Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
M C W
  OST  HILDREN  ITH 
 
M F S
E DICAID IN  OUR  TATES 
A N R
RE  OT  ECEIVING 
R D S
EQUIRED  ENTAL  ERVICES 
 
Suzanne Murrin 
Deputy Inspector General for 
Evaluation and Inspections 
   
  January 2016 
  OEI-02-14-00490 
         
EXECUTIVE SUMMARY:  MOST CHILDREN WITH MEDICAID IN FOUR STATES 
ARE NOT RECEIVING REQUIRED DENTAL SERVICES  
OEI-02-14-00490 
 
WHY WE DID THIS STUDY 
Medicaid is the primary source of dental coverage for children in low-income families and 
provides access to dental care for approximately 37 million children.  However, access to dental  
care for children with Medicaid has been a longstanding concern.  When children lack dental 
care, untreated decay and infection in their mouths can result in preventable emergency room  
visits or more complicated and expensive dental and medical interventions later in life.   
Medicaid provides dental services to children through the Early and Periodic Screening, 
Diagnostic, and Treatment program.  Under this program, States are required to cover all 
medically necessary dental services and these services must be provided at the intervals specified  
in States pediatric dental periodicity schedules.  
 
HOW WE DID THIS STUDY  
This study focuses on four States: California, Indiana, Louisiana, and Maryland.  We analyzed 
Medicaid dental claims with service dates in 2011 and 2012, analyzed Medicaid beneficiary 
enrollment files, and conducted structured interviews with State officials.  We focused our 
analysis on three required dental servicesbiannual oral exams, dental cleanings, and fluoride 
treatmentsfor children continuously enrolled in Medicaid for 2 years.   
 
WHAT WE FOUND 
We found that three out of four children did not receive all required dental services, with one in 
four children failing to see a dentist at all.  All four States reported that they do not routinely 
track whether children are receiving all the required services.  In addition, two of the four States 
had policies that do not allow payment for particular services in accordance with their periodicity 
schedules. The States we reviewed reported facing shortages of participating dental providers 
and challenges in educating families about the importance of regular dental care.  While the 
States reported that they employ a variety of strategies to address these problems and the Centers 
for Medicare & Medicaid Services (CMS) has taken some positive steps in this area, we continue 
to have concerns that children are not receiving required dental services. 
 
WHAT WE RECOMMEND  
We provided CMS with eight recommendations designed to monitor and ensure that children 
with Medicaid receive all of their EPSDT required dental services.  Specifically, CMS should 
(1) develop a comprehensive plan to increase the number of children who receive required 
services; (2) develop benchmarks for dental services and require States to create mandatory 
action plans to meet them; (3) work with States to identify areas with limited providers and the 
barriers preventing providers from participating in Medicaid; (4) work with States to analyze the 
effects of Medicaid payments on access to dental providers; (5) work with States to educate 
families about the importance of dental care and to encourage ongoing relationships between 
children and their dentists; (6) work with States to track childrens utilization of required dental 
services; (7) identify and share effective strategies with States; and (8) ensure that States pay for 
services in accordance with their periodicity schedules.   
   
CMS concurred either fully or partially with all but one of our recommendations.  With regard to 
our sixth recommendationwith which CMS did not concurCMS does not agree that it is 
necessary to require additional data on dental services beyond the data collected on Form 
CMS-416. With regard to our second recommendationwith which CMS partially concurred 
CMS does not agree that it is necessary to require mandatory action plans for meeting 
benchmarks for dental services.  Also, in response to the first recommendation, CMS argued that 
childrens dental services are not one size fits all and that a child who receives an exam may 
not need a second one during the year. While we agree that services should be customized, we 
do not agree that children with Medicaid should receive services less frequently than at the 
minimum frequency set by States in their periodicity schedules, which for the four States we 
reviewed is twice per year. 
   
   
TABLE OF CONTENTS 
 
Objectives ....................................................................................................1 

Background..................................................................................................1 

Methodology................................................................................................4 

Findings........................................................................................................6 

In the four States we reviewed, 78 percent of children did not                       

receive required dental services .......................................................6 

Two of the four States had coverage policies that may limit             

childrens ability to receive the required services ............................8 

The States we reviewed reported facing a shortage of               

participating dentists and challenges in educating families about                          

the importance of regular dental care ...............................................9 

Conclusion and Recommendations ............................................................12 

Agency Comments and Office of Inspector General Response .....15 

Appendixes ................................................................................................18 

A: Detailed Data Sources and Analysis ........................................18 

B: Percentages of Children Who Did Not Receive Required                

Dental Services ..............................................................................21 

C: Percentages of Children Who Did Not Receive All Required                

Dental Services ..............................................................................23 

D: Agency Comments ...................................................................24 

Acknowledgments......................................................................................29
 
   
OBJECTIVES 
1. 	  To describe the extent to which children enrolled in Medicaid in four 
States received pediatric dental services in 2011 and 2012.  
2. 	  To describe barriers and strategies to increase access in these States.  
BACKGROUND 
Tooth decay is one of the most common chronic diseases of children.  The 
disease is almost entirely preventable through a combination of good oral 
health habits at home, a healthy diet, and early and regular use of 
preventive dental services. 
Medicaid is the primary source of dental coverage for children in 
low-income families, providing coverage to approximately 37 million 
children.1  However, access to dental care for children with Medicaid has 
been a longstanding concern. According to a Government Accountability 
Office (GAO) report, millions of children with Medicaid are estimated to 
be living with untreated tooth decay and other dental issues.2 In addition, 
the report found that inadequate receipt of services is a significant problem 
for children in Medicaid. 
A lack of access to dental care can lead to serious health consequences.  
Preventable dental conditions were the primary cause of more than 
850,000 emergency room visits in 2009.3  Notably, in 2007 the family of a 
12-year-old Maryland boy with tooth pain was unable to find a Medicaid 
dentist who would treat him.  The family eventually sought treatment for 
the boy in an emergency room, but ultimately he died.  Untreated dental 
disease has also been linked to various health issues such as ear and sinus 
infections, weakened immune systems, diabetes, and heart disease.4     
Medicaid Coverage for Childrens Dental Services 
Medicaids Early and Periodic Screening, Diagnostic, and Treatment 
(EPSDT) benefit requires States to cover all medically necessary dental 
services for children 18 years of age and under, and States may choose to 
____________________________________________________________ 
1 Thomas P. Wall, Dental Medicaid2012, American Dental Association  (ADA), 2012.  
Centers for Medicare & Medicaid Services (CMS), Annual EPSDT Participation Report, 
Form CMS-416 (National), Fiscal Year 2012, April 3, 2014. 
2 GAO,  Extent  of Dental  Disease in Children Has Not  Decreased, and Millions Are  
Estimated to Have Untreated Tooth Decay, GAO-08-1121,  September 2008. 
 
3 The Pew Charitable Trusts, A Costly Dental  Destination:  Hospital Care Means  States 

Pay Dearly, February 28, 2012. 

4 The Kaiser Family Foundation,  Children and Oral Health:   Assessing Needs, Coverage, 

and Access, June 2012. 
   
Most Children With Medicaid in Four States Are Not  Receiving Required Dental Services (OEI-02-14-00490)   1    
extend this benefit up to age 20. 5 Medically necessary services include a 
variety of services intended to prevent tooth decay and dental disease.  The 
benefit covers diagnostic and preventive services, as well as needed 
treatment and follow-up care.  Diagnostic services include oral exams and 
x-rays of the mouth; preventive services include cleanings, topical fluoride 
treatments, and dental sealants.  Dental treatment covers a wide range of 
services, such as fillings and tooth extractions.  
The Social Security Act requires that EPSDT dental services be provided 
both (1) at intervals that meet reasonable standards of dental practice and 
(2) at other intervals as indicated by medical necessity.6  Further, CMS 
states in its State Medicaid Manual that [d]ental services must be 
provided at intervals [that States] determine meet reasonable standards of 
dental practice.7   To establish these standards of dental practice, each 
State must develop a dental periodicity schedule in consultation with 
recognized dental organizations involved in child health.  In lieu of 
developing their own periodicity schedules, States may choose to adopt a 
nationally recognized periodicity schedule, such as the one developed by 
the American Academy of Pediatric Dentistry (AAPD).  
The four States in our study adopted the AAPD periodicity schedule.  This 
schedule recommends that children receive a number of services at a 
minimum of every 6 months to maintain oral health.  These services 
include oral exams, dental cleanings, and fluoride treatments, among other 
services. 
The Dental Home 
The AAPD and the American Dental Association (ADA) define a dental 
home as an ongoing relationship between a child and a dentist that 
includes all aspects of oral health care delivered in a comprehensive and 
continuously accessible way.8   According to the AAPD and ADA, a dental 
home assures continuity of care and assures that appropriate referral to 
dental specialists occurs when care cannot directly be provided by the 
dental home.  They recommend that a child have a dental home no later 
than 1 year of age. Several studies found that dental visits at a very young 
age can improve health outcomes and reduce future dental costs.9 
 ____________________________________________________________ 
5 Social Security Act (SSA)  1905(r)(3); 42 CFR   441.56.  All four  States reviewed in 

this report  provide coverage to children up to  20 years of age.  California allows 

Medicaid coverage to continue until the last day of the month in  which the child turns 21.  

See California Code of Regulations  22 CCR   50193.   

6  SSA  1905(r)(3)(A). 
   
7 State Medicaid Manual, Pub. No. 45, ch. 5,   5140(A). 
 
8 AAPD Foundation,  Dental Trade Alliance Foundation, and  ADA, The Dental Home
 
Its Never Too Early to Start, February 2007.   
9 AAPD, Early Preventive Dental Visits, April  2014.  
Most Children With Medicaid in Four States Are Not  Receiving Required Dental Services (OEI-02-14-00490)   2    
Federal Initiatives  
Over the past several years, the Centers for Medicare & Medicaid Services 
(CMS) has worked to improve childrens access to dental care.  In 
April 2010, CMS created its Oral Health Initiative with the goal of 
increasing the number of children receiving preventive dental care.10   As 
part of this initiative, CMS set State-specific goals for childrens use of 
preventive dental services for FY  2015.  CMS asked States to voluntarily 
submit Oral Health Action Plans as a roadmap to achieving these goals.  
CMS offered technical assistance to States to develop and implement these 
plans. The Oral Health Initiative ended in September 2015.   
CMS also established the Core Set of Childrens Health Care Quality 
Measures. These measures help States to monitor and improve the quality 
of health care provided to enrollees in Medicaid and in the Childrens 
Health Insurance Program. The goals of this effort are (1) to encourage 
national reporting by States on a uniform set of measures and 
(2) to support States in using these measures to drive quality improvement.  
As a part of this initiative, CMS established two measures that track 
utilization of preventive dental services and sealants, respectively.11  
Related Work 
This report is a part of a series that also looked at Medicaid dental 
providers with questionable billing practices. 12  Our findings from those 
reports raise concerns that providers with questionable billing may be 
billing for services that are not medically necessary or were never 
provided, and the findings also raise concerns about the quality of care 
being provided. 
This report is also part of a body of work that looks at utilization of 
services by children with Medicaid.  In one report, we found that three out 
of four children did not receive all required EPSDT medical, vision, and 
hearing screenings in 2007.13 In a followup report, we found that although 
____________________________________________________________ 
10 Specifically, CMS sets benchmarks for each State that, if met, would (1) increase by 
10 percentage points the proportion of children in Medicaid and the Children's Health  
Insurance Program (CHIP) who receive a preventive dental service; and (2) increase by 
10 percentage points the proportion of Medicaid and CHIP  children ages 6 to  9 who 
receive a sealant on a permanent molar.   
11 A sealant is a plastic material applied to the surface of a tooth to help prevent cavities. 

12 See OIG, Questionable Billing for Medicaid Pediatric Dental Services in  New York, 

OEI-02-12-00330, March 2014; OIG,  Questionable Billing for Medicaid  Pediatric 

Dental Services in Louisiana, OEI-02-14-00120, August 2014;  OIG,  Questionable Billing 

for Medicaid Pediatric Dental Services in  Indiana, OEI-02-14-00250, October 2014; and 

Questionable Billing for Medicaid Pediatric Dental  Services in California, 

OEI-02-14-00480, May 2015.    

13 OIG,  Most Medicaid Children in Nine States Are Not Receiving All Required 
 
Preventive Screening Services, OEI-05-08-00520, May 2010. 
Most Children With Medicaid in Four States Are Not  Receiving Required Dental Services (OEI-02-14-00490)   3    
CMS disseminated strategies aimed at improving participation in EPSDT  
screenings and made efforts to improve the delivery of medical screenings, 
there was evidence that children continued to receive fewer medical 
screenings than required.14    
In another report, OIG found that nearly a third of children in foster care 
who were enrolled in Medicaid did not receive at least one required health 
screening in 2011 and 2012.15  Further, the reviews by the Administration 
for Children and Families (ACF) did not ensure that children in foster care  
receive the required screenings. OIG recommended that ACF identify and 
disseminate State strategies to ensure that all children in foster care 
receive required health screenings and that it expand the scope of its 
reviews to determine whether children in foster care receive these 
screenings. ACF concurred with the first recommendation and said that it 
was considering the second. 
METHODOLOGY   
Scope 
This study focuses on four States: California, Indiana, Louisiana, and 
Maryland. We selected a mix of States based on the following factors:  the 
number of children with Medicaid per State, geographic location, and 
input from CMS staff.  The four States serve approximately 19 percent of 
all children with Medicaid.16  
This report provides detailed information about dental services for 
children who were continuously enrolled in Medicaid for 2 years.  The 
data in this report are not comparable to the data that States report 
annually to CMS about their utilization of services under the EPSDT  
benefit.17   Specifically, we provide a more comprehensive look at whether 
children were receiving required dental services over a longer period of 
____________________________________________________________ 
14 OIG,  CMS Needs To  Do More To Improve Medicaid Children's  Utilization of  
Preventive Screening Services, OEI-05-13-00690, November 2014.  

15 OIG, Not All Children in  Foster Care Who Were Enrolled in Medicaid Received 

Required Health Screenings, OEI-07-13-00460, March 2015. 

16 The percentage was derived from beneficiary enrollment data from the four States and 
from data collected from CMSs Form-416.  
17 States report this information on CMSs Form-416, which  CMS uses to monitor 
EPSDT performance.  The dental data collected are based on the number of children who 
were continuously enrolled in Medicaid for at  least 90 days during the fiscal year of 
review.  CMS does not collect information on the frequency of particular services.  For 
further details on the data collected on  Form-416, see 
http://www.medicaid.gov/medicaid-chip-program-information/by-
topics/benefits/downloads/cms-416-instructions.pdf. 
Most Children With Medicaid in Four States Are Not  Receiving Required Dental Services (OEI-02-14-00490)   4    
time and also determine whether they received required services at the 
intervals specified in their respective States periodicity schedules.   
All four States in this review adopted the AAPD schedule, which specifies 
that children should receiveat a minimumbiannual oral exams, dental 
cleanings, and fluoride treatments.  We focused our review on these 
services because they are essential to maintaining oral health. 
Data Sources 
We based this study on (1) Medicaid dental claims with service dates in 
2011 and 2012, (2) Medicaid beneficiary enrollment files, and 
(3) structured interviews with State officials.  Appendix A provides a 
detailed description of the methodology. 
Limitations 
The study includes services paid for by Medicaid; it does not include 
services that these children may have received that were paid for by other 
sources. As a result, we may not be capturing all dental services that 
children received.  
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency.  
   
Most Children With Medicaid in Four States Are Not  Receiving Required Dental Services (OEI-02-14-00490)   5    
FINDINGS 
In the four States we reviewed, 78 percent of children 
did not receive required dental services 
All four States in this review adopted the AAPD schedule, which specifies 
that children should receiveat a minimumbiannual oral exams, dental 
cleanings, and fluoride treatments.  Seventy-eight percent of children who 
were continuously enrolled in Medicaid in these four States did not 
receive these required services, representing 2.9 million children.  See 
Chart 1. 
The percentage varied by State, with a low of 73 percent in Maryland and 
a high of 81 percent in Louisiana.  See Appendix B for detailed 
information about children who did not receive required 
services.  Receiving dental services to identify and prevent tooth decay 
and other dental problems is critical for ensuring childrens overall health.   
 
Chart 1:  Percentage of Children Who Did Not Receive Required Dental 
Services    
50% received  
some but not 
all required 
services 
78% 
28% did not 
receive any  
dental services 
22% received all 
required dental  
services 
Source:  OIG analysis of State Medicaid data, 2015. 
Note: Includes all children who were at least 1 year of  age and were continuously enrolled in Medicaid in 2011 and  2012.           
          Required  services include biannual oral exams, dental cleanings, and fluoride treatments. 
 
Over a quarter of children with Medicaid did not receive any 
dental services over a 2-year period  
In the four States we reviewed, 28 percent of children with Medicaid who 
were continuously enrolled received no dental services over a 2-year 
period.  This amounted to over 1 million children in these four States.  An 
Most Children With Medicaid in Four States Are Not  Receiving Required Dental Services (OEI-02-14-00490)  6    
additional 14 percent of children had only one visit to the dentist during 
the 2-year period. 
Children younger than 3 years old were the least likely to receive dental 
services when compared to children in the other age groups.  Notably, 
41 percent of children under 3 received no dental care over a 2-year 
period, compared to 21 percent of children 6 to 9 years of age. 18 In 
addition, children in rural areas were slightly less likely than children in 
urban areas to receive dental services. 
Another 50 percent received somebut not allof the required 
dental services over a 2-year period   
Fifty percent of children who were continuously enrolled in Medicaid over 
a 2-year period received some, but not all of the required dental services.  
These services include biannual oral exams, dental cleanings, and fluoride 
treatments.  As shown in Chart 2, children most commonly did not receive 
fluoride treatments at the intervals specified in their States periodicity 
schedule, followed closely by dental cleanings and oral exams.  See 
Appendix C for detailed information by State. 
 
Chart 2:  Percentage of Children Who Did Not Receive All the Required 

Dental Services, By Type of Service 

 
50%  49% 
46%  45% 
All required  Fluoride  Dental cleanings  Oral exams 
services  treatments 
  Source:  OIG analysis of State Medicaid data, 2015. 
Note: Includes all children who were at least 1 year of  age and were continuously enrolled in Medicaid in 2011 and  2012.    
          Required  services include biannual oral exams, dental cleanings, and fluoride treatments. 
 
This raises concerns about the States  abilities to ensure that children are 
receiving the services they need.  Although States have to report to CMS 
____________________________________________________________ 
18 Our analysis  of children under the age of  3 included children from the age of 1 year to  
2 years.   
Most Children With Medicaid in Four States Are Not  Receiving Required Dental Services (OEI-02-14-00490)   7    
the number of children receiving at least one preventive dental service, 
they do not have to report data on the frequency of any services.  Notably,  
all four States reported that they do not routinely track whether children 
are receiving services at the intervals specified in their periodicity 
schedules. As a result, States may not be capturing critical data or 
monitoring whether children are getting the care needed to prevent disease 
and promote good oral hygiene.   
Children who received required services appear to have a 
dental home 
A dental home is an ongoing relationship between a child and a dentist 
that includes all aspects of oral health care delivered in a comprehensive 
and continuously accessible way. Eighty-six percent of the children who 
received all the required services visited the same practice over a period of 
2 years.19  Children who received only some of the required services were 
more likely to visit multiple practices. This suggests that children in an 
established dental home are more likely to receive the required services.   
Two of the four States had coverage policies that may 
limit childrens ability to receive the required services  
As noted earlier, States must provide certain dental services at the 
intervals specified in their periodicity schedules.  All four States adopted 
the AAPD schedule, specifying that children should receiveat 
a minimumbiannual oral exams, dental cleanings, and fluoride 
treatments.  However, two States had policies that do not allow payment 
for particular services in accordance with the established schedules.  One 
State had a schedule specifying that children should receive biannual 
fluoride treatments and dental cleanings beginning at 6 months of age; 
however, the States coverage policy would pay for such services only for 
children 1 and older.  Similarly, another States schedule specified that 
children 6 months and older should receive biannual fluoride treatments; 
however, the States coverage policy allowed payment for such treatment 
only for children up to 15 years of age.20 
 
 
 
 ____________________________________________________________ 
19 Maryland was not included in this analysis.  For more information, see Appendix  A. 
20 Our analysis showed that despite its coverage policy, this State paidat least in some  
casesfor fluoride treatments for children over 15 years of age. 
Most Children With Medicaid in Four States Are Not  Receiving Required Dental Services (OEI-02-14-00490)   8    
The States we reviewed reported facing a shortage of
participating dentists and reported challenges in 
educating families about the importance of regular 
dental care 
Officials in each of the four States identified a number of barriers that 
impeded access to Medicaid dental services in each of their States, as well 
as strategies to address these barriers.  When children lack access to dental 
care, untreated decay and infection in their mouths can result in more 
complicated and expensive dental and medical interventions later in life.21     
Shortage of participating dentists: Officials in all four States expressed  
concerns about the lack of providers available to treat children with 
Medicaid, particularly very young children.  They also reported shortages 
in certain geographic areastypically, rural areas.  Officials further noted 
a reluctance of some providers to participate in Medicaid because of low 
reimbursement rates and administrative burdens.  They added that some  
providers are concerned that Medicaid patients are more likely to miss 
appointments, with providers in one State complaining of no show rates 
as high as 50 percent. 
Officials described several 
strategies aimed at  Pay-for-Performance Contracts 
ameliorating these  Maryland highlighted its contract with
problems.  Officials in  an administrative services organization 
one State reported that the  (ASO) that focuses on building a robust 
State provides student  network of dental providers.  The ASO 
loan repayments to dental  earns a significant additional payment if 
it meets specified targets in its contract, 
providers who serve 
such as increasing the number of dental 
children with Medicaid in 
providers in certain geographic areas.  
rural areas that have a 
To meet these targets, the ASOs staff 
shortage of providers. 
visit dental providers to encourage them  
Providers can receive up 
to participate in Medicaid.   
to $30,000 annually for a 
3-year commitment, with 
a possible extension of 2 additional years.   
In addition, States have implemented other strategies to encourage 
providers to participate in Medicaid.  In two States, officials reported that 
their States had previously increased provider reimbursement rates.  One 
of these States targeted their rate increases to a limited set of dental 
services that are more often provided to children, such as sealants and the 
application of fluoride, so that dental providers who treat young children 
____________________________________________________________ 
21 CMS, Guide to Childrens Dental Care in Medicaid, October 2004. 
Most Children With Medicaid in Four States Are Not  Receiving Required Dental Services (OEI-02-14-00490)   9    
could particularly benefit. State officials also described efforts to reduce 
administrative burdens, particularly regarding their Medicaid enrollment 
process. For example, one State is creating a streamlined application form 
that automatically checks the providers credentials, thus reducing the 
amount of time it takes to become  a Medicaid provider.  In addition, 
officials in two States reported following up with families when providers  
alerted them that a child had missed an appointment, which can help 
reduce the States no show rates, thereby encouraging more providers to 
participate in Medicaid.   
In spite of these efforts, officials noted that in some areas, there was an 
extremely limited number of dentists.  To combat this problem, two States 
are allowing midlevel dental providers and other nondentists (e.g., 
hygienists, medical providers) to provide certain dental services.  One 
State recently passed legislation that allows for teledentistry services, 
which helps expand access to dental services in remote and underserved 
areas.   The law also expands the types of procedures that dental hygienists 
and certain dental assistants can perform without a dentist onsite.  The 
other State is allowing pediatricians and primary care providers to provide 
a limited set of diagnostic and preventive services.  In addition, officials in 
this State reported working to set up a dental health safety net clinic in 
each county.    
To further combat provider shortages, another State analyzed how many 
providers submitted a high volume of Medicaid claims so that these 
providers could be targeted for outreach.  Our analysis of providers in the 
four States showed that a small concentration of dentists served the 
majority of children with Medicaid in 2012.  Notably, 896 dental 
providers in the 4 States served 55 percent of the children with Medicaid 
who received care. 
Most Children With Medicaid in Four States Are Not  Receiving Required Dental Services (OEI-02-14-00490)   10    
Educating families about the 
Connecting Families with Dentists 
importance of regular dental 
care: Officials in three States  California operates a call center that helps to 
expressed concern that many  make dental appointments for children with 
caregivers were not aware of the  Medicaid. When a parent or caregiver of a 
child with Medicaid contacts the call center to 
importance of regular dental care.  
obtain information about participating dental 
They highlighted particular 
providers, the operator on the phone not only  
concerns about a lack of 
identifies a provider, but calls the providers 
awareness about the importance  office to make an appointment for the child 
of dental care for children  while the family member is on the phone.   
younger than 3. They noted that 
California officials noted that they put this 
many families may not know that  system in place because in the pastwhen the 
dental services are covered for  State only provided families with a list of dental 
children in this age group.  providersfamilies often called back and 
reported that the providers on the list were no 
At the same time, State officials 
longer participating in Medicaid.  By making 
reported having strategies in place  appointments for children with Medicaid, the 
to reach out to families.  One of   State not only ensures that more children are 
these strategies is to ensure that   served, it is also able to track which providers 
are no longer serving children with Medicaid.  
children with Medicaid have a 
dental home.  Officials in one 
State reported that they assign a dentist to each child at a very young age.  
Officials in another State noted that they assign a local dentist to each 
child who is not already seeing a particular provider.  The State sends out 
information and makes calls to families when they join Medicaid.  
Officials stated that they have seen an influx of calls from families who 
did not know that Medicaid covered dental services for children.   
Officials also emphasized the importance of tracking the number of 
children who are seeing dentists regularly.  For example, one State 
identifies the children who have not seen a dental provider over the last 
12 months and reaches out to their families to encourage them to seek 
care. Another State particularly targets children under 3.  The State 
identifies those children who are not receiving care and provides 
information on the importance of early oral health care.  Officials added 
that they plan to make system changes to increase their ability to track the 
effects of these outreach efforts.  
   
Most Children With Medicaid in Four States Are Not  Receiving Required Dental Services (OEI-02-14-00490)   11    
CONCLUSION AND RECOMMENDATIONS 
Childrens lack of Medicaid dental care has been a longstanding concern.  
Tooth decayan almost entirely preventable diseaseis one of the most 
common chronic diseases of children, and children in low-income families 
experience more tooth decay than their peers in other income groups.  
When children lack dental care, untreated decay and infection in their 
mouths can result in more complicated and expensive dental and medical 
interventions later in life.   The goal of the EPSDT program is to ensure 
that children with Medicaid receive needed dental care to combat a wide 
range of oral health problems.   
The EPSDT program requires each State to provide dental services to all 
children enrolled in Medicaid.  However, we found that three out of four 
children with Medicaid in the four States are not receiving required dental 
services, with one in four children failing to see a dentist at all over a 
2-year period. The States we reviewed reported facing shortages of 
participating dental providers and challenges in educating families about 
the importance of regular dental care.  While the States reported that they 
employ a variety of strategies to address these problems, they need to do 
more to ensure that children receive needed dental care. 
These findings pose a potentially larger problem, as the number of 
children with Medicaid is increasing as a result of the Affordable Care Act.   
CMS and States must work together to ensure that children receive the 
dental care they need.  
We recognize that CMS has already taken some steps towards addressing 
the issues we found in this report. It has developed materials to educate 
consumers and providers about positive oral health practices, and it has 
shared strategies with States to improve access to and utilization of dental 
care. However, we continue to have concerns that children are not 
receiving required dental services.   
We recommend that CMS take the following steps, in addition to those it 
has already taken: 
Develop a comprehensive plan to increase the number of 
children who receive required services 
CMS should develop a comprehensive plan for how it can help increase 
the number of children who receive required services, such as biannual 
exams, fluoride treatments, and cleanings.  The plan should include 
strategies for working with States and cover short-term and long-term  
objectives, as well as timelines to meet these objectives.  The plan should 
include the initiatives that CMS decides to pursue in response to the other 
Most Children With Medicaid in Four States Are Not  Receiving Required Dental Services (OEI-02-14-00490)   12    
recommendations in this report as well as other initiatives that it develops  
to increase the number of children receiving required dental services.   
Develop benchmarks for dental services and require States to 
create mandatory action plans to meet them 
CMS should set State-specific benchmarks to increase in future years the 
number of children who are receiving  preventive dental care.  CMS should 
require States to create mandatory action plans to meet these benchmarks 
and should require States to submit their plans to CMS.  
Work with States to identify  areas with limited providers and 
the barriers preventing providers from participating in 
Medicaid 
To increase provider participation, CMS should help States identify where 
there are shortages of Medicaid providers and develop strategies to 
decrease barriers to participation. Such strategies could include provider 
outreach, improving the enrollment process, reducing the number of 
missed appointments, and evaluating whether certain dental services can 
be provided by other providers or in alternative settings.  
Work with States to analyze the effects of Medicaid payments 
on access to dental providers  
CMS should work with States to analyze Medicaid dental payments and 
ensure that States document whether their payment rates for providers are 
sufficient to encourage dental providers to participate in the program.  To 
address this recommendation, CMS should work closely with States to 
effectively implement new regulationsfinalized in November 2015 
that are designed to assure access to covered Medicaid services, including 
dental care.22  Specifically, it should ensure that States have a process to 
monitor access to dental care and that they take these data into account 
when setting Medicaid payment rates for dental providers.   
Work with States to educate families about the importance of 
dental care and to encourage ongoing relationships between 
children and their dentists  
CMS should work with States to educate families about the importance of  
regular dental care. The outreach should focus on the importance of 
regular dental care, particularly for children under the age of 3.  CMS 
should prepare materials and collaborate with States on media events.  In 
addition, CMS should work with States to set up systems to pair children 
with participating dentists to help ensure that more children receive 
____________________________________________________________ 
22  42  CFR  447.203; 80  Fed.  Reg. 67575 (Nov. 2,  2015). 
Most Children With Medicaid in Four States Are Not  Receiving Required Dental Services (OEI-02-14-00490)   13    
regular dental care. Such systems should encourage the establishment of 
dental homes.  The goal of these efforts is to increase the number of 
children receiving dental care. 
Work with States to track childrens utilization of required 
dental services 
Although the data in CMSs Form-416 provide important information 
about the dental services that children with Medicaid receive, they do not 
include comprehensive information about whether children receive 
required services at the appropriate intervals.  CMS should work with 
States to monitor their claims data to identify and track children with 
Medicaid who are receiving the required services according to each States 
periodicity schedule. One area of focus might be to look at children who 
have been continuously enrolled in Medicaid for an extended period of 
time, such as 18 months or 2 years, because these children in particular 
rely on Medicaid for these services.  States should use the results of their 
tracking to target their educational and outreach efforts to the population 
of children who are not receiving required dental services at the intervals  
specified in States periodicity schedules.   
Identify and share effective strategies with States 
As shown in this report, States have implemented different strategies to 
increase assess to pediatric dental care.  CMS should identify and review 
States strategies and share this information on an ongoing basis with all 
States. These strategieswhich can encompass those identified in this 
report as well as othersshould include ways to increase dental provider 
participation in States Medicaid dental programs as well as ways to 
encourage and increase childrens visits to the dentist.  CMS could publish 
periodic reports or facilitate information sharing by creating a forum for 
States on its website. 
Ensure that States pay for services in accordance with their 
periodicity schedules 
CMS should ensure that States are paying for services in accordance with 
their periodicity schedules. As a part of this process, CMS should require 
that States review their periodicity schedules, and should ensure that 
States that adopted their schedules from professionally recognized 
associations (such as the AAPD) are relying on the most current 
guidelines. CMS should require States to conduct regular reviews to 
ensure that States are paying for services in accordance with their 
periodicity schedules. 
Most Children With Medicaid in Four States Are Not  Receiving Required Dental Services (OEI-02-14-00490)   14    
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
CMS concurred with five of our recommendations, partially concurred 
with two recommendations, and did not concur with one recommendation. 
CMS partially concurred with our first recommendationthat it develop a 
comprehensive plan to increase the number of children who receive 
required servicesand stated that it will update its current plan to identify 
both new and continuing opportunities for collaboration with States to 
improve the use of preventive dental services among children.  This plan 
would include strategies that focus on managed care organizations or other 
contracted entities that provide dental services in States.  
CMS argued that childrens dental services are not a one size fits all 
requirement and stated that a child who receives an exam, a cleaning, and 
a fluoride treatment may not need an additional exam, cleaning, or 
fluoride treatment within a year.  While we agree that services should be 
customized, we do not agree that children with Medicaid should receive 
services less frequently than at the minimum frequency set by States.  As 
we note in the background of this report, the EPSDT benefit requires that 
all medically necessary services be provided at intervals that meet 
reasonable standards of dental practice, as determined in each States 
periodicity schedule. The four States we reviewed adopted the AAPD 
schedule, which sets as a reasonable standard of practice that oral exams, 
dental cleanings, and fluoride treatments be provided at a minimum of 
twice per year. 
CMS partially concurred with our second recommendationthat it 
develop benchmarks for dental services and require States to create 
mandatory action plans to meet themand said that it has already set 
improvement benchmarks for utilization of preventive dental services as 
part of the Oral Health Initiative.  It also believes that continuing to work 
collaboratively with States on current successful initiatives to improve 
dental access, instead of requiring mandatory action plans, is an effective 
way to increase the number of children receiving needed dental services.   
Given the findings of this report, we continue to recommend that CMS 
require States to create mandatory action plans to meet their benchmarks.  
CMS concurred with our third recommendationthat it work with States 
to identify areas with limited numbers of providers and the barriers 
preventing providers from participating in Medicaidand said that it is 
currently working with States to identify such barriers.  It also plans to 
work with States to address and decrease these barriers and to seek ways 
to increase the number of providers.  
Most Children With Medicaid in Four States Are Not  Receiving Required Dental Services (OEI-02-14-00490)   15    
CMS concurred with our fourth recommendationthat it work with States 
to analyze the effects of Medicaid payments on access to dental 
providersand said that it issued a final rule (with comment period) titled 
Methods for Assuring Access to Covered Medicaid Services. This rule, 
which will take effect in 2016, requires States to submit Access 
Monitoring Review Plans that must include methodologies for measuring 
access to care. The plans must include a core set of five services, 
including primary care, which includes dental services.   
CMS concurred with our fifth recommendationthat it work with States 
to educate families about the importance of dental care and to encourage 
ongoing relationships between children and their dentistsand stated that 
it has already taken many steps in educating families about the importance 
of dental care, such as creating consumer education materials.  It agrees 
that additional actions are needed to highlight dental homes as a successful 
strategy because the dental home is an effective tool for making sure that 
children are receiving dental services.   
CMS did not concur with our sixth recommendationthat it work with 
States to track childrens utilization of required dental servicesand 
stated that States are already required by law to report a variety of dental 
utilization data to CMS every year on the Form CMS-416.  CMS also said 
that it must balance the need for additional data with current reporting 
expectations for States. Currently, Form CMS-416 collects summary 
information, such as the number of children who received a dental service 
and what type of service it was (i.e., preventive, diagnostic, or treatment).  
However, States do not have to track whether children are receiving all 
required EPSDT services. Given the findings of this report, we believe 
that it is essential to track whether children are receiving services 
according to each States periodicity schedule to help States make 
improvements in this area.  
CMS concurred with our seventh recommendationthat it identify and 
share effective strategies with Statesand stated that it has published 
Keep Kids Smiling, which details dozens of successful approaches 
developed by States. CMS also said that it has conducted and published 
summaries of reviews of Medicaid dental programs and has provided 
periodic technical assistance Webinars to States on strategies to improve 
their dental programs.    
CMS concurred with our eighth recommendationthat it ensure that 
States pay for services in accordance with their periodicity schedulesit 
stated that it will work with States to crosswalk their payment policies 
with the dental periodicity schedules and make any necessary adjustments 
to their payment policies. 
Most Children With Medicaid in Four States Are Not  Receiving Required Dental Services (OEI-02-14-00490)   16    
The full text of CMSs comments is provided in Appendix D. 
   
Most Children With Medicaid in Four States Are Not  Receiving Required Dental Services (OEI-02-14-00490)   17    
APPENDIX A 
 
Detailed Data Sources and Analysis 
 
State Medicaid Data. From each State, we requested Medicaid dental 
claims for children up to age 20 from its Medicaid Management 
Information Systems.  These claims included fee-for-service claims, 
claims from Federally Qualified Health Centers (FQHCs), and in one 
Statewhich covers the dental benefit through managed care in part of 
the Statemanaged care claims.23   They also included claims from  
nondental providers who are allowed to provide certain dental services, 
such as fluoride treatments.  We also requested each States Medicaid 
beneficiary files for these years. 
Using information from the Medicaid beneficiary enrollment file for each 
State, we identified the children who were both (1) between the ages of 
1 and 20 years old and (2) continuously enrolled in Medicaid in 2011 and 
2012.24  In total, we identified 2,091,343 children in California, 
563,030 children in Indiana, 554,330 children in Louisiana, and 
454,669 children in Maryland. 
As a first step, for all four States, we calculated the total number and 
proportion of children who were continuously enrolled in Medicaid who 
did not receive required dental services in 2011 and 2012.  This includes 
the proportion of children who did not receive any dental services and 
those who did not receive all the required services that we reviewed at the 
intervals specified in States periodicity schedules.   The services that we 
reviewed were biannual dental cleanings, fluoride treatments, and oral 
exams.25   We considered a child to have not received all the required  
 
 
 
____________________________________________________________ 
23 California provided managed care claims  from Los Angeles County and  Sacramento  
County.  For the other counties, the State provided  fee-for-service claims.   
24 For the purposes of this report, if a State offered a Medicaid expansion program under 
its Childrens  Health Insurance Program (commonly referred to as M-CHIP),  we 
considered children in this program to be children  with Medicaid and included their 
claims and their enrollment data in our analyses. 
25 These services are distinguished from each other in the claims by their Healthcare 
Common Procedure Coding  System codes.   We also considered  reviewing the use of 
sealants as another important  preventive service that is included in  State periodicity 
schedules.   However, we were not able to analyze the use of sealants because the claims  
data did not have sufficient information to accurately measure whether children received 
sealants appropriately. 
Most Children With Medicaid in Four States Are Not  Receiving Required Dental Services (OEI-02-14-00490)   18    
APPENDIX A  (CONTINUED)  
 
services if he or she did not receive all of these services at least three times 
in the 2-year period.26    
For the measures, we determined whether there were any differences by 
State. We also determined whether there were any differences by age 
group. We defined the age groups as follows:  1 to 2 years of age, 3 to 
5 years of age, 6 to 9 years of age, 10 to 14 years of age, and 15 to 
20 years of age.27  Lastly, we determined whether there were any 
differences between children in urban and rural areas.  We defined urban 
and rural areas based on the ZIP Code associated with the child during his 
or her most recent enrollment period.28    
Next, we determined whether children who met the periodicity schedule 
appeared to have a dental home.  To do this, we determined the proportion 
of children who received all the required services from the same practice 
(a likely indicator that a child has a dental home).  For the purpose of 
this analysis, we used the billing provider identification number on the 
claim, rather than the rendering provider identification number, as an 
indicator that the child went to the same practice.29   The billing provider 
identification number is typically the  same for all providers in the same  
practice. In addition, we determined the percentage of children who 
received all the required services who visited multiple practices and 
compared it to the percentage of children who received only some of the 
required services and visited multiple practices. 
 ____________________________________________________________ 
26 In California and Maryland, FQHC dental claims did not include information on the 
specific services that were provided.  For those who received services from FQHCs in 
these States, we considered a child to have  received the required services if the child 
visited an FQHC three or more times or if the child  visited  an FQHC in addition to  
receiving required services in other practice settings at least three or more times. 
27 For children  who fell into two age groups during the 2-year  period, we included the 
child in the category that  he or she was in for the longest  amount of time.  For example, if  
a child was 6 years old for more days in the period  than he was 5 years old, we included  
the child in the category of  6 to  9 years of age. 
28  We matched ZIP Codes to the rural-urban commuting area codes (RUCAs), which 
classify counties using measures of population density, urbanization, and  daily  
commuting distance.  We defined an area as urban if  30  percent or more of its workers  
commute to or  live within an  area with  50,000 people or more.  We considered all  other 
areas to be rural.  For further details on  RUCAs, see the University of Washingtons 
WWAMI [Washington,  Wyoming, Alaska, Montana, and Idaho] Rural  Health Research  
Center at http://depts.washington.edu/uwruca/. 
29 Almost all of  Marylands claims had the same billing identification number, which  
represents the administrator for the dental program in the State.  Therefore, we were not 
able to include Maryland in this analysis. 
Most Children With Medicaid in Four States Are Not  Receiving Required Dental Services (OEI-02-14-00490)   19    
APPENDIX A  (CONTINUED)  
 
Lastly, we analyzed the 2012 dental claims and identified the dentists who 
provided services to 1,000 or more children with Medicaid.30   We  
considered this group to be high-volume dentists.  We determined the 
number of high-volume dentists and the proportion of children with 
Medicaid that these dentists served in the four States.  
Comparison of coverage policies to periodicity schedules. We compared 
each States periodicity schedule to its coverage policy to determine 
whether there were any inconsistencies.   We focused this analysis on the 
following required services: biannual oral exams, dental cleanings, and 
fluoride treatments. 
Structured Interviews with State Officials.   We conducted structured 
interviews with officials in each State who were responsible for the States 
Medicaid pediatric dental programs.  Our questions focused on any 
barriers that the State faced in increasing access to Medicaid pediatric 
dental services. We also asked about any strategies that the State had 
implemented to improve access to dental services.  We conducted these 
interviews in September 2014.  We  analyzed the responses from each 
State and identified common themes across States regarding the barriers 
and strategies to improve access to services. 
 
   
 ____________________________________________________________ 
30 For the purpose of this analysis, we used  rendering provider identification numbers to  
identify the dentists and  we excluded FQHCs in California and Maryland that submit 
their claims by facility, rather than by individual provider. 
Most Children With Medicaid in Four States Are Not  Receiving Required Dental Services (OEI-02-14-00490)   20    
APPENDIX B 
Percentages of Children Who Did Not Receive Required Dental 
Services 
 
Chart B-1:  Percentage of Children Who Did Not Receive Required Dental 
Services, by  State  
22%  21%  19%  27% 
49%  47%  55% 
50% 
29%  31%  26%  23% 
California  Indiana  Louisiana  Maryland 
Received all required dental services 
Did not receive all required dental services 
Received no dental services 
 
Source: OIG analysis of State Medicaid data, 2015. 
Note: 	Includes all children who were at least 1 year  of age and were continuously  enrolled in Medicaid in 
2011 and 2012.  Required services include biannual oral exams, dental cleanings, and fluoride 
 
treatments. 
 
Chart B-2:  Percentage of Children Who Did Not Receive Required Dental 
Services, by  Age  
13%  11% 
26%  30%  23% 
46%  50% 
49% 
51%  49% 
41%  39% 
23%  21%  28% 
Under 3  Ages 3 to  5  Ages 6 to  9  Ages 10 to 14 Ages 15 to 20 
Received all required dental services 
Did not receive all required dental services 
Received no dental services 
Source: OIG analysis of State Medicaid data, 2015. 
Note: 	Includes all children who were at least 1 year  of age and were continuously  enrolled in Medicaid in 
2011 and 2012.  Required services include biannual oral exams, dental cleanings, and fluoride 
treatments.         
Most Children With Medicaid in Four States Are Not  Receiving Required Dental Services (OEI-02-14-00490)   21    
APPENDIX B (CONTINUED)  
 
Chart B-3:  Percentage of Children Who Did Not Receive Required Dental 
Services, by  Urban and Rural Areas  
22%  22% 
48%  50% 
30%  28% 
Rural  Urban 
Received all required dental services 
Did not receive all required dental services 
Received no dental services 
Source: OIG analysis of State Medicaid data, 2015. 
Note: 	Includes all children who were at least 1 year  of age and were continuously  enrolled in Medicaid in 
2011 and 2012.  Required services include biannual oral exams, dental cleanings, and fluoride 
treatments. 
 
 
 
 
 
   
Most Children With Medicaid in Four States Are Not  Receiving Required Dental Services (OEI-02-14-00490)   22    
APPENDIX C 
Percentages of Children Who Did Not Receive All Required 
Dental Services 
 
Chart C-1:  Percentage of Children Who Did Not Receive All Required Dental Services, by  
Service  
55%  53% 
49% 47%  50%  48% 47%  48%  45% 45% 50% 48%  43% 44% 49%47% 
All  three services  Flouride treatments  Dental  cleanings  Oral exams 
California  Indiana  Louisiana  Maryland 
Source: OIG analysis of State Medicaid data, 2015. 

 
Note: Includes all children who were at least 1 year of age and were continuously  enrolled in Medicaid in 2011 and 2012. 

  
Chart C-2:  Percentage of Children Who Did Not Receive All Required Dental Services, by  
Age  
63% 
53% 55%  51% 49% 54% 50%  49% 49% 52% 48%  49% 48% 52% 50%  49% 46%  51% 
44% 
40% 
Under 3  Ages 3 to  5  Ages 6 to  9  Ages 10 to 14  Ages 15 to 20 
California  Indiana  Louisiana  Maryland 
Source: OIG analysis of State Medicaid data, 2015. 
Note: 	Includes all children who were at least 1 year of age and were continuously  enrolled in Medicaid in 2011 and 2012.  
Required services include biannual oral exams, dental cleanings, and fluoride treatments. 
 
   
Most Children With Medicaid in Four States Are Not  Receiving Required Dental Services (OEI-02-14-00490)   23   APPENDIX D 

Agency Comments 

.r
~!>f.llVIClis 
~ 
~
(  DEPAR:TMENTOFHEALTH&HUMANSERVICES  Centers for Medfcare & Medfcald Services 
,~,... 
200 Independence Avenue SW 
Washington, DC 20201 
DATE:  NOV 16  2015 
TO:  Daniel R. Levinson 
Inspector General 
FROM:  Andrew M. Slavitt 
Acting Administrator 
SUBJECT:  Office of Inspector General (OIG) Draft Report: "Most Children With Medicaid 
in Four States Are Not Receiving Services" (OEI~02~14~00490) 
The Centers for Medicare and Medicaid Services (CMS) appreciates the opportunity to review 
and comment on the Office oflnspector General's (OIG) draft report. CMS recognizes the need 
to continue and increase our focus on improving access to dental services for Medicaid~eligible 
children and to make sure children receive the full scope of services available under the Early 
and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. 
CMS is committed to improving access to dental and oral health services for children enrolled in 
Medicaid and the Children's Health Insurance Program (CHIP). CMS has made considerable 
progress in our efforts to make sure that low-income children have access to oral health care. 
From 2007 to 2014, sixty percent of all states achieved at least a ten percentage point increase in 
the proportion of children enrolled in Medicaid and CHIP that received a preventive dental 
service during the reporting year. 
To support continued progress, CMS launched the Children's Oral Health Initiative and set goals 
for improvement. To achieve those goals, CMS has adopted a national oral health strategy1 
through which CMS is working diligently with states and federal partners, as well as the dental 
provider community, children's advocates, and other stakeholders to improve children's access to 
dental care. 
To support state Medicaid and CHIP programs in achieving their improvement goals, CMS 
published Keep Kids Smiling: Promoting Oral .Health Through the Medicaid Benefit.for 
Children and Adolescents. It provides an overview ofthe children's dental benefit in Medicaid, 
examples of evidence-based policies at the state level, and details of successful strategies with 
state examples. 
In addition, CMS bas developed two learning collaboratives: one to support states in developing 
and implementing state oral health action plans, and the other for states to develop oral health 
1 National Oral Health Strategy can be found on http://www.medlcald.gov/Medlcaid-CHIP-Program
lnformation/Bv~Topics/Qualitv-of-Care/Downloads/CM~-Qral-Health-Strategy.pdf 
Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEl-02-14-00490)  24   
APPENDIX D (CONTINUED)
  
   
Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEI-02-14-00490)   25   
APPENDIX D (CONTINUED)
  
 
 
 
Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEI-02-14-00490)   26   
APPENDIX D (CONTINUED)
  
 
Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEI-02-14-00490)   27   
APPENDIX D (CONTINUED)
  
 
Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEI-02-14-00490)   28   
ACKNOWLEDGMENTS 
This report was prepared under the direction of Jodi Nudelman, Regional 
Inspector General for Evaluation and Inspections in the New  York regional 
office, and Nancy Harrison and Meridith Seife, Deputy Regional Inspectors 
General. 
Judy Kellis served as team leader for this study.  Other Office of Evaluation 
and Inspections staff from the New York regional office who conducted the 
study include Lucia Fort. Central office staff who provided support include 
Clarence Arnold, Meghan Kearns, and Christine Moritz. 
 
 
 
 
 
 
Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEI-02-14-00490)   29   
Office of Inspector General
http://oig.hhs.gov  
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95452, 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 individuals served by those programs.  
This statutory mission is carried  out through a nationwide network of audits, investigations,  
and inspections conducted by the following operating components: 
Office of Audit Services 
The Office  of  Audit Services  (OAS) provides 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.  These assessments help reduce waste, abuse, and  
mismanagement and promote economy and efficiency  throughout  HHS. 
Office of Evaluation and Inspections 
The Office  of  Evaluation and Inspections (OEI)  conducts national evaluations to  provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud,  waste, or abuse  and promoting  
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations  
of fraud and misconduct  related to HHS programs, operations, and individuals.  With  
investigators working in all 50 States and the District of Columbia, OI  utilizes its resources 
by actively  coordinating with the Department  of Justice  and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to  criminal 
convictions, administrative sanctions,  and/or  civil monetary  penalties.  
Office of Counsel to the Inspector General 
The Office of Counsel to the  Inspector  General (OCIG) provides general legal services to 
OIG, rendering  advice and opinions on HHS programs and operations and  providing all  
legal support for OIGs  internal operations.  OCIG represents  OIG in all civil and 
administrative fraud and  abuse cases involving HHS programs, including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In  connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program  guidance, publishes fraud alerts, and provides other  
guidance  to  the health care industry concerning the anti-kickback statute and other  OIG  
enforcement authorities.