW ELIGIBLE CHILDREN RECEIVE PREVENTIVE DENTAL SERVICES 
Our interviews confirmed what the HCFA data show5--few children receive EPSDT dental 
services, and the extent of the problem varies significantly from State to State.  (See 
appendix A for a State-by-State breakdown of the 1993 data.)  In fact, HCFA data show 
that only 1 in 5 (4.2 million out of 21.2 million) eligible Medicaid children received 
preventive dental services in 1993.  This was a slight decrease from the 1992 data as 
shown in the following table: 
PERCENT OF EPSDT CHILDREN WHO RECEIVED

PREVENTIVE DENTAL SERVICES

BY AGE GROUP, 1992 AND 19936

All  < 1   1-5  6-14  15-20 
Year  Ages  Year  Years  Years  Years 
1992  22.0  0.3  18.1  33.7  22.2 
1993  19.7  0.4  16.0  30.0  19.5 
Also in 1993, three-fourths of the States provided preventive services to fewer than 
30 percent, and none of the States provided them to more than 50 percent of all eligible 
children.  Since some of the States only began using HCFAs dental prevention service 
codes in 1993, they may have under-reported the care actually given. 
The States statistics of children participating in the EPSDT program are unreliable, 
because States vary in what data they collect and report to HCFA.  A 1992 OIG inspection 
found that the screening and participant ratios used to measure States performance were 
inaccurate.7  Therefore, it is difficult to accurately assess States success in reaching and 
screening Medicaid children under EPSDT.  The HCFA has issued guidelines clarifying 
how to compute the screening and participant ratios more accurately, but no information is 
5For data collection purposes, HCFA defines preventive dental services as the unduplicated count of 
individuals who receive (1) instruction in self-care oral hygiene procedures, (2) a teeth cleaning, and 
(3) when appropriate, an application of dental sealants to prevent decay. 
6This table is based on data from HCFA reports on EPSDT program indicators for fiscal years 1992 and 
1993, the most recent years available. 
7Office of Inspector General, Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) --
Performance Measurement, OEI-07-90-00130. 
6  available to determine whether the guidelines are improving the accuracy and consistency 
of the reported data. 
THE REASONS FEW CHILDREN RECEIVE DENTAL CARE ARE COMPLEX 
Children do not receive preventive dental services for three basic reasons: 
few dentists serve Medicaid children,

Medicaid families give dental services a low priority, and

the youngest children are the most difficult to serve and frequently are not screened

at all.

Respondents report that few dentists serve Medicaid children 
Despite the paucity of data, approximately 80 percent of the States attribute the low 
utilization rate to the shortage of dentists who are willing to accept Medicaid patients.  In 
many communities, families and EPSDT staff have difficulty getting timely dental 
appointments for Medicaid children.  They often have to wait 6 to 8 weeks or travel long 
distances.  Even among the 9 States reporting an adequate supply of dentists, 5 provided 
preventive services for fewer than 20 percent of eligible children.  Although shortages are 
usually more severe in rural areas or isolated locations, 13 States report statewide 
shortages. 
States report that inadequate reimbursement is the most significant reason why dentists 
dont accept Medicaid patients.  Respondents in some States report that Medicaid fees do 
not even cover overhead costs, and dentists lose money on each patient served.  Despite 
this, reimbursement increases do not guarantee greater provider participation immediately. 
(See the discussion of increased reimbursement incentives on page 9.)  The OIG did not 
verify respondents assertions that Medicaid reimbursement is inadequate. 
Like other health care providers, dentists are dissatisfied with the complex Medicaid claims 
process, slow payments, arbitrary denials, and prior authorization requirements for routine 
services.  While many States have taken steps to streamline claims processing, dentists 
may not be aware of these reforms because of inadequate provider outreach.  Some 
respondents say that the small size of solo dental practices keeps many dentists from fully 
utilizing claims processing improvements such as electronic billing. 
Many dentists also have difficulty treating Medicaid families and young children.  They 
find that Medicaid families are more likely than others to break appointments at the last 
minute or not show up at all.  Dentists claim that because of office scheduling practices, 
missed appointments are a more serious problem for them than for most physicians. 
Dentists also claim that Medicaid families sometimes create difficulties in their offices, for 
example, when a parent brings three children in addition to the child with the appointment 
and allows them to play raucously and disrupt others in the waiting room.  Furthermore, 
many non-pediatric dentists are unwilling to treat young children, because these youngsters 
often take more time to examine than older patients and may require sedation. 
7  Head Start grantees also report increasing difficulty in obtaining dental services for their 
children.  Even though grantees eventually get a majority of their children examined and 
treated, their health directors have to spend more time and effort to accomplish this than in 
the past.  The enrollment of 3-year-old children has made many dentists reluctant to serve 
Head Start.  Grantees often transport children long distances to see a dentist because local 
dentists refuse to accept Medicaid.  Some grantees persuade a local dental clinic or 
individual dentist to block off half a day for their children or persuade a dentist and 
hygienist to come to the Head Start site.  A few grantees locate available dentists, but then 
insist that the parents themselves make and keep the appointments so they can learn 
responsibility.  When a dental emergency precludes waiting or travel, some grantees spend 
funds from their own budgets to pay for treatment. 
Medicaid families give dental services a low priority 
Respondents report that Medicaid families have competing family priorities, and many of 
them are unaware of the importance of good oral health.  Some States are increasing 
efforts to educate families, but they still give less attention to dental issues than to medical 
services such as immunizations.  The result is that families give a lower priority to dental 
care than to medical care. 
Medicaid families often miss appointments or forgo dental services.  Because dental 
services are not a priority, many families are unwilling to wait for appointments or make 
necessary travel or child care arrangements.  This increases the likelihood of missed 
appointments and failure to seek services.  Many families will not make an effort to see a 
dentist even though they might to see a physician.  Despite reminders and offers of 
transportation, beneficiaries often do not keep their appointments unless their children are 
in pain on the day of the appointment.  Because dental care is a low priority, families 
often fail to follow dentists instructions. 
The youngest children are the most difficult to serve and frequently are not screened 
Although the American Academy of Pediatric Dentists (AAPD) recommends that dentists 
examine all children before their first birthday, only a small fraction of Medicaid children 
receive these services.  Twenty States have adopted the AAPD standard, another 12 States 
recommend that screening begin during the second year, and the rest start screening at age 
3.  States will pay for screening if a parent suspects a problem and takes the child to a 
dentist, even if the child is younger than the States screening schedule specifies. 
Even States adopting the AAPD standard often are unable to find dentists who will 
examine and treat children who are less than 3 years old.  Non-pediatric dentists often are 
unfamiliar with the EPSDT program and are unsure of the protocol to follow in examining 
very young children.  Because of this, a few State EPSDT staff question whether States 
should consume resources trying to find a dentist to examine children under age 3 unless 
they are at high risk or the general medical screening identifies an oral health problem. 
8
 A few States are developing training programs and videotapes on techniques for detecting 
oral health problems of very young children.  These materials are primarily for general 
dentists and non-dental health care providers.  Dental experts in these and other States 
recognize the importance of careful oral examination in early infancy and oral health 
counseling to prevent conditions such as baby bottle tooth decay.  They believe that 
pediatricians and other non-dental personnel are more likely than dentists to screen 
children who are less than 3 years old.  They contend that with careful training non-dental 
health care providers are competent to detect oral health problems and refer children to 
dentists for diagnosis and treatment.  They hope to change some providers attitudes about 
oral examinations, such as the physician who liked to boast, "Oral exams are no problem. 
I look past the teeth to the tonsils." 
STATE, LOCAL, AND PRIVATE AGENCIES ARE EXPERIMENTING TO 
IMPROVE ACCESS AND UTILIZATION 
State and local governments and private agencies have begun initiatives to improve the 
participation of dentists in Medicaid and to encourage children and families to use dental 
services.  Their initiatives include: 
Increased reimbursement or other financial incentives 
In the past few years, more than half the States have increased dental reimbursement or 
taken steps to provide other financial incentives.  Fifteen States raised fees significantly, 
and another 11 by smaller amounts.  Several States are proposing additional financial 
incentives.  For example, Georgia legislators introduced a proposal to authorize State tax 
credits to dentists and other providers who agree to serve poor children. 
Preliminary data from a few States that have raised fees show that initially access and 
utilization do not increase proportionally.  Although Connecticut raised fees by 
80 percent, the overall increase in the number of services provided may not be substantial. 
California raised rates to 80 percent of the average amount billed in the previous year, but 
utilization still lags even though more dentists are available.  Costs for Medicaid dental 
services in California have gone from about $150 million in 1991 to a projected 
$750 million in 1995.  Other States report that fee increases have not been sufficient to 
bring fees close to the dentists usual and customary charges.  Several respondents note 
that dentists who drop Medicaid are frequently reluctant to return even if States raise fees 
or eliminate red tape. 
A few States have restricted coverage of some dental procedures and used the savings to 
increase payments for the rest.  For example, in response to a proposal from the State 
dental association, Indiana eliminated routine coverage for half of its childrens dental 
procedures and used the savings to increase fees for the remaining basic preventive and 
restorative services.  The State will still cover these procedures for EPSDT children when 
medically necessary, but at a lower rate and subject to prior authorization to justify 
medical necessity.  Other States have dropped or plan to drop most adult Medicaid dental 
services, some claiming this is necessary to keep childrens services fully funded. 
9  Managed care arrangements 
To facilitate access and contain costs, almost all the States are establishing managed care 
arrangements for Medicaid beneficiaries.  Only 22 States have set up some form of dental 
managed care, either statewide or pilot projects.  The rest either explicitly exclude dental 
services or have not yet decided because their plans are at a preliminary stage.  Those who 
are explicitly excluding dental services report they will reconsider at a future date.  Some 
States attempted to contract for dental managed care benefits but did not get any 
satisfactory bids because the fees they could pay were too low.  Respondents report that 
dentists resistance to managed care arrangements is a factor limiting implementation. 
Among the approaches States are using to acquire dental services under managed care 
plans are:  capitated risk plans, primary care case management, fee-for-service programs, 
and a mixture of capitation and fee-for-service.  None of these is mutually exclusive.  In 
some States, a physician serves as a gatekeeper to medical and dental services.  In Arizona 
and Tennessee, dentists contract with local or statewide health plans to provide services 
either through a capitated rate or a fee for service arrangement.  Illinois has a statewide 
contract with Delta Dental to provide all EPSDT services at a fixed price.  Several 
respondents are critical of plans that subcontract dental managed care arrangements 
through health plans, claiming that the extra administrative costs reduce funds available to 
dentists providing actual services and therefore limit access.  States are just beginning to 
develop monitoring procedures for dental services under managed care arrangements. 
Streamlined claims processing 
Nineteen States report taking recent steps to streamline claims processing, speed up 
payment, and reduce denials.  Many other States already have taken these steps.  States 
are: 
replacing HCFA claims forms with universal forms issued by the American Dental

Association (ADA),

removing prior authorization requirements,

reducing denials,

setting up electronic billing, and

speeding up payments.

New Mexico, for example, is adopting the ADA claims forms and will supply dentists with 
the software for electronic claims processing.  Florida has set up electronic billing but 
reports dentists are resistant to it.  Arizona eliminated most prior authorization 
requirements.  North Carolina worked with its dental association to establish use of ADA 
claims forms and electronic billing.  Some respondents praise State steps to streamline 
claims processing but maintain this factor will not significantly improve access if States do 
not also raise fees and help families to make and keep appointments. 
10
 Outreach and beneficiary education 
States report a wide range of new outreach and education efforts, either working directly 
with families or through dentists offices.  The Alaska Head Start dental initiative funds 
indigenous staff to provide oral health education and outreach to rural, remote Alaska 
native communities.  Illinois contracts with Delta Dental to educate beneficiaries about the 
importance of dental screening services.  Coupling Medicaid and private funding, New 
Hampshire established an access-to-care project to increase public and provider acceptance 
of Medicaid and EPSDT and to assure that every eligible child gets needed medical and 
dental services. 
Mandated provider participation 
A few States are mandating provider participation directly or through State plans for 
provider distribution.  Minnesota mandates that dentists treat Medicaid patients up to a 
specific threshold as a condition of participating as providers in health plans for State 
employees.  As part of a statewide health improvement initiative, Washington established a 
Health Personnel Resource Plan for regulating the supply and distribution of dentists and 
other health personnel. 
Training general dentists and non-dental health providers 
A few States have begun pilot projects to train non-pediatric dentists and non-dental health 
providers about pediatric oral health problems.  The Texas Medicaid program is developing 
a videotape for use by non-dental health workers who screen young children.  The video 
will explain techniques for adequate oral screening, describe necessary elements for oral 
health counseling, and specify that each child should be referred to a dentist if any decay 
or abnormality is found.  Washington is developing a pilot project to train non-pediatric 
dentists about new pediatric dental screening and treatment techniques.  With the 
University of Iowa pediatric dental department, Iowa established an educational task force 
to educate general dentists on pediatric dental issues and to assure that at least one dentist 
in each county is willing to examine year-old children.  Iowa has produced a monograph 
on childrens dental examinations and is reviewing data to determine how many children 
under age one dentists actually examine. 
Clinics for dental care 
Respondents from 20 States report efforts are under way to set up new dental clinics or 
expand existing ones to increase dental services available to Medicaid and other low-
income beneficiaries.  Expansion of dental clinic capacity is underway in a variety of clinic 
settings, including Federally Qualified Health Centers, hospital-based clinics, and clinics 
operated by State and local health departments.  In Delaware, for example, all Medicaid 
beneficiaries are served in State-operated clinics; almost no private practice dentists 
participate in Medicaid.  In Alabama, some local health or primary care clinics make a 
block of time available for dental services and treat clients on a first-come, first-served 
basis.  The New Mexico and Nevada legislatures decided to expand clinics to assure 
11  greater availability of dental services to low-income clients.  Some respondents point out 
that legislators and others see clinics as a way to expand or maintain services without 
significant dental fee increases. 
Voluntary efforts by dentists 
Several States, localities, and dental associations are encouraging dentists to serve their fair 
share of Medicaid children.  Starting about 1990, Californias Contra Costa County dental 
society and EPSDT staff began a "share-the-care" project.  Participating dentists agree to 
take one to three new Medicaid cases yearly or quarterly.  County EPSDT staff make the 
referrals and ensure that participating dentists receive no more patients than they have 
agreed to.  Other counties, not only in California but also in States such as Wisconsin, 
Colorado, and Texas, have started similar programs.  North Dakota encourages dentists to 
accept a fair share of Medicaid patients and may provide non-monetary public recognition 
through "exemplary service" awards.  Respondents report that while these voluntary 
programs are worthwhile, they usually reach only a small percentage of eligible children. 
While some States are planning to evaluate their projects, most do not yet have data to 
show whether they are effective.  A description of selected projects to improve access and 
utilization is contained in appendix B. 
12
 R E C O M M E N D A T I O N 

We recognize that there is significant legislation pending before Congress and the 
Administration that would alter the relationship between the Federal government and the 
States on matters discussed in this report.  Nonetheless, we believe the following 
recommendation and the options discussed for implementing it remain relevant under the 
current or future Federal-State relationship. 
THE DEPARTMENT SHOULD CONVENE A WORK GROUP THAT, AT A 
MINIMUM, WOULD INCLUDE HCFA, HRSA, ACF, OPHS, AND ASPE TO 
DEVELOP AN INTEGRATED APPROACH TO IMPROVE DENTAL ACCESS 
AND UTILIZATION FOR EPSDT ELIGIBLE CHILDREN 
With expanded membership, the existing PHS Oral Health Coordinating Committee 
Working Group could fulfill this need.  We suggest the work group consider the following 
issues: 
Should a special conference with State participants be convened to facilitate an 
exchange of ideas on existing and possible demonstrations, evaluation strategies, 
and dissemination protocols? 
Can a coordinated approach be developed to identify demonstration projects, grants, 
and other activities that would improve access and utilization? 
Are there ways to encourage professional volunteerism that would increase the 
availability of dentists to this underserved population? 
How can the Department support, promote, and improve education and outreach to 
Medicaid beneficiaries, their families, and the dental community? 
What incentives and demonstration projects can be developed or promoted at the 
State and local levels to increase provider participation? 
How can existing community organizations, many of which are supported by the 
Department, become involved in providing access to childrens dental services? 
13
 A G E N C Y   C O M M E N T S 

We received comments on the draft report from the Assistant Secretary for Health, the 
Centers for Disease Control and Prevention, the National Institutes of Health, HRSA, and 
HCFA.  Both the Assistant Secretary for Health and the National Institutes of Health 
suggested that the existing PHS Oral Health Coordinating Committee Working Group, with 
expanded membership, could adequately address our recommendation and obviate the need 
for a new Departmental work group.  We agree that this is a viable alternative and have 
amended our recommendation accordingly. 
We also would like to draw the readers attention to the full text of the comments, which 
is contained in appendix C.  In addition to some technical comments, they provide 
valuable information concerning issues that are not discussed in our report as well as other 
activities that the Department has undertaken to address childrens oral health. 
14
 A P P E N D I X   A

NUMBER AND PERCENT OF CHILDREN WHO RECEIVED

EPSDT PREVENTIVE DENTAL SERVICES

IN 1993, BY STATE1

STATE  NUMBER OF  NUMBER  PERCENT 
EPSDT  WHO RECEIVED  OF 
ELIGIBLE  PREVENTIVE  ELIGIBLES 
CHILDREN  SERVICES 
Connecticut  193094  52543  27.2 
Maine  106828  36819  34.5 
Massachusetts  404857  139414  34.4 
Rhode Island  66136  21003  31.8 
New Hampshire  40011  17905  44.8 
Vermont  52251  17636  33.8 
Region I Total  863177  285320  33.1 
New Jersey  447272  101410  22.7 
New York  1585786  283453  17.9 
Region II Total  2033058  384863  18.9 
Delaware  50585  6283  12.4 
Maryland  229146  33129  14.5 
Pennsylvania  880017  185289  21.1 
Virginia  328090  64718  19.7 
District of Columbia  73837  11800  16.0 
West Virginia  135594  41452  30.6 
Region III Total  1697269  342671  20.2 
Alabama  279138  31369  11.2 
Florida  1355013  222493  16.4 
Georgia  643424  161496  25.1 
Mississippi  470032  56843  12.1 
Kentucky  293083  27604  9.4 
North Carolina  550567  75794  13.8 
South Carolina  302471  37876  12.5 
Tennessee  534231  129886  24.3 
Region IV Total  4427959  743361  16.8 
1This table is based on data from the HCFA-416 performance report on EPSDT 
program indicators for fiscal year 1993. 
A - 1   Illinois  1027303  214810  20.9 
Indiana  345751  144005  41.6 
Michigan  823052  215885  26.2 
Minnesota  291466  73539  25.2 
Ohio  948612  216584  22.8 
Wisconsin  342664  77103  22.5 
Region V Total  3778848  941926  24.9 
Arkansas  207085  35062  16.9 
Louisiana  498389  128199  25.7 
New Mexico  133524  8290  6.2 
Oklahoma  162598  30949  19.0 
Texas  1330465  160284  12.0 
Region VI Total  2332061  362784  15.6 
Iowa  169516  56210  33.2 
Kansas  113286  40106  35.4 
Missouri  403702  86619  21.5 
Nebraska  102285  34267  33.5 
Region VII Total  788789  217202  27.5 
Colorado  210749  44305  21.0 
Montana  57019  5119  9.0 
North Dakota  32799  2625  8.0 
South Dakota  47702  8543  17.9 
Utah  123966  19186  15.5 
Wyoming  34976  15157  43.3 
Region VIII Total  507211  94935  18.7 
Arizona  413100  1153  0.3 
California  3583936  601451  16.8 
Hawaii  68008  503  0.7 
Nevada  34845  5010  14.4 
Region IX Total  4099889  608117  14.8 
Alaska  51691  14468  28.0 
Idaho  71269  14967  21.0 
Oregon  206524  71661  34.7 
Washington  304257  89128  29.3 
Region X Total  633741  190224  30.0 
TOTAL  21162002  4171403  19.7 
A - 2 
 A P P E N D I X   B 
STATE AND LOCAL INITIATIVES TO IMPROVE 
DENTAL SERVICES FOR CHILDREN 
INTRODUCTION  B-2

BENEFICIARY ACCESS, EDUCATION, AND OUTREACH 
Alaska Head Start Collaboration Projects Dental Initiative  B-2

Illinois Statewide Dental Contract  B-3

Maryland Head Start Collaboration Projects Dental Initiative  B-4

Michigan Projects to Improve Dental Access  B-4

New Hampshire Access to Care Project  B-5

Washington Oral Health Improvement Plan  B-5

PROVIDER PARTICIPATION 
California Dental Access Program  B-6

Delaware Clinic Program  B-7

Georgia Tax Credit  B-7

Indiana Dental Procedure Priorities  B-8

Minnesota Medicaid Provider Mandate  B-8

New Mexico Patient Management Assistance  B-9

North Carolina Clinic Program  B-9

Wisconsin Access and Utilization Initiatives  B-10

Wisconsin Fee Increases  B-10

Contra Costa County (CA) "Share-the-Care" Dental Access Project  B-11

PROVIDER TRAINING AND EDUCATION 
Iowa Pediatric Dental Education Program  B-12

Texas Oral Health Video Project  B-12

Spokane (WA) Dental Prevention Project  B-13

B - 1 
 INTRODUCTION 
The activities described in this appendix are representative of initiatives to improve 
childrens access to and utilization of dental services.  Some are designed to increase the 
supply of available dentists by increasing fees or reducing red tape, while others are 
designed to help families with access, education, and outreach or to train professionals. 
Some were initiated by State Medicaid or public health agencies and others by professional 
and community organizations in cooperation with the States. 
The listing is not a complete catalog of all State or local initiatives or a complete 
description of each project.  More detailed information can be obtained from the contact 
person listed. 
This listing does not constitute an OIG endorsement of any of the initiatives.  While some 
States or other entities are planning to evaluate these projects, most do not yet have data to 
show whether they are effective. 
BENEFICIARY ACCESS, EDUCATION, AND OUTREACH 
Alaska Head Start Collaboration Projects Dental Initiative 
The Alaska Head Start Health Improvement Initiative, which began in 1991, is designed to 
improve the dental health of children living in remote Alaskan villages across the State. 
Native Alaskan children have one of the highest rates of tooth decay in the United States. 
This is a result of factors such as infrequent and intermittent access to care, detrimental 
nutrition patterns, and child rearing traditions that do not include oral hygiene. 
Historically, Head Start programs serving rural Alaska communities have not been able to 
comply with the dental screening standard. 
The project (1) established a provider network of culturally-sensitive dentists who travel to 
the villages to screen and treat children and (2) trained community staff in the villages to 
provide oral health education and outreach to children and families.  While the target 
population is primarily native Alaskan children, the project includes all Medicaid-eligible 
children from birth to age 6. 
The State Medicaid agency, the tribal health corporation in Nome, the State Head Start 
Association, and the State dental association have formed a coalition to work with the 
project and seek its continuation.  The project will attempt to generate data showing that 
village-based care is cost effective and will distribute a manual for providers and others 
seeking to set up similar networks. 
B - 2 
 For more information contact: 
Sally Mead, Director

Alaska Head Start Health Improvement Initiative

Prevention Associates

101 East 9th Avenue, Suite 10B

Anchorage, AK  99501

907-272-6925

Illinois Statewide Dental Contract 
Beginning in 1992, Illinois contracted for a fixed price with the Delta Dental Plan of 
Illinois to provide all EPSDT dental services statewide, including outreach, oral health 
education, screening, follow-up treatment, and tracking the children and families to assure 
they get the required services.  Delta contacts all families who have children between the 
ages of 3 to 20 who have not been screened in the past year.  Names and addresses are 
also provided to the local EPSDT offices for follow-up.  Other outreach efforts include 
press releases, public service announcements, and messages about dental services targeted 
to specific communities.  Delta will refer families to dentists and make appointments, if 
necessary, for the initial screening or follow-up treatment. 
Delta contracts with dentists, paying a fee based on the dentists usual and customary 
charges.  Delta also contracts with schools, health centers, and other clinics to make 
dentists available for group screenings and preventive services.  A Delta manual specifies 
provider responsibilities and a protocol for screening in schools. 
The contract requires Delta to provide services to at least one-half of the EPSDT-eligible 
children in Illinois.  Delta must assure that screening goals are met, screening results are 
recorded, and referrals for treatment are issued.  The State conducts compliance reviews 
and fiscal audits. 
For more information contact: 
Michael Berger, Vice President  Deborah Saunders, Coordinator 
of Government Programs  Illinois Department of Public Aid 
Delta Dental Plan of Illinois  201 South Grand Avenue, East 
2001 Butterfield Road, Suite 900  Springfield, IL  62763-0001 
Downers Grove, IL  60515  217-524-7163 
708-964-2400 
B - 3 
 Maryland Head Start Collaboration Projects Dental Initiative 
The Maryland Head Start Collaboration Project was initiated in 1993 to eliminate barriers 
to health care for Head Start children.  To identify problems and develop statewide 
solutions, the project formed a coalition of representatives from public and private 
agencies.  The project is part of the governors office and, because of its location, project 
staff not only work closely with the Medicaid program but also have access to State 
policymakers. 
One of the projects early initiatives was to survey Head Start grantee staff.  The survey 
found that 38 percent of grantees have difficulty obtaining dental care for their children. 
According to grantees, only about 12 percent of dentists in their areas accept Medicaid. 
As a result of the survey, the project is recommending early outreach and oral health 
education for parents and children. 
Recruiting dentists for Medicaid has been very difficult largely because the Maryland 
Medicaid program pays lower fees than almost any other State.  The project will initiate a 
survey to clarify dentists concerns about reimbursement and other issues.  The survey will 
ask about dentists problems with the claims process and about difficulties they may have 
in examining and treating young children.  Staff will work with Medicaid, other State 
agencies, and dentists to determine appropriate solutions.  The project will then undertake 
educational efforts to encourage more dentists to treat 3- and 4-year-olds. 
For more information contact: 
Gayla Sanders, Head Start Collaborator

Division of Policy and Planning

Governors Office for Children, Youth, and Families

301 West Preston Street, 15th Floor

Baltimore, MD  21201

410-225-4160

Michigan Projects to Improve Dental Access 
Michigan funded eight oral health outreach projects in 1994 as part of its "Healthy Kids" 
program.  The projects include such initiatives as: 
 utilizing mobile dental vans and portable equipment, 
 establishing county dental clinics, 
 coordinating efforts with schools regarding dental hygiene education, and 
 improving data collection and dissemination. 
Michigan formed a statewide oral health coalition to help generate legislative support for 
these projects and for other oral health improvement activities. 
B - 4 
 For more information contact: 
Christine Cascaddan, Senior Policy Analyst

Medical Services Administration

Michigan Department of Social Services

Bureau of Policy and Management Information

400 South Pine Street

P.O. Box 30037

Lansing, MI  48909

517-335-5129

New Hampshire Access to Care Project 
New Hampshire established the Access to Care Project in 1992 to increase public 
acceptance of Medicaid and EPSDT and to insure that every eligible child receives needed 
medical and dental services.  The project is jointly sponsored by the State Medicaid 
program, the New Hampshire Alliance for Children, and the New Hampshire Pediatric 
Society.  Funding is provided by the Jessie B. Cox Charitable Trust in Boston and matched 
with New Hampshire Medicaid funds. 
The project (1) seeks support from the general public for increased childrens services 
through outreach and education about EPSDT, (2) insures that all eligible children have a 
primary care physician to serve as an oral health advocate for the child and family in 
addition to providing other care, and (3) explains EPSDT mandates and benefits to dentists 
and other health professionals and persuades them to participate. 
For more information contact: 
Carol Currier, Administrator

Division of Human Services

Office of Medical Services

6 Hazen Drive

Concord, NH  03301-6521

603-271-4350

Washington Oral Health Improvement Plan 
In 1993, Washington enacted the Public Health Improvement Plan to improve general 
health status in Washington through prevention and improved public health services 
capacity.  Among other goals, the plan seeks to ensure universal access to needed health 
services for all State residents.  Oral health is a key component of the health improvement 
initiative.  The oral health component emphasizes that lack of access to dental care is at 
crisis levels, especially for low income and Medicaid-eligible children.  Because of the 
lack of early preventive care and family education, hospital emergency rooms are handling 
cases of baby bottle tooth decay with charges up to $3000 per child.  The Oral Health 
B - 5 
 Improvement Plan has developed several strategies to address these problems.  They 
include: 
 programs to screen children in the first year of life, 
 universal dental screening of school children, 
 increasing Medicaid dental fees, 
 training non-dental medical professionals to recognize oral health problems, 
 innovative interventions to prevent caries in infants and young children, and 
 increasing families willingness to see dentists by getting parents to understand that 
dental care is as important as medical care. 
One goal of the plan has been to sensitize doctors and nurses to begin to see dental issues 
in a medical framework.  State dental staff say that getting health professionals to think of 
dental caries as a preventable infectious disease fits very well into their medical 
orientation.  This also fits into the University of Washington dental schools program to 
educate health professionals and make them more responsive about oral health issues.  For 
example, staff designed an oral health training program for public health nurses so the 
nurses understand how to integrate oral health into their public health work.  Ultimately, 
the State believes this understanding will result in better access to dentists and earlier 
intervention with dental problems. 
For more information contact: 
Elizabeth Hines, Oral Health Service Administrator

Community and Family Health

Washington Department of Health

P.O. Box 47880

Olympia, WA  98504-7880

360-753-5423

PROVIDER PARTICIPATION 
California Dental Access Program 
Beginning in 1992, the California EPSDT program conducted a statewide dental access 
improvement program which resulted in 40 county volunteer dental coalitions and the wide 
distribution of dental access resource manuals.  The project established 9 regional 
workshops which were attended by more than 700 individuals representing private practice 
dentists, local public health programs, community clinics, professional organizations, 
universities and others concerned about childrens oral health issues.  Community dental 
providers were introduced to their county EPSDT program, Head Start, and other local 
childrens programs. 
The local coalitions developed specific strategies and activities for improving access to 
dental care in their respective communities.  The most widespread strategy has been the 
B - 6   establishment of volunteer share-the-care programs similar to those started in Contra Costa 
and other counties.  Some coalitions have become involved with preventive strategies 
including baby bottle tooth decay, community water fluoridation campaigns, and the 
planning of community health fairs. 
For more information contact: 
Renee Nolte-Newton, Dental Hygienist Consultant

Childrens Medical Services Branch

California Department of Health Services

714 P Street, Room 400

Sacramento, CA  95814

916-653-4860

Delaware Clinic Program 
Because almost none of Delawares approximately 400 private practice dentists participate 
in Medicaid, nearly all EPSDT dental services are provided through clinics.  For some 
years, the State has provided dental services to approximately 50,000 EPSDT-eligible 
children in 8 public health clinics.  The State pays each clinic a monthly fee of $111 for 
each enrolled child to cover all medical and dental services.  Each clinic is staffed with 
one dentist and one assistant.  For specialized care, the clinic may refer children to a 
pediatric dentist and pay fee-for-service rates.  In addition to the clinics, a few hospitals 
and a community college employ dentists who provide Medicaid services. 
For more information contact: 
David Mihalik, Social Service Senior Administrator

Delaware Department of Health and Social Services

1901 North DuPont Highway

New Castle, DE  19720

302-577-4900

Georgia Tax Credit 
Georgia legislators introduced a proposal in 1995 (House Bill LC-10-0948) to authorize 
State tax credits to dentists and other providers who agree to serve poor children.  The bill 
would have given a credit of $50 against State income taxes due from physicians or 
dentists for each indigent patient treated in a public clinic and from whom no 
compensation is received.  Providers could carry forward indefinitely unused credits.  The 
proponents of the legislation believe that the amount of the credit is enough to partially 
overcome losses for treating indigent patients, but it is not high enough to cause providers 
to substitute non-paying for paying patients.  The bill was not passed in 1995, but 
legislators plan to re-introduce it in the 1996 legislative session. 
B - 7 
 For more information contact: 
Tim Burgess, Director

Office of Planning and Budget

254 Washington Street SW, Suite 614

Atlanta, GA  30334

404-656-3820

Indiana Dental Procedure Priorities 
In 1995, to retain participation of dentists in the EPSDT program, Indiana eliminated many 
adult dental services and reduced the number of childrens procedures that will be 
reimbursed routinely.  With the savings, the State increased fees for the remaining 
procedures which are the most important preventive and restorative services for children. 
The State will continue to cover all procedures deemed medically necessary for EPSDT 
children but will require prior authorization and pay only current rates for any procedures 
that have been eliminated for adults.  These actions were based on discussions with and 
recommendations from the State dental association. 
For more information contact: 
Carol Gable, Consultant

Office of Medicaid Policy and Planning

Indiana Family and Social Services Administration

402 West Washington Street, Room W382

Indianapolis, IN  46204

317-232-2091

Minnesota Medicaid Provider Mandate 
In 1994, Minnesota enacted legislation (Rule 101) requiring that dentists and other 
providers treat Medicaid beneficiaries as a condition of participation in health insurance 
and workers compensation plans for State employees.  Minnesota EPSDT staff believe 
that Rule 101 has improved childrens access to dental services by increasing the supply of 
available dentists. 
Rule 101 requires that providers accept new Medicaid patients on a continuing basis, using 
the same acceptance criteria they would use for non-Medicaid patients, up to a threshold of 
20 percent.  If a providers active Medicaid patient case load exceeds 20 percent, the 
provider may refuse to accept new beneficiaries.  The rule includes a formula for 
determining this threshold.  The formula includes such factors as active patient caseload, 
number of patient visits, and length of time enrolled as a Medicaid provider.  Providers 
must notify the State when they have reached the threshold and will not take new 
Medicaid patients. 
B - 8 
 For more information contact: 
Lawrence D. Grewach, Manager

Dental Demonstration Project

Minnesota Department of Human Services

444 Lafayette Road, 6th Floor

St. Paul, MN  55155

612-296-1481

New Mexico Patient Management Assistance 
New Mexico worked closely with its State dental association in 1994 and 1995 to 
streamline claims processing and help dentists better manage Medicaid families and 
children.  For example, as part of a training program on improving claims processing, New 
Mexico offered suggestions to dentists on how to manage young children in the dental 
office.  State officials also are seeking to allow dentists who participate in this training to 
receive continuing education credits. 
For more information contact: 
Dr. Ken Padilla, Planner

Ambulatory Care Section

Medical Assistance Division

New Mexico Human Services Department

P.O. Box 2348

Santa Fe, NM  87504-2348

505-827-3177

North Carolina Clinic Program 
North Carolina is enabling local health departments and other clinics to contract with local 
dentists for EPSDT services.  In some localities, State staff believe this is the only way to 
assure the availability of dental services for EPSDT-eligible children.  The State clinic 
program also will improve access for Head Start programs and initiate or expand dental 
services in rural, community, and migrant health centers.  By enlisting the support of local 
dental societies, the State is hoping to attract dentists who might otherwise not participate 
to work full or part time in the clinics. 
For more information contact: 
Dr. C. Jean Spratt, Director

Division of Dental Health

North Carolina Department of Environment, Health and Natural Resources

P.O. Box 27687

Raleigh, NC  27611

919-733-3853

B - 9   Wisconsin Access and Utilization Initiatives 
In 1993, the Wisconsin Dental Association, in cooperation with State Medicaid and dental 
public health staff, initiated projects to help dentists deal with problems such as "no-show 
patients."  By alleviating such problems, dentists may be more willing to participate in the 
EPSDT program. 
To formulate recommendations, the dental association and the State formed a task force of 
Medicaid staff and dentists who provide EPSDT services.  The task force interviewed 
dentists and their support staff and developed suggestions to deal with "no-show patients." 
The suggestions include: 
 mailing reminders to patients and following up with phone calls a day in advance; 
 requiring patients to call the office and confirm their appointment 24 hours in advance 
or their appointment will go to someone else; 
 explaining why keeping appointments is important; 
 setting aside a specific block of time or certain days for Medicaid patients and treating 
patients on a first-come, first-served basis during those times; and 
 letting patients know where they can get help with transportation or child care so they 
can keep appointments. 
The dental association has prepared an informational pamphlet describing these suggestions 
and others.  Other informational materials describe county dental society clinic and 
volunteer programs in Wisconsin. 
For more information contact: 
Maryann Dillon, Director of  Dr. Warren LeMay, Oral Health Consultant

Dental Services  Bureau of Public Health

Wisconsin Dental Association  Division of Health

111 East Wisconsin Avenue,  1414 East Washington Avenue

Suite 1300  Madison, WI  53703

Milwaukee, WI  53202  608-266-5152

414-276-4520 
Wisconsin Fee Increases 
In addition to general dental fee increases over the past few years, which have raised 
payments to approximately 61 percent of Statewide average charges, Wisconsin was paying 
a $3.50 "bonus payment" for 20 dental procedures most frequently performed on children 
under 21.  Beginning in 1995, these additional payments have been folded into a further 
fee increase which applies only to claims for EPSDT services.  These fees are now set at 
B - 10  approximately 75 percent of average charges.  In part, these increases were possible 
because of the States decision to eliminate some adult dental benefits and hold the line on 
increasing fees for non-EPSDT dental services. 
For more information contact: 
Dr. Warren LeMay, Oral Health Consultant

Bureau of Public Health

Division of Health

1414 East Washington Avenue

Madison, WI  53703

608-266-5152

Contra Costa County (CA) "Share-the-Care" Dental Access Project 
In 1990, the county dental society and the EPSDT staff in Contra Costa County, 
California, initiated a voluntary "share-the-care" project.  Participating dentists agree to 
take one to three new EPSDT cases, with the understanding that they will not be put on a 
list requiring them to see all referred children.  County EPSDT staff insure that 
participating dentists receive no more patients than they have agreed to treat.  Some 
dentists choose to bill Medicaid for services; others treat without charge. Some low-income 
patients who are not eligible for Medicaid are included. 
County staff provide education and outreach to insure that patients keep their 
appointments.  Staff schedule initial appointments and provide transportation and 
translation, if needed.  They instruct families about proper hygiene and behavior in the 
dentists office and strive to overcome any fear of dentists on the part of children or their 
parents.  Some dentists will drop a family for breaking an appointment without calling to 
cancel.  The Contra Costa program claims to have an 85 percent "kept-appointment" rate. 
County staff and the dental association continue to support the Contra Costa program.  It is 
a model.  Similar programs have been established in other counties in California and in 
other States, such as Colorado and Wisconsin. 
For more information contact: 
Robert Isom, Deputy Director
 Dr. Colleen Zimmer 
Child Health and Disability Prevention Program
 1004 McHugh Street 
Contra Costa County
 Fort Collins, CO  80524 
595 Center Avenue, Suite 310
 303-221-4500 
Martinez, CA  94553

510-313-6150

B - 11
 Maryann Dillon, Director of Dental Services

Wisconsin Dental Association

111 East Wisconsin Avenue, Suite 1300

Milwaukee, WI  53202

414-276-4520

PROVIDER TRAINING AND EDUCATION 
Iowa Pediatric Dental Education Program 
Staff from State Medicaid and dental public health programs are collaborating with the

pediatric dentistry department of the University of Iowa to develop training programs for

general practitioners.  They plan to (1) train dentists about pediatric dental issues,

(2) determine how many dentists currently screen children under 3 years of age, and

(3) produce a monograph about what should be included in a childs first dental exam.

The State will establish panels of dentists who are willing to treat very young or disabled

children.  Iowas EPSDT screening schedule specifies an initial screening at 12 months of

age, but parents in many communities find that few dentists are willing to examine

children that young.  In addition, few dentists are willing to serve children with disabilities.

The State has established a panel of dentists who are willing to treat disabled children and

hopes to set up a similar panel of dentists who are willing to see children before their first

birthday.  Among other methods to improve access for this age group, the State will (1)

conduct a survey to find out how many children are screened before their first birthday, (2)

assess dentists attitudes about treating young children, and

(3) locate dentists willing to staff Iowas 25 child health clinics.

For more information contact: 
Dr. William C. Maurer, Chief

Dental Health Bureau

Iowa Department of Public Health

Lucas State Office Building

Des Moines, IA  50319-0075

515-281-4916

Texas Oral Health Video Project 
In 1995, the Texas Medicaid program began developing a videotape about oral health 
examinations for use by non-dental health workers who screen young children.  The video 
will describe techniques for adequate oral screening, explain what should be included in 
oral health counseling, and specify that children should be referred to dentists if decay or 
abnormalities are found.  To prepare the videotape, Texas staff consulted with the pediatric 
dental department of the University of Washington and others. 
B - 12
 For more information contact: 
Dr. Nana Lopez, Chief 
Bureau of Dental Services 
Texas Department of Health 
1100 West 49th Street 
Austin, TX  78756 
512-458-7323 
Spokane (WA) Dental Prevention Project:  "Access to Baby and Child Dentistry" 
Spokane, Washington is the site of a demonstration project that (1) provides dental 
prevention services to young, at-risk children from birth through age 5 and (2) trains 
dentists on recent developments in pediatric dentistry.  Initiated in 1995, the project 
established a coalition of pediatric dentists from the University of Washington dental 
school, dentists in Spokane, and State Medicaid and dental public health staff.  The project 
will: 
 screen, diagnose and treat the children, 
 provide family oral health education, 
 calculate the direct costs and cost savings derived from the preventive program, 
 study factors that determine childrens utilization of dental services, 
 determine if improved access changes parents attitudes so that they will visit dentists 
more frequently, and 
 assess the cost effectiveness of a new technique to provide fluoride varnish. 
Pediatric dentists from the dental school will train participating dentists in recent pediatric 
dental techniques.  According to project staff, training is needed because most general 
practitioners lack pediatric dental knowledge.  The Washington Department of Health 
Services will pay participating Spokane dentists higher fees than dentists get for similar 
services in the rest of the State. 
Although the project will cost the State an estimated $3 million, project staff hope to 
demonstrate significant cost benefits.  The project has submitted an application to the 
National Institute of Dental Research to fund a 4-year cost benefit and utilization study. 
For more information contact: 
Dr. Peter Milgrom, Director  Elizabeth Hines, Oral Health Service

Dental Fears Research Clinic  Administrator

Dental Public Health Sciences  Community and Family Health

University of Washington School  Washington Department of Health

of Dentistry  P.O. Box 47880 
Box #357475  Olympia, WA  98504-7880 
Seattle, WA  98195  360-753-5423 
206-685-2453 
B - 13  A P P E N D I X   C

AGENCY COMMENTS

C - 1 
 C - 2 
 C - 3 
 C - 4 
 C - 5 
 C - 6 
 C - 7 
 C - 8 
 C - 9 
 C - 10
 C - 11
 C - 12
 C - 13