DEPARTMENT OF HEALTH & HUMAN SERVICES 
Health Care Financing Administration 
Center for Medicaid and State Operations 
7500 Security Boulevard 
Baltimore, MD 21244-1850 
May 8, 2000 
Dear State Medicaid Director:

Dear State Childrens Health Insurance Program Director:

As part of our effort to improve access to quality oral health services for children eligible for Medicaid

and the State Childrens Health Insurance Program (SCHIP), the Health Care Financing Administration

(HCFA), in collaboration with our partners, the Centers for Disease Control and Prevention (CDC),

the Health Resources and Services Administration (HRSA), and the Indian Health Service (IHS), is

soliciting applications from State Medicaid and SCHIP agencies for a new grant demonstration

program, Innovative Management of Dental Decay for Young Children Enrolled in Medicaid/SCHIP. 

This grant program (Catalogue of Federal Domestic Assistance Program Number 93.779) is designed

to identify methods of innovative management of oral conditions among young children enrolled in

Medicaid and SCHIP that result in oral health improvement and dental care cost savings. 

This grant program will furnish administrative funds to assist States to provide and evaluate preventive

and therapeutic regimens that are considered efficacious, but have not been widely implemented in

dental practice or in publicly-funded dental services delivery programs.  Specifically, the program is

designed to demonstrate that such disease management interventions can reduce disease burden and

associated dental repair costs. Ultimately, we will encourage States to incorporate successful

intervention programs in their oral health care components. 

Under this four-year demonstration program, HCFA will make awards to one or two States in the

estimated amount of $220,000-$445,000 for an initial project period of up to 18 months. The

enclosed grant announcement provides information regarding the goals and structure of the project,

application procedures, eligibility requirements, and review criteria. As identified in the

announcement, the deadline for submitting an application is August 1, 2000.  Proposals sent

by commercial carrier must be received in the HCFA grants office on or before August 1.  If

delivered by the U.S. Postal Service, the postmark on the submission must be on or before

August 1.

Grant funds may be used for administrative tasks such as program development, provider training, data

collection and analysis, and consultative or other contracts relevant to the project. We anticipate that

most States applying for this project will wish to enter into an agreement for the scientific development

and day-to-day management and operation of the project with an entity having strong research

management experience involving oral health 
 Page 2 - State Medicaid Director and State Childrens Health Insurance Program Director 
benefits/status and cost assessment. Grant funds may not be used for payment of direct 
dental, medical and other services provided as part of the project.  Direct services must be paid with 
funds from State Medicaid, SCHIP, or State-only programs. 
This collaboration between HCFA, CDC, HRSA, and IHS is an outgrowth of increasing cooperation 
among Federal agencies concerned about oral health disparities and dental care access barriers among 
low income populations. This grant program is but one of several planned or in-progress activities 
which are designed to assist States in addressing and resolving long-standing oral health access 
problems in the Medicaid program. Since 1998, HCFA and HRSA have been involved in an 
interagency Oral Health Initiative designed to address oral health disparities through integration of 
Federal programs, partnering with other stakeholders, and integrating new technology and science to 
reduce oral disease burden. 
An additional example of this growing interagency collaboration is found in a recently issued Request 
For Application (RFA) from the National Institute of Dental and Craniofacial Research (NIDCR) and a 
broad group of other Federal agencies.  The NIDCR research program will involve multiple projects 
aimed at, among other things, developing interventions to prevent or reduce oral health disparities 
among children and their caregivers. We bring this RFA to your attention not only as an example of 
other interagency interest in reducing oral health disparities through research, but also as a possible 
opportunity for you to collaborate with a developing NIDCR research center as you consider a 
response to this HCFA solicitation. 
If you have any questions regarding the HCFA grant announcement, please contact Dr. Don Schneider, 
Chief Dental Officer, at telephone (410) 786-5133, or e-mail dschneider@hcfa.gov. 
We look forward to receiving your application. 
Sincerely, 
/s/ 
Timothy M. Westmoreland 
Director 
Enclosure  Page 3 - State Medicaid Director and State Childrens Health Insurance Program Director 
cc:

All HCFA Regional Administrators

All HCFA Associate Regional Administrators 
for Medicaid and State Operations 
William Maas

Director, Division of Oral Health 

Centers for Disease Control and Prevention

John Rossetti

Chief Dental Officer

Health Resources and Services Administration

Eric Broderick

Principle Dental Consultant

Indian Health Service

Lee Partridge

Director, Health Policy Unit

American Public Human Services Administration

Joy Wilson

Director, Health Committee

National Conference of State Legislatures

Matt Salo

Director of Health Legislation

National Governors Association

INNOVATIVE MANAGEMENT OF DENTAL DECAY

FOR YOUNG CHILDREN ENROLLED IN MEDICAID/SCHIP

I. Purpose 
The Health Care Financing Administration (HCFA), along with the Centers for Disease Control and 
Prevention (CDC), the Health Resources and Services Administration (HRSA), and the Indian Health 
Service (IHS), is soliciting project proposals from State Medicaid agencies and agencies administering 
the State Childrens Health Insurance Program (SCHIP). The purpose of these projects is to 
demonstrate oral health improvement and dental care cost savings resulting from early case identification 
and innovative management of oral conditions among young children enrolled in Medicaid and SCHIP. 
This grant program will provide administrative resources which will assist States in providing and  assessing a constellation of services which include preventive and therapeutic regimens that are 
considered efficacious, but have not been widely implemented in dental practice or in publicly-funded 
dental services delivery programs. The objective of the program of Innovative Management of Dental 
Decay for Young Children Enrolled in Medicaid/SCHIP is to demonstrate that such disease 
management interventions can reduce dental disease, and reduce the need for conventional treatment 
and associated dental repair costs. Under this four-year demonstration program, the HCFA will make 
awards to one or two State Medicaid agencies in the estimated amount of $220,000-$445,000 for the 
initial project period of up to 18 months. 
II. Background 
Pediatric dental caries as a public health problem. Despite substantial reduction in pediatric tooth decay 
(dental caries) which has occurred in the U.S. over the past two decades, dental caries remains a major 
problem for many children, especially among children disadvantaged by low income, minority and 
immigrant status (Edelstein and Douglass, 1995).  Progressive tooth decay causes children to suffer pain 
and infection, dysfunction in eating and speech, distraction and irritable behavior, and creates attendant 
learning limitations and issues of negative self-esteem. Healthy People 2000 updates show no reduction 
in caries prevalence among 6-8 year old children since the 1986 baseline, and a modest increase in the 
percentage of children with unfilled cavities. The National Institute of Dental and Craniofacial Research 
reports that 80 percent of tooth decay is isolated in only 25 percent of children (Kaste et al., 1996), with 
the most untreated disease occurring in those of low income. Children below 200 percent of poverty 
have substantially more dental disease, and more untreated dental disease than those above the 200 
percent poverty level. Mexican-American and African-American children are about twice as likely to 
experience caries, and have higher levels of untreated caries than their non-Hispanic white counterparts 
(Vargas et al., 1998) 
Preschoolers (2-5 years of age) below 200 percent of poverty have four to five times more cavities than 
children above 200 percent of poverty (Vargas et al., 1998). While Healthy People 2000 noted 
improvement in the percentage of young children who had access to dental care, a recent report from 
the Medical Expenditure Panel Survey did not show such improvement (Edelstein and Manski, 2000). 
In certain populations, such as American Indian and Alaskan Native children, early childhood caries has 
been found to be an especially significant public health problem as the condition affects more than 50 
percent of preschool children (Bruerd and Jones, 1996).  High rates of dental caries have also been 
reported for Head Start children. Chronically poor oral health is associated with failure to thrive in 
toddlers (Ayhan et al., 1996) and compromised nutrition in young children (Acs, 1992). Following 
therapeutic intervention, children with low weight and early childhood caries exhibit significant catch-
up growth (Acs et al., 1998). 
Pediatric dental caries as a concern in Medicaid/SCHIP. Children at elevated risk of acquiring dental 
caries are often covered for dental services by Medicaid, with its comprehensive Early and Periodic, 
Screening, Diagnostic and Treatment services, or by SCHIP programs which generally provide routine 
dental care. HCFAs Office of the Actuary estimates that combined Medicaid Federal and State  expenditures for dental care in 1998 account for about $2 billion in annual spending (HCFA, 1999).  Of 
that amount, roughly 60 percent is expended on mandated dental care for children under 21 years of age 
(calculated from HCFA 2082 Report, FY 1996) 
Recent studies of Medicaid expenditures in Louisiana and Iowa (Griffin, et al., 2000; and Kanellis, et al., 
2000) report that substantial costs for treating dental caries in young children accrue to both dental and 
non-dental Medicaid program fiscal accounts. Non-dental costs arise from when traditional surgical 
services (such as hospital laboratory, ambulatory facility, and anesthesia fees) are required during repair 
of teeth of young children with extensive dental caries in the hospital operating room under general 
anesthesia.  Extrapolating from the costs ($1,500-$2,000 per surgical case) and disease prevalence 
noted in these studies, it is estimated that combined Federal and State Medicaid expenditures for 
ambulatory hospital and dental care attributable to dental caries among young children may be $70-115 
million annually. If early childhood caries prevalence among Medicaid beneficiaries in other States is 
more extensive than in Louisiana and Iowa--as is likely because of ethnic and cultural differences--or, 
Medicaid per case reimbursement is higher elsewhere, then the impact on overall Medicaid expenditures 
may be even greater.  In addition, low income children covered by Medicaid and SCHIP who lack 
routine dental care often seek relief of pain and infection in hospital emergency rooms where costs are 
high and care is not definitive.  Such palliative treatment usually only postpones the eventual need for 
restorative or surgical services. Anecdotal reports suggest that emergency room dental services are 
more costly than definitive dental care. Such expenses are reported as medical costs despite their 
strictly dental origin. 
The fiscal impact of dental care for children enrolled in SCHIP is more difficult to estimate because the 
program is still in the early stages of being implemented and tracked. Fifty-four of fifty-six State and 
Territorial Title XXI plans submitted thus far to HCFA have included substantial routine dental services 
for most of the beneficiary population, despite the fact that dental benefits are optional under Title XXI. 
States may elect different mechanisms for implementing SCHIP; 44 percent have expanded Medicaid, 
28 percent have developed separate, non-Medicaid programs, and 32 percent are developing 
combinations of an expanded Medicaid program and a separate SCHIP activity. One State recently 
reported that 22.8 percent of SCHIP claims for the first six months of program operation were 
expended on dental preventive and restorative care. This percentage is substantially higher than the 
amount expended by Medicaid for childrens dental care--estimated at about 2-3 percent of all child 
health expenditures, but is in line with national estimates of the amount expended on dental care in 
comparison to medical office expenditures for children (Manski, 1999). 
The low percent of child health expenditures attributable to dental care relative to total expenditures for 
children in Medicaid is partly indicative of long-standing access problems that have beset the Medicaid 
beneficiary population. These problems recently were highlighted by the DHHS Office of the Inspector 
General which reported that less than 20 percent of Medicaid children received any required preventive 
dental service (OIG, 1996). Reports of other populations with substantial reliance on Medicaid, such as 
Native American children, also indicate access problems; in 1996, only one Native American child in 
four had access to dental care (Breuard and Jones, 1996). In response to these reports, HCFA, in 
collaboration with the HRSA, sponsored a major conference in 1998 for Medicaid and dental  community stakeholders in an effort to identify solutions to access barriers (Spisak and Holt, 1999). The 
following year, the American Dental Association sponsored another major national leadership 
conference (ADA 1999) on Medicaid dental services, signaling its commitment to finding solutions. 
Subsequently, several States are considering implementation of State level access strategies that can be 
expected to increase costs to Medicaid, further enhancing interest in cost-saving, non-traditional 
program efficiencies and oral disease interventions. 
Innovative management of dental caries (tooth decay). Traditional clinical caries management may be 
viewed as focusing on surgical repair of damaged teeth through the removal of diseased tooth structure 
and its replacement with biocompatible filling materials. New dental technologies and therapies provide 
potential for dramatic change in the way that this common dental disease is managed in the United 
States. Dental practice may now also include medical, as well as surgical management of dental caries. 
The concept of medical management recognizes that tooth decay is a transmissible, infectious bacterial 
disease and that interventions can be applied to prevent and control this infectious process (Anusavice, 
1998, Ismail, 1998). It recognizes that decay is a chronic process with periods of damage and repair 
that can be controlled effectively in many people by life-long self- and professional care.  In this 
management approach, dental caries is identified at its earliest stages and interventions are applied to 
stop disease progression, reverse early structural damage, and, when restoration is necessary because of 
excessive tooth destruction, teeth are repaired with simplified techniques that aim to avoid anesthesia and 
conserve tooth structure.  Finally, in this model, affected children are placed into customized follow-up 
and prevention programs based on risk that has been assessed at the individual and/or community level 
and are monitored at intervals appropriate to assure that progression and recurrence are reduced or 
eliminated. 
Health benefits and cost-savings of this medically managed approach may accrue to children and their 
families and to Medicaid/SCHIP programs.  Care may be tailored to the level of disease activity so that 
children receive neither too many nor too few services, and disease is treated early and progression is 
checked. In this approach, interventions are designed to identify early disease when it can be stopped 
and reversed, reduce the need for conventional therapies, provide interventions that are less invasive, 
minimize physical pain and discomfort, and avoid exposure to local and general anesthesia (i.e., the 
Atraumatic Restorative Technique, or ART, (Frencken et al., 1996; Kanellis, 1998; Mallow et al., 
1998)).  Primary teeth are retained until normal shedding instead of being extracted prematurely, thereby 
avoiding functional problems with speech and chewing and reducing downstream orthodontic problems. 
Application of innovative oral health management models in the Medicaid and SCHIP arena may also 
enhance access by utilizing providers in addition to dentists to deliver specific components of the model. 
Appropriately trained caregivers including physicians, nurse practitioners, nurses, dental hygienists, 
dental assistants, social workers, peer counselors, community health workers and home visitors may 
each play appropriate roles in preventive service delivery, behavioral modification and dietary 
counseling, and case identification and referral. The model may allow for some services to be provided 
under the auspices of the dentist, but in locations other than the dental office, such as schools and pre-
schools, Head Start settings, WIC facilities, community centers and homes, thus freeing dentist time for 
diagnostic and restorative treatment.  Prevention of early dental caries also may be cost effective  (Ramos, 1999) and may decrease future needs for an expanded dental provider network over the longer 
term. An economic projection model of potential cost savings from innovative management of dental 
caries shows a potential savings of 12.5 percent in dental care expenditures for young children (Zavras 
et al., in press).  These savings are generated primarily from reduction in hospital care for traditional 
surgical and restorative approaches. 
III. The Project 
Project structure and use of funds. The purpose of this four-year demonstration project is to provide 
States with administrative resources which will assist in developing, implementing, and assessing the 
health benefits and cost-savings attributable to preventive and therapeutic regimens which, although 
considered efficacious, have not been widely implemented in or assessed by the private dental sector or 
publicly-funded dental services delivery programs. Grant funds of approximately $220,000-$445,000 
will be available for the initial budget period of up to 18 months. The number of grant awards depends 
upon the availability of funds and the technical quality of the applications. All future year funding is 
contingent upon acceptable performance and funding availability. States are encouraged to contribute 
additional funds or seek further funding support for this project from other agencies and organizations in 
order to expand the scope of the proposed study and to add evaluation components. 
Grant funds may only be used for administrative tasks such as program development, provider training, 
data collection and analysis, research-related tasks, consultative or other contracts relevant to the 
project, and development of a budget neutrality model, if such a model is necessary (see discussion of 
Budget Neutrality below).  These grant funds may not be used to obtain Federal matching funds under 
any Federal-State program. A State may elect to contribute State funds to improve or expand the 
administration of the proposed study; if these expenditures meet requirements under Medicaid, SCHIP, 
or another Federal-State program, Federal matching funds may be available. 
Example. Assume that the entire $445,000 grant amount is awarded to one State, and the total 
administrative expenditures incurred under the States demonstration project are $485,000. In 
this example, $40,000 ($485,000-$445,000) represents additional State expenditures under the 
project.  The grant award of $445,000 would be applied against the first $445,000 of the 
incurred administrative expenditures, and the remaining $40,000 may be claimable under 
Medicaid or SCHIP by the State at the appropriate Federal financial participation (FFP) for the 
type of administrative expenditures incurred. 
Grant funds may not be used for payment of direct dental, medical or other services. Such payment 
must be made from State Medicaid, SCHIP, or State-only programs. Waiver of Federal requirements 
of  comparability, statewideness of services, or freedom of choice of providers may be needed if 
the project includes a modification of the Medicaid benefit package, such as introduction of a new 
service for the study population, or plans to require beneficiaries to obtain services only from specified 
providers (see discussion of Waivers below). Other waivers also may be needed. In addition, an  amendment to the Medicaid State Plan or SCHIP plan may be necessary.  Grantee States will be 
responsible for obtaining necessary approval of waivers. 
It is anticipated that most States applying for this project will wish to enter into an agreement for 
research design and evaluation, scientific development, and day-to-day management and operation of 
the project with an entity (e.g., a school of dentistry or medicine, school of public health, community-
based health center, IHS dental facility, CDC Prevention Research Center, or other State or local health 
agency, etc.) having strong research management experience, especially in conducting studies involving 
oral health benefits/status and cost assessment. 
In this regard, applicants are advised of a recently issued Request for Application (RFA) (DE-99-003) 
from the National Institute of Dental and Craniofacial Research (NIDCR) and a consortium of Federal 
agencies including the National Institute of Nursing Research, the National Institute of Child Health and 
Human Development, HRSA, IHS, CDC, HCFA, the National Institutes of Healths (NIH) Office of 
Minority Health, the Office of Behavioral and Social Science Research (NIH), and the Office of 
Research on Womens Health (NIH).  Research supported by applications in response to this RFA will 
involve multi-project, multi-disciplinary studies aimed at, among other things, developing interventions to 
prevent or reduce oral health disparities in children and their caregivers.  One requirement of the RFA is 
that, in developing centers for research to reduce oral health disparities, consortia be formed between 
academic health centers, community/migrant health clinics, IHS clinics, CDC Prevention Research 
Centers, State and local health care and health care financing agencies, and other providers of oral 
health to children and their caregivers.  The endpoint of this research is to provide a database that can be 
used to generate and test interventions, including those involving funding of and access to oral health 
services, that will eliminate and prevent oral health disparities.  These data also may be used to develop 
or modify policies pertaining to all phases and levels of prevention and treatment of dental caries in 
children. We bring this RFA to your attention as a possible opportunity to become involved in a 
developing centers research activities, and establish collaborations and partnerships with research 
institutions that will be responding to the RFA DE-99-003 referred to above. 
Project goals and guidelines. Each of the following goals should be addressed, at least in part, in any 
application for these funds: 
1. 	 Identify innovative management interventions, which over time, can reduce dental disease among 
young children enrolled in Medicaid and/or SCHIP, shift care from surgical dental services to 
less expensive preservative care that seeks to avoid or delay operative intervention for as long as 
possible, reduce the number of dental restorations and replacement of restorations, decrease the 
need for orthodontic care by retaining primary teeth, reduce emergency room visits for dental 
emergencies, and reduce the use of general anesthesia in dental treatment. 
2.	 Test approaches that result in improved access to dental care for the population by enhancing 
dentist and other provider participation in Medicaid and/or SCHIP, and increasing the number 
of children seeking and receiving diagnostic, preventive and therapeutic services.  3.  Develop and document innovative management policies and procedures so that similar programs 
may be duplicated across the country.  Documentation is needed, for example, for: 
C  defining such items as the process for educating and enabling or certifying dentists and 
other providers to receive reimbursement for use of new procedures, therapies and 
technologies (which are cutting edge and may not be used widely in dental practice); 
C  identifying the need for new dental claims codes not currently available as part of the 
American Dental Associations CDT-3 coding system and in the HCPCS coding 
system; 
C  refining the protocols for, and utility of the techniques selected to assess risk of dental 
disease at the individual and/or community level; 
C  describing how physicians and other health care providers may participate in triage, risk 
assessment, primary prevention, disease suppression and health maintenance, and 
C  identifying approaches that take into account cultural/ethnic differences in beliefs and 
practices about health care, health care seeking, and health care delivery. 
4.	 Control or reduce costs of oral health care (both per capita and for the demonstration 
population) by, for example, reducing the number and altering the type of treatments and repeat 
treatments; reducing the potential need for orthodontic services; reducing emergency room and 
general anesthesia use for dental problems; and using non-dentist personnel to provide novel 
services. 
Additional guidelines for States in preparing applications for funding may be found in Appendix One, 
Application Guidelines  Project requirements: 
Selection of interventions: States are encouraged to propose a project which utilizes several of many 
possible oral health management interventions. These interventions may include, but are not limited to: 
C  Triage of enrolled, young child populations to identify dental caries risk and heightened disease 
activity at the individual and/or community level; 
C	 Primary caries prevention by dentists, other health professionals, and peer counselors through 
provision of family-level interventions, including prevention of infectious transmission of caries 
from mother to child, which may include emphasis of healthy dietary and hygienic behaviors; 
C	 Tooth-level interventions using antimicrobial and fluoride preparations, such as fluoride varnishes 
which suppress bacterial flora and remineralize early caries; 
C	 Caries management using new therapeutic techniques and materials (e.g., ART) that reduce the 
need for local and general anesthesia and help retain affected teeth until the child may better 
tolerate traditional dental repair. 
C	 Maintenance and preventive care that is adjusted and proportional to assessed level of risk, 
effective in reducing caries progression, while avoiding services not demonstrated to be effective 
(Frame et al., 2000). 
C	 Traditional preventive and therapeutic oral and medical services which may be organized and 
delivered in non-traditional settings or at variable frequencies. 
Study population. The study population for the project must be young children enrolled in Medicaid or 
SCHIP.  States may choose to provide oral health services and interventions to any range of young 
children, up to six years of age, e.g., ages 0-3, age 2 through age 5 years, etc.  If the proposed 
intervention is directed at the child, but the parent is integral to delivery of the educational or clinical 
intervention, e.g., assuring the childs home care regimens, or attendance for regular professional care to 
reduce oral bacteria in the adult caregiver in efforts to delay caries transmission to the child, then the 
caregiver may be included in the project plan. The subject population must be of sufficient size to 
provide statistically meaningful comparisons among the new treatment group(s) and the current standard 
of care control group for this population.  Standard statistical analyses with sufficient power to detect 
clinically meaningful outcomes should be incorporated into the research plan.. 
Data collection and analysis. The project must describe a method of data collection and analysis 
capable of tracking and discerning selected differences in the health status and associated costs/savings 
of the projects study and comparison populations.  The project should provide a census of the 
enrollment characteristics of the population and evidence that the project can enroll and follow-up for 
patients to be  included in the study.  The project proposal should describe plans for protecting the 
confidentiality of any project-related information that identifies individuals. The proposal should indicate 
that such information is confidential and may not be disclosed directly or indirectly except for purposes 
connected with the conduct of the project, and assure that informed written consent of the individual is 
obtained for any disclosure. 
Data and Safety Monitoring. Each project will need to describe an independent Data and Safety 
Monitoring Board (DSMB) consisting of individuals not connected in any way to the study.  The DSMB  should consist at least of a chair who is knowledgeable in the area of study, a biostatistician, an ethicist, a 
pediatric dentist, a health economist and others whose expertise reflects the scientific focus of the 
demonstration project.  The DSMB members are responsible for monitoring the safety of the patients 
and the internal progress of the project. They should meet annually to review these items and prepare an 
annual report which may be provided to HCFA as to whether progress is acceptable, patients are safe 
and the project should continue for an additional year. The DSMB should meet to review and approve 
the proposed protocol and manual of operations before any patients are entered into the project. The 
manual of operations will contain details about the intervention(s) to be tested, the research plan, 
protocol, etc. and will be used by study staff in guiding their day-to-day activities (i.e., it will help assure 
that everyone within the study is consistent in how they do things). 
IV. General Provisions 
Although applicants have considerable flexibility in developing demonstration projects under this 
solicitation, proposals for the Innovative Management of Dental Decay for Young Children Enrolled in 
Medicaid/SCHIP must comply with the following: 
Duration of Proposed Program. States applying for a grant should plan to expend grant budgets in a 
period of no more than 18 months from the date of award. 
Waivers. The grantee States must identify waivers or Medicaid or SCHIP requirements that they will 
require to carry out the demonstration project. Under Section 1115 (a)(1) of the Social Security Act, 
the Secretary may waive compliance with Medicaid State plan requirements (Section 1902) to further a 
demonstration project consistent with the objectives of the underlying statute. 
In addition, Section 1115(a)(2) authorizes the Secretary to permit FFP for (1) expenditures for services 
or individuals who would not otherwise be covered, or (2) expenditures which would otherwise be 
denied based upon a limitation or condition imposed by Section 1903 of the Act. This authority, 
described as costs not otherwise matchable, may be used to cover additional individuals or services 
not in the State plan or to permit the State to use alternative delivery systems. 
Medicaid demonstration projects often require approval of such waivers or costs not otherwise 
matchable prior to implementation. Essentially, these waivers permit HCFA to pay for services that 
would otherwise not be reimbursable. For example, States may propose that service benefits may be 
available only to Medicaid enrolled beneficiaries who are included in the study population, or may 
require program participants to obtain their dental services through designated providers.  In these 
circumstances, a waiver of Federal statutes requiring comparability, statewideness of services, and 
freedom of choice of providers may be necessary. States should indicate whether or not they consider 
a waiver to be needed under this project. 
A State, however, is not required to submit an application under the applicable waiver program(s) as 
part of its grant proposal.  Typically, demonstration projects go through a developmental phase before  they need Medicaid waivers to become operational.  Thus, most Medicaid demonstrations will need 
approval of demonstration waivers by the Federal Government before they enter their operational phase 
and begin operations. Hence, if the government deems that a waiver is necessary, the State will need to 
submit a waiver request prior to implementation of the project. Moreover, all applicable required 
demonstrations of cost-neutrality, cost-effectiveness, or budget neutrality remain in effect should any of 
the above noted waiver authorities be sought under this grant program. (Note that Medicaid waivers 
generally are not required for demonstrations which selectively alter reimbursement for covered benefits; 
such provisions are usually aimed at changing provider incentives for delivery of the service). 
Title XXI, however, permits considerable flexibility in designing the benefit package for States with 
separate (non-Medicaid) SCHIP plans. In addition, comparability and statewideness are not factors 
in these programs since States may define geographic areas in which their programs will be implemented. 
Budget Neutrality. In general, current Federal policy is that Federal Medicaid expenditures in a Section 
1115 demonstration must not be higher than they would have been in the absence of the waiver. A 
budget neutrality cap is established at this expenditure level, and States cannot receive Federal matching 
funds in excess of this cap. If Medicaid 1115 waivers are pursued in the future as part of this 
demonstration, the demonstration will have to be budget neutral and will have to include a cap on 
applicable Medicaid expenditures. However, HCFA staff will be available to provide technical 
assistance for developing a model for budget neutrality. 
Independent Evaluation. All grantees receiving awards under this grant program must agree to 
participate in an independent evaluation of the programs effectiveness.  Grantees agree to provide 
health status, expenditure, utilization, outcome and additional data as appropriate to support the 
evaluation.  States may be required to submit case studies of persons participating in the project. 
Applicants are encouraged to plan to submit an independent, annual evaluation of the project, and to 
identify individuals, not directly connected with the project, who may be called upon to conduct that 
assessment.  (This evaluation differs from that conducted by the DSMB, in that the DSMB is focused on 
internal operations, whereas the independent evaluation addresses findings and other progress towards 
achievement of program goals).  The applicants budget should include funds which will enable key 
project personnel to meet at least annually with HCFA staff in Baltimore, Maryland, to describe the 
progress of the project. 
Civil Rights. All grantees receiving awards under this grant program must meet the requirements of Title 
VI of the Civil Rights Act of 1964; Section 504 of the Rehabilitation Act of 1973; the Age 
Discrimination Act of 1975; Hill-Burton Community Service nondiscrimination provisions, and Title II, 
Subtitle A, of the Americans with Disabilities Act of 1990.  States are encouraged to contact the Office 
of Civil Rights, DHHS, at (202) 619-0403 for technical assistance in developing a grant proposal that 
meets all the requirements of the civil rights and disability laws. 
Intergovernment Review of Federal Programs. This program is not covered by Executive Order 12372, 
"Intergovernment Review of Federal Programs." Executive Order 12372 provides for a State 
Clearinghouse in each State to review Federal Programs. Research grants are exempt from this review."  V. Applying For A Grant 
Eligible Applicants. Applicants must be State Medicaid or SCHIP agencies.  State Medicaid and 
SCHIP agencies are encouraged to work with each other, consumers and their families, other State 
agencies, community organizations, dental and other provider organizations, and other entities in 
developing applications. 
Proposed Format. Appendix One contains a format for submitting a proposal. 
Application Forms. In addition to the application, applicants must submit completed application forms 
included with this package: Application for Federal Assistance (Standard Form 424), Budget 
Information (Standard Form 424A) Assurances (Standard Form 424B), and Disclosure of 
Lobbying Activities (Standard Form LLL). Standard Form LLL also may be obtained by FAX from 
Dr. Don Schneider at the address in Section VII. Standard Forms 424, 424A, and 424B are also 
available at http://www.hcfa.gov/ord/Grantop.htm on the Internet.  On Standard Form 424, Section 10, 
insert 93-779 for the Catalog of Federal Assistance Number, and in Section 11, insert Innovative 
Management of Dental Decay for Young Children Enrolled in Medicaid/SCHIP as the descriptive title. 
Deadline for Submission. The closing date for proposals submitted under this solicitation is August 1, 
2000. If the proposal is sent by a commercial delivery service, it must be received in HCFAs grants 
office on or before August 1, 2000.  If the proposal is mailed through the U.S. Postal Service, it must be 
postmarked on or before August 1, 2000.  A proposal delivered by the U.S. Postal Service and 
postmarked after the closing date will be considered late.  Late proposals will not be considered for an 
award. 
An original proposal should be sent with two copies to: 
Attn: Mrs. Linda Bianco

Health Care Financing Administration

AGG, Grants Management Staff

Mail Stop C2-21-15

7500 Security Boulevard

Baltimore, Maryland 21244-1850

Phone: (410) 786-7080

Although States are not required to submit more than an original and two copies of an application,

submission of additional five copies will help alleviate administrative burden and assist in expedient

processing of incoming applications by the grant office.

VI. Application Review  An independent review of proposals will be conducted by a panel of experts. The panelists 
recommendations will contain numerical ratings (based on criteria specified in Appendix Two), the 
ranking of all applicants, and a written assessment for each proposal. The recommendations of the panel 
will be reviewed by HCFA and ASPE. HCFA reserves the right to conduct site visits to those States 
receiving the highest ratings from the technical review panel. The number of States who may receive site 
visits will be determined based on the number of submissions and the number of proposals scored as 
technically acceptable by the technical review panel. 
Final award decisions will be made by the HCFA Administrator after consideration of the comments and 
recommendations of the technical review panelists, comments and recommendations of the site visit 
teams (if conducted), and availability of funds. 
Awards will be made by September 30, 2000. States will receive written notification of the final award 
decision.  We expect to announce award decisions in September 2000. 
VII.  Additional Information 
For additional information regarding this solicitation, please contact: 
Don Schneider, D.D.S., M.P.H.

Chief Dental Officer, HCFA

Center for Medicaid and State Operations

Health Care Financing Administration

Mail Stop: S2-26-12

7500 Security Boulevard

Baltimore, Maryland 21244-1850

Telephone: (410) 786-5133

E-mail: dschneider@hcfa.gov
 For additional information about the NIDCR Project, RFA DE-99-003, Centers for Research to 
Reduce Oral Health Disparities, please contact: 
Norman S. Braveman, Ph.D.

Associate Director for Clinical, Behavioral and Health Promotion Research

National Institute of Dental and Craniofacial Research

45 Center Drive, Building 45, Room 4AN-24B

Bethesda, Maryland 20892-6402

Telephone: (301) 594-2089

E-mail: Norman.Braveman@nih.gov

For information about the Centers for Disease Control and Prevention's Prevention Research Centers," 
contact Dr. Barbara Gooch at the following address, or visit http://www.cdc.gov/prc on the Internet: 
Barbara F. Gooch, D.M.D., M.P.H.

Division of Oral Health

National Center for Chronic Disease Prevention and Health Promotion

Centers for Disease Control and Prevention

4770 Buford Highway, MS F-10

Atlanta, GA  30341

Telephone: 770-488-6068

FAX: 770-488-6080

E-mail: bfg1@cdc.gov

VIII.  Authority 
Sections  1110, 1115(a) of the Social Security Act, As Amended (Catalogue of Federal Domestic 
Assistance Program Number 93.779, Health Financing Research Demonstrations and Experiments  Appendix One 
Application Guidelines 
The following guidelines are intended to assist States in preparing an application for funding under the 
program for Innovative Management of Dental Decay for Young Children Enrolled in Medicaid/SCHIP. 
C	 The narrative portion of the proposal (Item 3 below) should not exceed 30 double spaced 
typewritten pages, using a font size no smaller than 11.5. 
C	 Additional documentation should be appended; however, material should be limited to information 
relevant to the specific scope and purpose of the grant.  Do not include critical details in an 
Appendix. 
Recommended Proposal Format 
A complete proposal consists of the narrative application (Item 3) plus the required material noted below. 
Application materials should be organized as follows: 
1. Cover Letter From the Medicaid or SCHIP Director

A cover letter signed by an authorized individual on behalf of the lead organization.  The letter should

indicate the title of the project, the name of the lead organization and principal contact person, the amount

of funding requested, the amount of any State matching funds committed for the planning and implementation

phases, and the names of all organizations collaborating in the effort.

2. Project Abstract

A project abstract limited to one page. The abstract should serve as a succinct description of the proposed

project and should include:

C  The overall goals and organization of the project 
C  A description of the proposed target population, covered benefits/interventions, and data 
collection and analysis plans. 
3. Narrative Application

The narrative application should provide a concise and complete description of the proposed project. The

narrative or body of the application must not exceed 30 double-spaced pages using a font size not less than

11.5.  Please do not rely on appendices to describe key details.  This narrative should contain the

information necessary for reviewers to fully understand the project being proposed and should be further

organized as follows: 

A.	 Provide a brief description of the operation of the oral health care delivery system in the State, with 
emphasis on Medicaid and/or SCHIP (to the extent that each of these programs will be the focus 
of the proposed project). Specify:  C	 the epidemiology of dental caries in the State and in populations served by State 
programs, emphasizing the oral health status of the population less than 21, and less 
that 6 years of age, to the extent that such information is available. 
C  the  way in which oral health services are organized and delivered, including 
important relationships with other health care delivery organizations and entities; 
C  how the States program is administered, identifying key organizational units with 
responsibility for day-to-day management of State programs. 
C	 any problems of access, accessibility, quality, availability or other problems relating 
to oral health and oral health services, and any initiatives underway to resolve those 
problems. 
B.	 Describe the proposed project. While planning for some areas may be incomplete, please include 
as much detail about the proposed project components as possible: 
C	 Innovative management model/hypotheses: Identify and describe the problem(s) that the 
proposed innovative management model will address.  Describe the hypotheses to be 
tested.  Describe the types of services to be provided, and the scientific basis for 
assumptions that the selected innovative services will improve health outcomes and contain 
or reduce cost.  Describe the way in which the management model will be offered to the 
beneficiary demonstration population, specifying the providers who will participate and their 
availability and accessibility to the population, and the mechanisms for delivery of the 
services.  Describe the services offered and the care delivery system in the control 
community(s). 
C	 Target population:  Identify and describe populations in one or more cities, counties, or 
other defined areas of the State in which the demonstration will occur, and define  a 
population which may serve as the control cohort.  Both demonstration and control 
populations must include enough children within the age range 0-6 years to assure that there 
will be sufficient power to obtain statistical significance for analyses made over the course 
of the demonstration; assure that demonstration and control populations are comparable in 
socio-economic and oral disease status, and that other critical variables and confounders 
are controlled from the outset of the demonstration. A description of relevant local dental 
delivery system issues in the target population communities should be included; 
C	 Data collection and analysis plan: For both the demonstration and control populations, 
specify the data to be collected, the method of data collection, and proposed plan for 
analyzing the data such that there is assurance of adequate program evaluation capability 
and statistical analyses necessary to measure the effect of interventions. At a minimum, data 
must be obtained annually for the demonstration and control populations on the utilization 
of dental and dentally-related services (e.g., in hospitals and ambulatory surgical facilities), 
the specific types of services provided to the populations, the dental and dentally-related 
costs of the services both per capita and for the total population, and the oral health status 
of the populations.  If data will be obtained from sources other than currently available  administrative data sets, (or through integration of separate data sets), provide details of the 
data collection (e.g., chart audits, clinical epidemiologic assessments, etc) and sampling 
methods to be used. 
C	 Documentation: Describe the documentation, protocols, and procedural manuals that will 
be developed during the course of the project, and how that documentation might be of use 
to other States desiring to duplicate the demonstration. 
C	 Partnerships:  Describe the participation and collaboration of State Medicaid program 
officials,  and/or  SCHIP  program  officials,  if  appropriate,  and  the  dental  provider 
community, and other relevant stakeholders (e.g., dental schools, medical societies, 
managed care organizations, State and local health agencies, community health centers, 
parent/community organizations, school authorities, Indian Health Service or Tribal 
authorities, WIC, Head Start) anticipated to play a role in the project. 
C	 IRB: Indicate if there will be a need for IRB approval and, if so, describe the plan to assure 
that all IRB procedures and requirements are met. 
C	 Waivers/State Plan Amendments. Provide an initial assessment of the need for waivers, 
ifany, or amendments to the State plan that the State feels are necessary to implement the 
program.  States may need to request Medicaid waivers to provide services not available 
to all Medicaid beneficiaries in the State or for other reasons, or may need to submit an 
amendment to the State Plan. 
C.  Describe the milestones and work products/tasks to be accomplished during the grant period. The 
purpose of this section is to outline clearly what the State hopes to achieve in the allotted four-year 
grant period. 
C  Example of work products/tasks might include: an analysis of collected data, a completed 
waiver application, a training module for providers, or a health status survey instrument. 
C  Timetables for accomplishing the major work products/tasks to be undertaken should be 
included and should include key dates relevant to the proposed project (e.g., State budget 
cycles and legislative sessions, if the project will require legislative/budget action). 
C  Plans for conducting a periodic, independent evaluation of project progress, the operation 
of the Data and Safety Monitoring Board and plans for obtaining IRB approval. 
D.  Describe the project organization and staffing including: 
C  Proposed management structure and how Project Administrator/Director will relate to the 
Principal Investigator, other key staff, and other partner and participating agencies. 
C  As an appendix (not included in the 30 page limit), provide biographical sketches of the 
Project Administrator/Director (generally a State official), Technical Director or Principle 
Investigator (who may not be a State official) and other key project personnel, indicating 
their qualifications and prior experiences relevant to the project.  Resumes for the key 
project personnel should be provided as an attachment.  E.	 Describe the support and commitments that have been pledged for the proposed project (e.g., 
cooperation from other State agencies, the States executive and legislative branches, professional 
associations, collaborating academic and other institutions, key clinical service delivery sites and 
entities, fiscal agents or managed care entities with responsibilities for managing the States 
Medicaid/SCHIP programs, etc.). Individual letters of support should be included as an appendix 
and are not included in the 30 page narrative limit. 
4.  Program Budget 
The proposed budget for the project should distinguish the grant funded portion of the project from 
the direct services portion of the project.  Appendix Two 
Review Criteria 
1.  Technical Approach (50 points) 
The State must define how it will design and implement the project, addressing the following areas: 
C  description of current State and relevant, local level oral health care delivery system issues and 
concerns. 
C  innovative management model described with justification for selection of the constellation of 
proposed therapeutic and preventive services in terms of health benefits and cost savings. 
C	 target and comparison populations identified.  Additional points will be awarded for projects which 
incorporate American Indian and Alaskan Native populations into the study populations. 
C	 hypotheses to be tested, and data collection and analysis plans are described, along with plans for 
gaining access to population data where administrative data sets are not available.  Additional points 
will be awarded for projects which demonstrate an ability to collect or incorporate additional data not 
commonly available to State Medicaid or SCHIP agencies, and which expand the depth of the 
proposed analyses in assessing health improvement and cost savings. 
C	 description of the potential for the model selected to be duplicated elsewhere and importance of the 
materials and documentation developed during the project to facilitate duplication. 
2.  Staff (20 points) 
Identification of key program staff and evidence that the staff (including the Project Administrator/Director) 
are qualified and possess the experience and skills to implement and conduct the program within available time 
frames. 
3.  Project Feasibility (15 points) 
The States should demonstrate that critical elements of the project will be accomplished in the proposed time 
frame.  Key issues include potential for obtaining State-contributed resources for service delivery, difficulty 
in  conducting necessary training and training materials, likelihood that providers of the services will be 
available, inclusion in the proposal of wrap-around services such as transportation and case management which 
might facilitate childrens receipt of services, evidence that elements of the proposal are already underway 
in the State, etc.  4.  Level of Commitment to the Project (15 points) 
States must demonstrate their commitment to undertake this initiative, providing any evidence of support for 
the project, including evidence of coordination among and collaboration with other agencies and organizations. 
Additional points will be awarded to applications from States which demonstrate use of their own resources 
in  combination with grant fund, or which can demonstrate funding support from other agencies and 
organizations. 
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