DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, Maryland   21244-1850 
 
CMCS Informational Bulletin 
 
DATE:  July 10, 2014 
 
FROM:  Cindy Mann 
Director 
     
SUBJECT:  Update on CMS Oral Health Initiative and Other Oral Health Related Items 
 
 
This informational bulletin provides an update on the CMS Oral Health Initiative, describes an 
array of CMS resources available to support states in their efforts to improve the delivery of 
dental and oral health services in Medicaid and CHIP, discusses how CMS policy supports 
dental workforce innovations, addresses the use of oral health quality measures to encourage 
improvement and track progress, and encourages states to adopt the use of three new risk-based 
dental billing codes to improve care and the use resources.   
Fifteen States Meet or Exceed First-Year CMS Oral Health Initiative Goal 
CMS is pleased to report that, between FFY 2011 (the baseline year) and FFY 2012, 15 states 
achieved at least a two percentage point improvement on their CMS Oral Health Initiative 
preventive dental services goal. An additional 18 states achieved an improvement of at least one 
percentage point, and the national average advanced by a similar one percentage point.  
States Meeting or Exceeding First Year CMS Oral Health Initiative Goal  
Percentage of Medicaid-enrolled children, age 1-20, who received a preventive dental service 
 
Source: FFY 2011 - FFY 2012 CMS 416 reports, lines 1b, 12b.  CMCS Informational Bulletin  Page 2 
State baseline percentages were computed using FFY 2011 data reported to CMS as of May 28, 2013. 
State progress was computed using FFY 2012 data reported to CMS as of April 10, 2014. 
Launched in April 2010, the CMS national Oral Health Initiative (OHI) asks states to increase 
the use of preventive dental services by children enrolled in Medicaid by at least ten percentage 
points over five years. Our national goal is for at least 52 percent of enrolled children ages 1-20 
to receive a preventive dental service in FFY 2015. Each state has its own FFY 2011 baseline 
and FFY 2015 goal, with interim yearly improvement goals of two percentage points. A chart 
showing the baselines, progress and goals is available on Medicaid.gov: 
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-
Topics/Benefits/Downloads/OHIBaselineGoals.pdf  
More information about the OHI is available on Medicaid.gov: 
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-
Care/Downloads/CMS-Oral-Health-Strategy.pdf  
More Improvement Is Needed in Use of Preventive Dental Services  
While fifteen states have met or exceeded their first year incremental goal, the remaining 36 
states have fallen short.  In order to support states work in meeting their goals, CMS encourages 
every state to develop an Oral Health Action Plan to articulate specific steps they plan to take to 
achieve improvement.  
To date, CMS has received Action Plans from the following 22 states: Alabama, Alaska, 
Arizona, California, Connecticut, Delaware, Maine, Maryland, Massachusetts, Michigan, 
Missouri, Nebraska, New Hampshire, New Jersey, North Dakota, Oklahoma, Pennsylvania, 
Tennessee, Vermont, Virginia, Washington and Wyoming. CMS continues to encourage all of 
the remaining 29 states to develop and submit their Plans, and CMS stands ready to provide 
technical assistance to any state that requests it. 
CMS Support for States in Achieving their Oral Health Initiative Goals 
The CMS Oral Health Initiative established two performance goals, to be accomplished over five 
years by FFY 2015: 
  Goal #1  Increase by 10 percentage points the proportion of Medicaid and CHIP 
children ages 1 to 20 (enrolled for at least 90 days) who receive a preventive dental 
service. 
 
  Goal #2  Increase by 10 percentage points the proportion of Medicaid and CHIP 
children ages 6 to 9 (enrolled for at least 90 days) who receive a sealant on a permanent 
molar tooth.   
 
    CMCS Informational Bulletin  Page 3 
CMS offers a variety of supports to states to help them achieve their Oral Health Initiative goals.  
 
  The CMS Learning Lab: Improving Oral Health Through Access is a series of technical 
assistance webinars focusing on improving the delivery of oral health services to children 
enrolled in Medicaid and CHIP. Recordings and transcripts can be accessed on 
Medicaid.gov: http://medicaid.gov/Medicaid-CHIP-Program-Information/By-
Topics/Benefits/Dental-Care.html. To be added to the invitation list for the CMS 
Learning Lab webinars, send an email to MACQualityTA@cms.hhs.gov.  
 
  CMS recently published Keep Kids Smiling: Promoting Oral Health Through the 
Medicaid Benefit for Children and Adolescents. This guide features four overarching 
approaches and more than a dozen strategies with concrete state examples to demonstrate 
how improvement can be achieved. http://www.medicaid.gov/Medicaid-CHIP-Program-
Information/By-Topics/Benefits/Downloads/Keep-Kids-Smiling.pdf   
 
  CMS has created Think Teeth! a set of free oral health education materials, targeted to 
parents, caregivers and pregnant women, available for bulk order. Find out more on the 
Insure Kids Now website: 
http://www.insurekidsnow.gov/professionals/dental/index.html.  
 
 
 
  CMS hosts monthly calls for the Medicaid and CHIP Oral Health Technical Advisory 
Group (OTAG) which provide an opportunity for states to advise CMS on oral health 
policy questions, to hear about updates from CMS, to discuss emerging issues with their 
peers in other states, and to learn about new developments in oral health policy and 
financing generally. To be added to the invitation list for the OTAG calls, send a request 
to Rosemary Feild at rosemary.feild@cms.hhs.gov.     
 
  CMS recently supported the publication of Improving Oral Health Care Delivery in 
Medicaid and CHIP: A Toolkit for States. The Toolkit can be found on Medicaid.gov: 
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-
Topics/Benefits/Downloads/Oral-Health-Quality-Improvement-Toolkit-for-States.pdf  
 
 
  CMCS Informational Bulletin  Page 4 
  The dental provider locator tool available on the Insure Kids Now (IKN) website is an 
important resource for states and consumers in connecting children to participating 
dentists in their communities. Access the tool on the Insure Kids now website: 
http://www.insurekidsnow.gov/state/index.html.  You can also download a widget to post 
on any website for easy access to the search tool: 
http://datawarehouse.hrsa.gov/tools/widgets.aspx#InsureKidsNow. 
 
 
  CMS is participating in the Medicaid/CHIP Oral Health Learning Collaborative hosted 
by the Center for Health Care Strategies (CHCS) in which seven states are designing and 
executing approaches intended to achieve the states CMS Oral Health Initiative goals. 
More information can be found on the CHCS website: http://www.chcs.org/info-
url_nocat3961/info-url_nocat_show.htm?doc_id=1261481  
 
How CMS Policy Supports Dental Workforce Innovations 
Although dental disease in children is largely preventable, and tooth decay remains the most 
common chronic illness among children in the United States, too many children still do not have 
access to regular oral health care. Children enrolled in Medicaid and CHIP are more likely to 
suffer from dental disease and less likely to use dental services than privately insured children. 
Increasing and diversifying the dental workforce can be an important part of a strategy to address 
these oral health disparities. To support state Medicaid and CHIP programs in using all available 
dental and medical professionals to improve the oral health of enrolled children, CMS clarifies 
the following policy issues: 
  Medicaid regulations define dental services as those diagnostic, preventive or 
corrective procedures provided by or under the supervision of a dentist. (See 42 Code of 
Federal Regulations  440.100(a).)   
 
  Services provided by non-dentists such as primary care medical practitioners, or by 
dental professionals not under the supervision of a dentist, are considered by Medicaid to 
be oral health services provided by a licensed practitioner. (See 42 Code of Federal 
Regulations  440.60(a).) 
  CMCS Informational Bulletin  Page 5 
  Both dental services and oral health services should be readily available to enrolled 
children. Services provided by a range of medical and dental providers work hand-in-
hand to support childrens oral health.  
 
  For Medicaid purposes, dental supervision is a spectrum, ranging from direct supervision 
through indirect and general supervision, all the way to public health supervision and 
collaborative agreements.  
 
  Services performed by new types of dental professionals such as dental therapists and 
community dental health practitioners are considered to be dental services if the dental 
professional has some sort of supervisory relationship or agreement or affiliation with a 
dentist. Services performed by new types of dental professionals are considered to be 
oral health services if no such relationship, agreement or affiliation with a dentist 
exists.  
 
  The distinction between a dental service and an oral health service is important in the 
context of reporting dental utilization data to CMS on the CMS Form 416. The recently 
revised instructions for the Form 416 detail how dental services and oral health 
services are to be reported. The revised instructions are available on CMS.gov: 
http://www.cms.gov/Regulations-and-
Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing-
Items/CMS1227564.html?DLPage=8&DLSort=1&DLSortDir=descending 
 
  States have two options for reimbursing for services provided by dental professionals 
(such as dental hygienists, dental therapists and community dental health practitioners) 
who are supervised by dentists but are not themselves dentists: (a) states may pay claims 
filed by the affiliated dentist for services rendered by the dental professional; or (b) states 
may allow the dental professionals to enroll as Medicaid providers and directly bill 
Medicaid using their own Medicaid provider identification numbers. Either way 
comports with federal requirements.  
 
  States may also allow dental professionals who are permitted by the terms of their license 
to practice without dental supervision to enroll as Medicaid providers and bill Medicaid 
directly for their services. 
 
  All dental services, regardless of whether they are performed by a dentist or by another 
type of dental professional, such as a dental hygienist or a dental therapist working under 
the supervision of a dentist (including those with an agreement or affiliation with a 
dentist), and regardless of whether the services are provided in a dental office or in a 
school or community setting, meet the dental requirement in the Early and Periodic 
Screening, Diagnostic and Treatment (EPSDT) benefit. (See 42 Code of Federal 
Regulations  441.56 (b)(1) and State Medicaid Manual (SMM)  5132.2G.). Oral 
health services, i.e., those performed by a dental professional without a supervisory 
relationship with a dentist or by another type of medical professional, do not meet this 
requirement.  
 
  CMCS Informational Bulletin  Page 6 
  In 2013 the American Dental Associations Code on Dental Terminology and 
Nomenclature (CDT) has added several new codes that may be used by states to support 
their efforts to maximize the ability of all healthcare professionals, both medical and 
dental, operating within the scope of state practice acts, to serve Medicaid and CHIP 
enrollees. D0190 (screening of a patient) and D0191 (assessment of a patient) can be 
used in settings such as schools and day care centers when a comprehensive dental 
examination is not conducted.  States are encouraged to adopt the use of these codes in 
Medicaid in order to expand opportunities for children to gain access to the dental 
delivery system. At least 16 states already reimburse for these codes.  
 
  CMS encourages state Medicaid and CHIP programs to reimburse medical providers for 
childrens oral health services such as risk assessment, fluoride varnish, and anticipatory 
guidance. The U.S. Preventive Services Task Force (USPSTF) supports this approach in 
its recently updated B recommendation on prevention of dental caries in infants and 
children up to age 5. Under the new recommendation, primary care clinicians are 
encouraged to apply fluoride varnish to the primary teeth of all infants and children 
starting at the age of primary tooth eruption. The recommendation is available on the 
USPSTF website: 
http://www.uspreventiveservicestaskforce.org/uspstf12/dentalprek/dentchdraftrec.htm.  
 
  Under section 4106 of the Affordable Care Act, States may elect to receive a one percent 
FMAP bump for payments for this recommended service by covering in Medicaid, 
without cost-sharing, all of the USPSTF A and B recommendations. States wishing to 
pursue this approach should submit a State Plan Amendment to CMS.   
 
Using Oral Health Quality Measures to Encourage Improvement and Track Progress 
 
In the context of the CMS Oral health Initiative, CMS has been working with states to improve 
tracking and reporting of dental utilization data. The majority of states contract with managed 
care entities or dental benefits managers to administer Medicaid and CHIP dental benefits. In this 
context, many states use dental performance measures in their contracts to encourage better 
performance and to track improvement. States also sometimes incorporate dental measures in 
their managed care quality strategies and their dental-related health plan performance 
improvement projects (PIPs).  
CMS has learned that for these purposes states often require collection of the Annual Dental 
Visit (ADV) measure from the Healthcare Effectiveness Data and Information Set (HEDIS). 
While the HEDIS measure may be appropriate in some cases, especially for managed care 
plans, we strongly encourage states also to collect the dental measures from the Child Core Set 
(PDENT: use of preventive dental services and TDENT: use of dental treatment services). The 
dental measures from the Child Core Set use an age range (1 to 20 rather than 2 to 21) and a 
length of continuous eligibility (90 days rather than 320 days) more appropriate to Medicaid and 
CHIP enrollees.  
Incorporating the dental measures from the Child Core Set into managed care contracts, quality 
strategies, PIPs and other improvement initiatives will help align the actions of states and their  CMCS Informational Bulletin  Page 7 
contractors with CMS goals and objectives, facilitate more complete reporting, and permit more 
meaningful comparisons across all states. More information about the Child Core Set measures is 
available on Medicaid.gov: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-
Topics/Quality-of-Care/Downloads/ChildCoreMeasures.pdf 
Three New Risk-Based CDT Billing Codes 
In 2014, three additional billing codes relevant to Medicaid and CHIP were added to the CDT:  
  D0601 (caries risk assessment and documentation with a finding of low risk);  
  D0602 (caries risk assessment and documentation with a finding of medium risk); and  
  D0603 (caries risk assessment and documentation with a finding of high risk).  
 
Guidelines for performing, evaluating and addressing the results of oral health risk-assessments 
are available from the American Academy of Pediatric Dentistry: 
http://www.aapd.org/media/Policies_Guidelines/G_CariesRiskAssessment.pdf     
 
State Medicaid and CHIP programs can use the new codes to help children access dental and oral 
health services based on their individual levels of risk of developing dental disease, instead of 
assuming that all children need the same level of intervention. Such an approach can help to 
apply resources more wisely as well as increase childrens oral and overall health. 
For more information about the CMS Oral Health Initiative or other oral health related matters, 
please contact Laurie Norris, Senior Policy Advisor, at laurie.norris@cms.hhs.gov, or Dr. Lynn 
Douglas Mouden, CMS Chief Dental Officer, at lynn.mouden@cms.hhs.gov.