July 3, 2023
Administrator Chiquita Brooks-LaSure
Centers for Medicare and Medicaid Services
Department of Health and Human Services
7500 Security Boulevard
Baltimore, MD 21244-1850
Re: CMS–2442–P, Medicaid Program; Ensuring Access to Medicaid Services
Dear Administrator Brooks-LaSure:On behalf of the members of the undersigned dental organizations, we are writing in responseto the proposed rule, CMS–2442–P, “Medicaid Program; Ensuring Access to MedicaidServices.”
We are dedicated to assisting dentists in advancing the oral health of the public and believe that
Medicaid plays an essential role in our nation’s oral health safety net. Oral health is alsoessential to overall health, especially for Medicaid beneficiaries, many of whom are disabled orface other serious health conditions. We appreciate the Centers for Medicare and Medicaid
Services’ (CMS) efforts in improving access to care, ensuring quality and health outcomes, andbetter addressing health equity issues in the Medicaid program across fee-for-service (FFS),
and offer the following comments on how this can best be achieved in dentistry. These
proposed improvements seek to increase transparency and accountability, standardize data andmonitoring, and create opportunities for states to promote active beneficiary engagement in theirMedicaid programs, with the goal of improving access to care.
Rate Transparency Requirements
CMS notes the relationship between provider payment rates and access to care by proposing
greater transparency on provider rates. This includes using an analysis that compares Medicaidand Children’s Health Insurance Program (CHIP) rates for certain services to Medicare rates for
those services. While many states make their FFS rates public this proposed rule would require
all states to do so in a simplified and uniform manner. CMS will continue to review states’
payment rates for managed care plans annually when states submit contracts for approval butwith the benefit of additional data from the new provider reimbursement analyses andmonitoring surveys. Greater federal scrutiny on FFS rates would be triggered if states seek toreduce rates for any service in a manner that could significantly diminish access, such as bybringing rates below 80 percent of comparable Medicare rates, and CMS retains authority towithhold federal payments for noncompliance. We support transparency requirements for
FFS rates but urge CMS to improve transparency further by also requiring more granular
data within the dental category, such as utilization numbers, median fees, and service
frequency. The tendency towards categorizing dental as a whole, without greaterbreakdowns in data, does not meet the transparency standards CMS seeks to implement
more broadly. Further comparisons to Medicare FFS would be inapplicable for dentalservices. We urge use of commercial data such as federal or state employee dental planpayment rates or FAIR Health data as benchmarks for such comparisons.
Provider Payment
As CMS notes many times throughout the proposed rule, states are required by law to ensurethat FFS provider payment rates are “sufficient to enlist enough providers so that care andservices are available under the plan at least to the extent that such care and services areavailable to the general population in the geographic area.” Along with network adequacy andaccess standards, sufficient provider payments are critical to ensuring Medicaid recipients haveaccess to an adequate network of providers. Current approaches to ensure provider rates are
not sufficient and are administratively burdensome for providers and states. They also varyacross states. Medicaid has historically paid very low rates to providers creating situations
where, in some states, a very small number of dentists serve a very high proportion of theMedicaid beneficiaries. Corrective actions should be initiated in payments to maintainnetwork adequacy and at a minimum, incentives should be offered. We support Medicaid
programs establishing policies that incentivize any dentist willing to provide a dental home forchildren from birth to age 5 and providing opportunities for early-career dentists to engage withstate Medicaid programs through loan repayment programs for dentists who are willing to treat
a disproportionate number of Medicaid beneficiaries. We also support additional funding suchas enhanced reimbursement to dental schools that treat Medicaid beneficiaries.
In addition to the policies put forth by CMS, we are also supportive of allowing dentists to claim
a tax credit for the first $10,000 of services (based on the most recent Code on Dental
Procedures and Nomenclature (CDT) codes) and credited at a rate consistent with the dentists’full fees for that region or state.
We wish to note the strong correlation between beneficiary access to dental services andpayment rates. Establishing an adequate dental provider network and setting a minimum
payment level are both elements that ultimately translate into timely access for enrollees anddentist participation. There are sound, reasonable principles related to payment that can be
tailored to meet the specific needs of states while being uniformly required by all. Two of theseconcepts are: regular assessments of fees; and establishing parity in payments across eligibility
groups.
Fee Assessment
Many states have not revisited their Medicaid dental payment rates for years. (This is important
not only in traditional FFS programs, but also in the state-provided fee guidance that is provided
to managed care contractors.) When rates do not adjust for the price of inflation or the CPI year
over year, this can eventually become prohibitory to participation, as the provision of carebecomes costlier than the associated reimbursement received for delivering the care.

We believe that a CMS requirement for states to conduct regular assessment of fee policies isprudent. The requirement could be to review on, for example, a tri -annual basis so as not tobecome too burdensome on the state agencies. The states should be required to make publicly
available the results of these fee assessments.
CMS could support states by providing information crucial to their assessment, such as rates ofinflation and dental CPI. When data is available, state agencies could compare Medicaid
payment rates to private insurance rates.
Payment Parity
In states that administer Medicaid programs separately from CHIP programs, it is notuncommon for the provider payment rates to be substantially higher for services rendered tochildren covered by CHIP compared to those in the Medicaid program. This is discriminatory
and perpetuates oral health disparities, as it disproportionately affects lower income families.
Establishing payment parity between Medicaid and CHIP and regardless of age promotes
health equity, as it reduces the likelihood of one underserved population accessing care at theexpense of another. Payment rates for all CMS programs should be on par with other CMS
programs, and states should benchmark these rates to private insurance rates using state-level
FAIR Health data.
Similarly, reimbursement rates for child dental services are typically higher than for the same
service delivered for the adult population in Medicaid. In a recent analysis, the American Dental
Association’s Health Policy Institute found that 2020 Medicaid reimbursement rates were 61.4%
of private insurance reimbursement rates for child dental services on average in the U.S., ascompared to 53.3% of private reimbursement rates for adult dental services. 1
Enrollee EngagementCMS is proposing to replace requirements for states to use a Medicare Care Advisory
Committee (MCAC) to advise on health and medical services with more broad stakeholder
committees. States would be required to create both a Beneficiary Advisory Group (BAG) and a
Medicaid Advisory Committee (MAC). While BAG membership would exclusively include current
or former Medicaid beneficiaries, their families, or their caregivers, the MAC membership would
include BAG members, advocacy or community-based organizations, managed care plans, andother state agencies. Though we are supportive of creating a broader stakeholder group,
we note the proposed rule only makes recommendations to states on provider inclusion.
While dental and oral health providers are recommended, we would suggest mandating
dental providers be part of such groups. Even if a state does not have an adult Medicaid

1

American Dental Association. Reimbursement rates for child and adult dental services in Medicaid bystate. Health Policy Institute Infographic. October 2021. Available from: https://www.ada.org//media/project/ada-organization/ada/ada-org/files/resources/research/hpi/hpigraphic_1021_1.pdf.
Accessed March 31, 2022.

benefit, the mandated dental coverage of the pediatric population must be taken into
account for group participation.
Website Improvements
The proposed rule would require states to update their websites to simplify navigation andensure the availability of certain types of information such as provider directories, formularies,enrollee handbooks, and information about payment rates and payment evaluation reports.
Improvements would be required as quickly as two years from the date of finalization. We agreewith requiring states to have a more simplified, single website with links to specificprogram and health plan information, explanations of the availability of assistance, andsecret shopper survey results to assist enrollees.
Access Monitoring
Oversight of access to care is important and the proposed rule questions whether additional
access standards for states with a fully FFS delivery system may be appropriate as in themanaged care proposed rule. We are supportive of efforts to require fully FFS states to use thesame standards in managed care, which could include “secret shopper” surveys through whichstates could assess appointment wait times for managed care enrollees and verify informationin provider directories. To further the engagement of enrollees and stakeholders and advanceequity goals, the proposed regulations should bolster opportunities for public input at the statelevel. Annual “satisfaction” surveys of managed care enrollees would be required, andwe would be supportive.
CMS notes it proposes approaches that states could consider addressing the access issue,
such as “increasing payment rates, improving outreach to providers, reducing barriers toprovider enrollment” among others. We fully support these approaches to improve access.
Additionally, we believe that an important part of ensuring access for patients is
reducing administrative burdens, especially audits, for dentists so that they enroll andstay in Medicaid. Any necessary audits should be conducted by a dentist who has thesimilar educational background and credential as the dentist being audited, as well as alicense in the state in which the audit is being conducted. We also support efforts toensure that each state establish a designated Provider Advocate position to conduct
educational sessions for participating providers and provide ongoing technical andnavigational support.
****
Thank you again for your commitment to Medicaid and for the opportunity to comment on thisimportant rule. We would welcome the opportunity to meet with you to discuss how we canassist CMS in meeting the challenges outlined here on Medicaid and dentistry. If you have anyquestions, please contact Mr. David Linn at 202-789-5170 or linnd@ada.org.

Sincerely,
American Dental Association
Academy of General Dentistry
American Academy of Oral & Maxillofacial Pathology
American Academy of Oral & Maxillofacial Radiology
American Academy of Pediatric Dentistry
American Academy of PeriodontologyAmerican Association of Oral and Maxillofacial Surgeons
American Society of Dentist Anesthesiologists
American Student Dental Association
Association of Dental Support Organizations