DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, MD 21244-1850 
 
 
CMCS Informational Bulletin 
 
 
DATE:  May 4, 2018 
 
FROM:  Timothy Hill, Acting Director  
  Center for Medicaid and CHIP Services (CMCS) 
 
SUBJECT:  Aligning Dental Payment Policies and Periodicity Schedules in the Medicaid 
and CHIP Programs 
Background  
Tooth decay continues to be one of the most prevalent1,2 chronic diseases of childhood despite 
the abundance of scientific evidence demonstrating that it can be prevented.3  Moreover, an 
estimated 80 percent of tooth decay is in 25 percent of children4  many of whom are enrolled in 
Medicaid and the Childrens Health Insurance Program (CHIP)  and the impacts can be 
significant and long-lasting.  Without access to appropriate dental care, untreated tooth decay can 
result in preventable emergency room visits or the need for more complicated and expensive 
dental and medical interventions at a young age as well as later in life.  
Forty-six million children are enrolled in either Medicaid or CHIP.5  For these children, 
Medicaid or CHIP is their primary source of dental coverage.  How that coverage is administered 
by states can have a significant impact on childrens oral health.  This informational bulletin 
discusses the importance of state Medicaid and CHIP programs properly implementing their 
pediatric dental periodicity schedules in order to ensure childrens access to critical dental 
coverage.  In particular, two dimensions are discussed.  First, states should ensure that fee 
schedules and payment policies are aligned with periodicity schedules: a 2016 report from the 
U.S. Department of Health and Human Services Office of the Inspector General (OIG) 
determined that this alignment is not present in all states. Second, the periodicity schedule should 
be treated as a floor for coverage of dental services, not a ceiling.  States should have a 
mechanism in place to cover medically necessary dental services that exceed the periodicity 
schedule. 
                                                 
1 Dye BA, Thornton-Evans G, Li X, Iafolla TJ. Dental caries and sealant prevalence in children and 
adolescents in the United States, 2011-2012. NCHS Data Brief. 2015(191):1-8. 
2 U.S. Department of Health and Human Services. Oral Health in America: a report of the surgeon general- 
executive summary. Rockville, Md., U.S. Department of Health and Human Services, National Institute of 
Dental and Craniofacial Research, National Institutes of Health, 2000. 
3 See, e.g., Colak H, Dulgergil C, Dalli M, Hamidi MM. Early childhood caries update: A review of causes, 
diagnoses, and treatments. Journal of Natural Science, Biology and Medicine. 2013 Jan-Jun; 4(1): 29-38. 
4 See American Academy of Pediatric Dentistry Fast Facts, 2014, available at: 
http://www.aapd.org/assets/1/7/FastFacts.pdf 
5 CMS FFY 2016 Childrens Enrollment Report.  Page 2  CMCS Informational Bulletin  
 
  
Coverage  
 
All children enrolled in Medicaid, regardless of whether that coverage is funded through title 
XIX or title XXI, have coverage for dental services.  This coverage is included as part of the 
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit.  Covered dental 
services must, at a minimum, include dental care needed for relief of pain, infection, restoration 
of teeth, maintenance of dental health (provided at as early an age as necessary), and medically 
necessary orthodontic services.6  States are required to adopt a periodicity schedule specific to 
pediatric dental services, detailing the recommended intervals at which enrolled children should 
receive dental check-ups.7  The recommended intervals should align with reasonable standards 
of dental practice, and states should establish this schedule in consultation with dental 
organizations involved in child health care.8 
 
The EPSDT benefit is designed to assure that enrolled children receive early detection and care 
so that health problems are averted or diagnosed and treated as early as possible.  EPSDT is 
important to the prevention and effective management of dental disease in children because early 
and frequent check-ups can help prevent the disease and when the disease is caught early, it can 
be managed and controlled at lower cost and with better outcomes.9  
 
Children enrolled in separate CHIP programs also have dental coverage.  At a minimum, separate 
CHIP programs must provide dental services necessary to prevent disease and promote oral health, 
restore oral structures to health and function, and treat emergency conditions.10  States with a separate 
CHIP program may choose from two options for providing dental coverage: a state-defined package 
of dental benefits that meets the CHIP requirements, or a benchmark dental benefit package.  States 
should specify the periodicity schedule with which preventative and medically necessary restorative 
services would be provided, as well as whether these services are sufficient to prevent further disease, 
as required by section 2103(c)(5).  This applies to state-defined benefit packages and dental 
benchmark packages.  We note that many separate CHIP programs adopt the EPSDT benefit, and 
thus provide a scope of dental services to children comparable to Medicaid. 
  
Proper Implementation of Pediatric Dental Periodicity Schedules 
 
Childrens dental coverage is not optimized in instances where a states Medicaid or CHIP dental 
fee schedule and payment policies are not aligned with its pediatric dental periodicity schedule.  
Each states Medicaid and CHIP pediatric dental periodicity schedule specifies the age at which 
children should begin receiving dental check-ups and preventive care, and their recommended 
frequency.  As such, the fee schedule and payment policies in the state must align with the 
periodicity schedule regarding both age and frequency to ensure providers are able to be 
                                                 
6 Section 1905(r)(3) of the Social Security Act.  See also, CMS, Keep Kids Smiling: Promoting Oral Health 
Through the Medicaid Benefit for Childrens & Adolescents, September 2013, available at 
https://www.medicaid.gov/medicaid/benefits/downloads/keep-kids-smiling.pdf. 
7 CMS, State Medicaid Manual, section 5140(A). 
8 Section 1905(r)(3) of the Social Security Act. 
9 Samnaliev M, Wijeratne R, Kwon EG, Ohiomoba H, Ng MW. Cost-effectiveness of a disease management 
program for early childhood caries. Journal of Public Health Dentistry, 75 (2015) 24-33. 
10 Section 2103(c)(5) of the Social Security Act.  Page 3  CMCS Informational Bulletin  
 
reimbursed for recommended care.  In states that provide dental benefits through managed care 
plan arrangements, states should ensure that the managed care plans fee schedules and payment 
polices align with the states periodicity schedule.  This holds true whether a state contracts for 
dental services through managed care organizations, prepaid ambulatory health plans, or other 
managed care plan arrangement.  
 
A 2016 report from the U.S. Department of Health and Human Services Office of the Inspector 
General (OIG) determined that not all states are ensuring this alignment.  In its study, the OIG 
found misalignments in two of the four states in their study.  One example of a misalignment is 
when the periodicity schedule calls for biannual fluoride treatments and dental cleanings 
beginning at 6 months of age but the fee schedule allows payment  only beginning at age 1.  
Another example would be a periodicity schedule calling for biannual fluoride treatments for all 
children 6 months of age and older but the associated payment policy allowing payment only up 
to the age of 15.  
 
Also note that oral health screening, risk assessment, and referral to appropriate dental care are 
recommended parts of visits with primary care medical providers, as described in the Bright 
Futures guidelinesa nationally recognized pediatric periodicity schedule that states may opt to 
use as their medical periodicity schedule.11  Payment policies for these oral health services 
should also be aligned to the states Medicaid and CHIP periodicity schedules.  Primary care 
medical providers can be part of a states strategy to improve oral health for beneficiaries, and 
these providers should also be aware of Medicaid and CHIP coverage policies for oral health 
services such as fluoride varnish. 
 
Second, the Medicaid and CHIP dental periodicity schedules should be implemented as the 
floor of coverage available for exams and preventive dental services, with additional services 
being covered based on each individual childs risk profile and health needs.  While the 
periodicity schedule is a generalized recommendation, it can be beneficial to develop 
individualized care plans for children since the risk of developing dental caries and the severity 
of the disease can vary across children.  These plans may involve caries risk assessments, exams, 
and preventive dental services such as fluoride treatments at more frequent intervals than what is 
specified in the coverage policy or the periodicity schedule.  While initial limits may be placed 
on coverage of a dental or oral health service, services must be covered if determined to be 
necessary to correct or ameliorate an individual childs condition.  This standard applies to dental 
services as well as to medical services provided in the EPSDT benefit.  As such, dental care 
necessary to correct or ameliorate an individual childs condition must be covered (and 
reimbursed) even when these services fall outside of the standard scope and even when the 
frequency of services is greater than specified in the periodicity schedule or coverage policy.12 
  
For example, the typical pediatric dental periodicity schedule covers dental exams and cleanings 
twice each year.  A child with a disability may need more frequent cleanings than twice each 
year, and a child with early childhood caries and an individual care plan may need re-evaluation 
more frequently than twice each year.  Another example is a child with a severe micrognathia 
                                                 
11 Casamassimo, P. and Holt, K., eds., 2016. Bright Futures: Oral Health  Pocket Guide (3rd ed.). 
Washington, DC: National Maternal and Child Oral Health Resource Center.  
https://www.mchoralhealth.org/pocket/  
12 CMS, State Medicaid Manual, section 5110, and Section 1905(r)(5) of the Social Security Act.  Page 4  CMCS Informational Bulletin  
 
(underdeveloped jaw) who might require palatal expansion or mandibular advancement to 
promote the childs proper speech and nutrition.  Even if these dental surgical procedures are not 
included in the states Medicaid or CHIP benefit, they must be covered if determined to be 
necessary to correct or ameliorate this childs condition under EPSDT, or restore function under 
requirements for separate CHIP programs.  
 
State Action to Ensure Pediatric Dental Periodicity and Fee Schedule Alignment and 
Flexibility  
To prevent misalignments between pediatric dental periodicity and fee schedules, states should 
review their Medicaid and CHIP payment policies for incongruities with their pediatric dental 
periodicity schedules and correct any identified issues.  Moreover, states should take care to ensure 
alignment when making changes to their dental program, such as adding coverage for new procedure 
codes, or updating frequency of some benefits to reflect changing clinical standards.  States should 
also be alert for any misalignments in the ages for which and the frequencies at which each service is 
covered and reimbursable.  In addition, states delivering dental services to children through managed 
care should ensure that their contracted health and dental plans that use fee schedules are paying 
providers for all services in alignment with the states Medicaid and CHIP pediatric dental periodicity 
schedules.  
 
To ensure that children can receive medically necessary dental care, states may need to 
implement a mechanism through which providers can obtain timely approval of, and payment 
for, additional or more frequent dental services beyond what is specified in the periodicity 
schedule or coverage policy.  States delivering dental services to children through managed care 
or other contracting arrangements should ensure that a similar mechanism is available through 
their contracted plan(s).  
 
As issues are identified, CMS is available to provide technical assistance to help states come into 
compliance. For more information about dental coverage in Medicaid and CHIP, see the dental 
care page on Medicaid.gov, or contact Andrew Snyder at andrew.snyder@cms.hhs.gov.