Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

CHILDREN’S DENTAL SERVICES 

UNDER MEDICAID 

ACCESS AND UTILIZATION 

JUNE GIBBS BROWN 

Inspector General 

APRIL 1996 

OEI-09-93-00240 
OFFICE OF INSPECTOR GENERAL 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 

amended, is to protect the integrity of the Department of Health and Human Services’ (HHS) 

programs as well as the health and welfare of beneficiaries served by those programs. This statutory 

mission is carried out through a nationwide network of audits, investigations, and inspections 

conducted by three OIG operating components: the Office of Audit Services, the Office of 

Investigations, and the Office of Evaluation and Inspections. The OIG also informs the Secretary of 

HHS of program and management problems and recommends courses to correct them. 

OFFICE OF AUDIT SERVICES 

The OIG’s Office of Audit Services (OAS) provides all auditing services for HHS, either by 

conducting audits with its own audit resources or by overseeing audit work done by others. Audits 

examine the performance of HHS programs and/or its grantees and contractors in carrying out their 

respective responsibilities and are intended to provide independent assessments of HHS programs and 

operations in order to reduce waste, abuse, and mismanagement and to promote economy and 

efficiency throughout the Department. 

OFFICE OF INVESTIGATIONS 

The OIG’s Office of Investigations (OI) conducts criminal, civil, and administrative investigations of 

allegations of wrongdoing in HHS programs or to HHS beneficiaries and of unjust enrichment by 

providers. The investigative efforts of OI lead to criminal convictions, administrative sanctions, or 

civil money penalties. The OI also oversees State Medicaid fraud control units which investigate and 

prosecute fraud and patient abuse in the Medicaid program. 

OFFICE OF EVALUATION AND INSPECTIONS 

The OIG’s Office of Evaluation and Inspections (OEI) conducts short-term management and program 

evaluations (called inspections) that focus on issues of concern to the Department, the Congress, and 

the public. The findings and recommendations contained in these inspection reports generate rapid, 

accurate, and up-to-date information on the efficiency, vulnerability, and effectiveness of 

departmental programs. This report was prepared in the San Francisco regional office under the 

direction of Kaye D. Kidwell, Regional Inspector General, and Paul A. Gottlober, Deputy Regional 

Inspector General. Project staff included: 

SAN FRANCISCO HEADQUARTERS 

Elizabeth Celniker Winnie Walker, Program Specialist 

Thomas Purvis 

For additional copies of this report, please contact the San Francisco office at (415) 437-7900. 
EXECUTIVE SUMMARY


PURPOSE 

This inspection (1) identifies the reasons why many children are not receiving Early and 

Periodic Screening, Diagnostic, and Treatment (EPSDT) dental services and (2) describes 

State activities to improve access and utilization. 

BACKGROUND 

Medicaid’s EPSDT is a comprehensive health program that provides for initial and 

periodic examinations and medically necessary follow-up care. Federal law requires that 

States provide EPSDT services to eligible children from birth through age 20. The two 

primary operational premises of EPSDT are access and utilization. That is, States must (1) 

assure that health care providers are available and accessible and (2) teach Medicaid 

families how to use available resources effectively. 

Specifically, States must (1) recruit physicians, dentists, and other providers to participate 

in EPSDT; (2) assure that these providers perform the medical and dental examinations, 

diagnoses, and treatments; (3) locate eligible families and inform them about EPSDT; 

(4) issue schedules specifying the desired frequency of medical, dental, vision, and hearing 

screenings, based on professional practice standards; (5) report information on use of 

EPSDT services to the Health Care Financing Administration (HCFA); and (6) provide all 

services needed to treat any condition identified by a screen even if the State does not 

include this service in its Medicaid plan. 

In recent years, a number of States, as well as HCFA, the Administration for Children and 

Families (ACF), the Public Health Service (PHS), and the Office of the Assistant Secretary 

for Planning and Evaluation (ASPE) have expressed concern about the number of dentists 

who are willing to see EPSDT enrollees. (As a result of a recent Departmental 

reorganization, responsibilities for oral health within the former PHS have been transferred 

to both the Office of Public Health and Science [OPHS] within the Office of the Secretary 

and the Health Resources and Services Administration [HRSA].) 

We interviewed Medicaid and dental public health officials in all 50 States and the District 

of Columbia. We also contacted a sample of Head Start health directors, State and 

national dental society representatives, private practice dentists, advocates, and other 

experts. 

FINDINGS 

Few eligible children receive preventive dental services 

Our interviews confirmed what the HCFA data show--few children receive EPSDT dental 

services, and the extent of the problem varies significantly from State to State. In fact, 

i 
HCFA data show that only 1 in 5 (4.2 million out of 21.2 million) eligible Medicaid 

children received preventive dental services in 1993, a slight decrease from the 22 percent 

who received services in 1992. Also in 1993, three-fourths of the States provided 

preventive services to fewer than 30 percent, and none of the States provided them to more 

than 50 percent, of all eligible children. The States’ statistics of children participating in 

the EPSDT program are unreliable, because States vary in what data they collect and 

report to HCFA. 

The reasons few children receive dental care are complex 

Approximately 80 percent of the States attribute the low utilization rate to a shortage of


dentists who are willing to accept Medicaid patients. Head Start grantees also report


increasing difficulty in obtaining dental services for their children. States report that


inadequate reimbursement is the most significant reason why dentists don’t accept


Medicaid patients. However, preliminary data from a few States that have raised fees


show that, at least initially, access and utilization do not increase proportionally. Dentists


also are dissatisfied with slow Medicaid payments, arbitrary denials, and prior


authorization requirements for routine services. Many dentists have difficulty treating


Medicaid families, and many non-pediatric dentists are unwilling to treat young children.


Medicaid families give dental services a low priority. Respondents report that Medicaid


families have competing family priorities, and many of them are unaware of the


importance of good oral health. Families often are unwilling to wait for appointments or


make necessary travel or child care arrangements which increases the likelihood of missed


appointments and failure to seek services.


The youngest children are the most difficult to serve and frequently are not screened at all.


Although the American Academy of Pediatric Dentists (AAPD) recommends that dentists


examine all children before their first birthday, only a small fraction of Medicaid children


receive these services. Twenty States have adopted the AAPD standard, another 12 States


recommend screening beginning during the second year, and the rest start at


age 3.


State, local, and private agencies are experimenting to improve access and utilization 

In the past few years, State, local, and private agencies have begun initiatives to improve 

the participation of dentists in Medicaid and to encourage children and families to use 

dental services. State initiatives include: (1) increased reimbursement, (2) managed care 

arrangements, (3) streamlined claims processing, (4) outreach and beneficiary education, 

(5) mandated provider participation, (6) training general dentists and non-dental health 

providers, (7) clinics for dental care, and (8) voluntary efforts by dentists. While some 

States are planning to evaluate their projects, most do not yet have data to show whether 

they are effective. 

ii 
RECOMMENDATION 

We recognize that there is significant legislation before Congress and the Administration 

that would alter the relationship between the Federal government and the States on matters 

discussed in this report. Nonetheless, we believe the following recommendation and the 

options discussed for implementing it remain relevant under the current or future FederalState relationship. 

The Department should convene a work group that, at a minimum, would include 

HCFA, HRSA, ACF, OPHS, and ASPE to develop an integrated approach to improve 

dental access and utilization for EPSDT eligible children. 

With expanded membership, the existing PHS Oral Health Coordinating Committee 

Working Group could fulfill this need. We suggest that the work group consider the 

following issues: 

Should a special conference with State participants be convened to facilitate an 

exchange of ideas on existing and possible demonstrations, evaluation strategies, 

and dissemination protocols? 

Can a coordinated approach be developed to identify demonstration projects, grants, 

and other activities that would improve access and utilization? 

Are there ways to encourage professional volunteerism that would increase the 

availability of dentists to this underserved population? 

How can the Department support, promote, and improve education and outreach to 

Medicaid beneficiaries, their families, and the dental community? 

What incentives and demonstration projects can be developed or promoted at the 

State and local levels to increase provider participation? 

How can existing community organizations, many of which are supported by the 

Department, become involved in providing access to children’s dental services? 

AGENCY COMMENTS 

We received comments on the draft report from the Assistant Secretary for Health, the 

Centers for Disease Control and Prevention, the National Institutes of Health (NIH), 

HRSA, and HCFA. Both the Assistant Secretary for Health and NIH suggested that the 

existing PHS Oral Health Coordinating Committee Working Group, with expanded 

membership, could adequately address our recommendation and obviate the need for a new 

Departmental work group. We agree that this is a viable alternative and have amended our 

recommendation accordingly. The full text of the comments is contained in appendix C. 

iii 
TABLE OF CONTENTS


PAGE


EXECUTIVE SUMMARY 

INTRODUCTION ................................................ 1


FINDINGS ...................................................... 6


Few eligible children served ......................................... 6


Complex reasons ................................................ 7


Experimental projects to improve access and utilization ..................... 9


RECOMMENDATION ............................................ 13


AGENCY COMMENTS ........................................... 14


APPENDIX A:� Number and percent of children who received EPSDT 

preventive dental services in 1993, by State 

APPENDIX B:� State initiatives to improve access and utilization 

of children’s dental services 

APPENDIX C: Agency Comments 
INTRODUCTION


PURPOSE 

This inspection (1) identifies the reasons why many children are not receiving Early and 

Periodic Screening, Diagnostic, and Treatment (EPSDT) dental services and (2) describes 

State activities to improve access and utilization. 

BACKGROUND 

The EPSDT Program 

Enacted by Congress in 1967, Medicaid’s EPSDT is a comprehensive health program that 

provides for initial and periodic examinations and medically necessary follow-up care. 

Federal law requires that States provide EPSDT services to eligible children from birth 

through age 20. 

The two primary operational premises of EPSDT are access and utilization. That is, States 

must (1) assure that health care providers are available and accessible and (2) teach 

Medicaid families how to use available resources effectively. Specifically, States must 

recruit physicians, dentists, and other providers to participate in EPSDT;


locate eligible families and inform them about EPSDT services; and


assure that Medicaid-certified physicians, dentists, or other providers perform the


medical and dental examinations, diagnoses, and treatments.


In other words, States are required to (1) inform all persons who are Medicaid eligible 

about EPSDT services, (2) provide or arrange for the provision of screening services, and 

(3) arrange for all corrective treatment needed as a result of the screening. 

Congress significantly amended EPSDT as part of the Omnibus Reconciliation Act of 1989 

(OBRA 1989). The amendments require States to: 

issue schedules specifying the desired frequency of medical, dental, vision, and


hearing screenings, based on professional practice standards (i.e., schedules


developed in consultation with recognized professional associations such as the


American Dental Association);


report more detailed information on use of EPSDT services to the Health Care


Financing Administration (HCFA); and


provide all services needed to treat any condition identified by a screen even if the


State does not include this service in its Medicaid plan.


Another OBRA 1989 amendment, which applies to the Medicaid program in general, 

requires States to set reimbursement rates at a level sufficient to assure that Medicaid 

1

beneficiaries have access to providers equal to that of the general population in the same 

geographic area. Prior to OBRA 1989, this requirement existed only in regulation. 

Frequency and Content of EPSDT Dental Screening 

States must establish and maintain schedules that specify how frequently children should 

be screened. A physician or nurse practitioner usually conducts a general medical 

examination when a child is born or when the family enrolls in Medicaid. The general 

examination includes an oral health assessment. This oral assessment cannot substitute for 

an examination by a dentist. Furthermore, States must assure that dentists examine 

children at least as often as their dental screening schedules require. 

States must establish the screening schedules in consultation with a recognized dental 

association. For example, they may choose to follow the American Academy of Pediatric 

Dentists (AAPD) screening guidelines that call for an initial examination by a dentist 

during the first year of life and subsequently at least twice a year. The AAPD schedule 

specifies that the initial screening should include a clinical oral examination and cleaning 

for the child plus dental health counseling for the family. This initial screening also may 

include fluoride treatments and the application of dental sealants. According to the AAPD, 

early screening and education can prevent "baby bottle tooth decay" and other causes of 

later childhood caries. Untreated, the conditions can produce severe tooth decay and gum 

infection that may require specialized treatment or hospitalization. 

EPSDT and the Head Start Program 

Head Start requires that enrolled children receive dental examinations and treatment. Most 

Head Start children are eligible for EPSDT services. The initial Head Start screening 

usually is conducted by dental hygienists or trained paraprofessionals rather than dentists. 

In addition, all Head Start children must receive an examination by a dentist at least once 

during the school year and must be treated for any problems found. 

In a previous study, the Office of Inspector General (OIG) reviewed a random sample of 

80 Head Start grantees for the 1991-92 program year and found that approximately 

85 percent received the required dental examination. Of the children requiring follow-up 

dental treatment, the OIG found that 67 percent had all their dental needs met, 7 percent 

had only some needs met, and 26 percent received no treatment.1 Nevertheless, these 

figures are substantially higher than States report for all of their EPSDT enrollees. 

Access to EPSDT Children’s Dental Services 

In recent years, a number of States, as well as HCFA, the Administration for Children and 

Families, the Public Health Service (PHS), and the Office of the Assistant Secretary for 

Planning and Evaluation have expressed concern about the number of dentists who are 

1

Office of Inspector General, Evaluating Head Start Expansion Through Performance Indicators (OEI-09-

91-00762), May 1993 

2 
willing to serve EPSDT enrollees. (As a result of a recent Departmental reorganization, 

responsibilities for oral health within the former PHS have been transferred to both the 

Office of Public Health and Science [OPHS] within the Office of the Secretary and the 

Health Resources and Services Administration [HRSA].) Several recent studies have 

focused on access problems and identified some of the reasons why few Medicaid children 

receive dental services. For example: 

The Congressional Office of Technology Assessment reported in 1990 that none of


the State Medicaid programs adequately covered children’s basic dental services


and that a variety of barriers, identified by both dentists and State staff, restrict


access.2


A 1990 California Policy Seminar report found that most California county EPSDT


programs were having trouble finding any dentists who were willing to see eligible


children.3


A series of oral health workshops sponsored in 1990 and 1991 by the PHS


Maternal and Child Health Bureau described regulatory, administrative, and


economic barriers that inhibit the delivery of dental services to children.


These studies identified inadequate reimbursement rates, complicated claims processing, 

prior authorization requirements, and dentists’ actual or perceived problems with 

beneficiaries as the reasons why so few dentists are willing to serve Medicaid children. 

Data concerning provider participation are not available 

National reporting requirements that would provide data concerning the number of dentists 

participating in Medicaid do not exist. Also, adequate access has not been defined. Many 

States look at only how quickly families or staff can find a dentist, rather than the number 

who are getting services. Some States consider dentists to be participating if they file at 

least one Medicaid claim during the year. This is misleading because many of these 

dentists may refuse to take new Medicaid patients. Most States also lack data to track 

referrals from EPSDT screenings to determine if needed diagnoses and treatment were 

completed. A few States are beginning to compare the ratio of dentists willing to take 

Medicaid patients to the Medicaid-eligible population, but most lack access data or 

common measures. 

The HCFA plans to collect and analyze data from selected States to provide information on 

the participation rate among dentists and the impact this has on Medicaid children’s use of 

dental services. 

2

Congress of the United States, Office of Technology Assessment, Children’s Dental Services Under the 

Medicaid Program, September 1990 

3

California Policy Seminar, Access to Dental Care for Medi-Cal Recipients, Research Report, University 

of California, Berkeley, 1990 

3 
Federal Oral Health 2000 Goals 

Although approximately 21.2 million children were eligible for EPSDT services in 1993 

(the last year for which data are available), only 1 in 5 received the required preventive 

dental services.4 As part of its efforts to mitigate this problem, PHS launched the Oral 

Health 2000 project in 1991 as a collaborative effort with a number of private and 

voluntary health agencies. (The Office of Public Health and Science now has oversight 

responsibilities for this project.) The primary goal of Oral Health 2000 is to raise public 

awareness and improve access to oral health care services. Specific objectives are 

designed to: 

reduce the occurrence and severity of oral diseases,


reduce the unnecessary loss of teeth from disease, neglect, or trauma, and


alleviate barriers that prevent individuals from achieving oral health.


Oral Health 2000 addresses the 16 oral health objectives that PHS developed as part of 

"Healthy People 2000," a broader national health promotion initiative. One objective 

specifically related to EPSDT is "to increase to at least 90 percent the proportion of all 

children entering school programs for the first time who have received an oral health 

screening, referral, and follow up for necessary diagnostic, preventive, and treatment 

services." Other issues concern increased use of fluorides, cessation of tobacco use, and 

the oral health of handicapped and minority populations. 

METHODOLOGY 

Our study methodology was four-fold. Basically, we: 

gathered existing EPSDT data from HCFA records, 

conducted telephone and in-person interviews to gather new information about the 

status of EPSDT dental services in the States, 

conducted telephone and in-person interviews to gather new information about State 

and local initiates to improve access and utilization, and 

presented the existing and new information in a single document. . 

We interviewed officials in all 50 States and the District of Columbia. In most States, we 

interviewed EPSDT coordinators and Medicaid dental consultants as well as the State’s 

chief dental officer. We also contacted a sample of Head Start health directors, State 

dental society representatives, private practice dentists, advocates, and other experts. The 

4

Health Care Financing Administration, EPSDT Program Indicators, Fiscal Year 1993, HCFA-416 

Performance Reports, Early and Periodic Screening, Diagnostic and Treatment Program, 50 States and 

District of Columbia 

4 
American Dental Association and the American Academy of Pediatric Dentists helped 

facilitate contacts with State organizations and provided other information and assistance. 

We conducted our review in accordance with the Quality Standards for Inspections issued 

by the President’s Council on Integrity and Efficiency. 

5

--

FINDINGS


FEW ELIGIBLE CHILDREN RECEIVE PREVENTIVE DENTAL SERVICES 

Our interviews confirmed what the HCFA data show5--few children receive EPSDT dental 

services, and the extent of the problem varies significantly from State to State. (See 

appendix A for a State-by-State breakdown of the 1993 data.) In fact, HCFA data show 

that only 1 in 5 (4.2 million out of 21.2 million) eligible Medicaid children received 

preventive dental services in 1993. This was a slight decrease from the 1992 data as 

shown in the following table: 

PERCENT OF EPSDT CHILDREN WHO RECEIVED


PREVENTIVE DENTAL SERVICES


BY AGE GROUP, 1992 AND 19936


Year 

All 

Ages 

<1 

Year 

1-5 

Years 

6-14 

Years 

15-20 

Years 

1992 22.0 0.3 18.1 33.7 22.2 

1993 19.7 0.4 16.0 30.0 19.5 

Also in 1993, three-fourths of the States provided preventive services to fewer than 

30 percent, and none of the States provided them to more than 50 percent of all eligible 

children. Since some of the States only began using HCFA’s dental prevention service 

codes in 1993, they may have under-reported the care actually given. 

The States’ statistics of children participating in the EPSDT program are unreliable, 

because States vary in what data they collect and report to HCFA. A 1992 OIG inspection 

found that the screening and participant ratios used to measure States’ performance were 

inaccurate.7 Therefore, it is difficult to accurately assess States’ success in reaching and 

screening Medicaid children under EPSDT. The HCFA has issued guidelines clarifying 

how to compute the screening and participant ratios more accurately, but no information is 

5

For data collection purposes, HCFA defines preventive dental services as the unduplicated count of 

individuals who receive (1) instruction in self-care oral hygiene procedures, (2) a teeth cleaning, and 

(3) when appropriate, an application of dental sealants to prevent decay. 

6

This table is based on data from HCFA reports on EPSDT program indicators for fiscal years 1992 and 

1993, the most recent years available. 

7

Office of Inspector General, Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) 

Performance Measurement, OEI-07-90-00130. 

6 
available to determine whether the guidelines are improving the accuracy and consistency 

of the reported data. 

THE REASONS FEW CHILDREN RECEIVE DENTAL CARE ARE COMPLEX 

Children do not receive preventive dental services for three basic reasons: 

few dentists serve Medicaid children,


Medicaid families give dental services a low priority, and


the youngest children are the most difficult to serve and frequently are not screened


at all.


Respondents report that few dentists serve Medicaid children 

Despite the paucity of data, approximately 80 percent of the States attribute the low 

utilization rate to the shortage of dentists who are willing to accept Medicaid patients. In 

many communities, families and EPSDT staff have difficulty getting timely dental 

appointments for Medicaid children. They often have to wait 6 to 8 weeks or travel long 

distances. Even among the 9 States reporting an adequate supply of dentists, 5 provided 

preventive services for fewer than 20 percent of eligible children. Although shortages are 

usually more severe in rural areas or isolated locations, 13 States report statewide 

shortages. 

States report that inadequate reimbursement is the most significant reason why dentists 

don’t accept Medicaid patients. Respondents in some States report that Medicaid fees do 

not even cover overhead costs, and dentists lose money on each patient served. Despite 

this, reimbursement increases do not guarantee greater provider participation immediately. 

(See the discussion of increased reimbursement incentives on page 9.) The OIG did not 

verify respondents’ assertions that Medicaid reimbursement is inadequate. 

Like other health care providers, dentists are dissatisfied with the complex Medicaid claims 

process, slow payments, arbitrary denials, and prior authorization requirements for routine 

services. While many States have taken steps to streamline claims processing, dentists 

may not be aware of these reforms because of inadequate provider outreach. Some 

respondents say that the small size of solo dental practices keeps many dentists from fully 

utilizing claims processing improvements such as electronic billing. 

Many dentists also have difficulty treating Medicaid families and young children. They 

find that Medicaid families are more likely than others to break appointments at the last 

minute or not show up at all. Dentists claim that because of office scheduling practices, 

missed appointments are a more serious problem for them than for most physicians. 

Dentists also claim that Medicaid families sometimes create difficulties in their offices, for 

example, when a parent brings three children in addition to the child with the appointment 

and allows them to play raucously and disrupt others in the waiting room. Furthermore, 

many non-pediatric dentists are unwilling to treat young children, because these youngsters 

often take more time to examine than older patients and may require sedation. 

7 
Head Start grantees also report increasing difficulty in obtaining dental services for their 

children. Even though grantees eventually get a majority of their children examined and 

treated, their health directors have to spend more time and effort to accomplish this than in 

the past. The enrollment of 3-year-old children has made many dentists reluctant to serve 

Head Start. Grantees often transport children long distances to see a dentist because local 

dentists refuse to accept Medicaid. Some grantees persuade a local dental clinic or 

individual dentist to block off half a day for their children or persuade a dentist and 

hygienist to come to the Head Start site. A few grantees locate available dentists, but then 

insist that the parents themselves make and keep the appointments so they can learn 

responsibility. When a dental emergency precludes waiting or travel, some grantees spend 

funds from their own budgets to pay for treatment. 

Medicaid families give dental services a low priority 

Respondents report that Medicaid families have competing family priorities, and many of 

them are unaware of the importance of good oral health. Some States are increasing 

efforts to educate families, but they still give less attention to dental issues than to medical 

services such as immunizations. The result is that families give a lower priority to dental 

care than to medical care. 

Medicaid families often miss appointments or forgo dental services. Because dental 

services are not a priority, many families are unwilling to wait for appointments or make 

necessary travel or child care arrangements. This increases the likelihood of missed 

appointments and failure to seek services. Many families will not make an effort to see a 

dentist even though they might to see a physician. Despite reminders and offers of 

transportation, beneficiaries often do not keep their appointments unless their children are 

in pain on the day of the appointment. Because dental care is a low priority, families 

often fail to follow dentists’ instructions. 

The youngest children are the most difficult to serve and frequently are not screened 

Although the American Academy of Pediatric Dentists (AAPD) recommends that dentists 

examine all children before their first birthday, only a small fraction of Medicaid children 

receive these services. Twenty States have adopted the AAPD standard, another 12 States 

recommend that screening begin during the second year, and the rest start screening at age 

3. States will pay for screening if a parent suspects a problem and takes the child to a 

dentist, even if the child is younger than the State’s screening schedule specifies. 

Even States adopting the AAPD standard often are unable to find dentists who will 

examine and treat children who are less than 3 years old. Non-pediatric dentists often are 

unfamiliar with the EPSDT program and are unsure of the protocol to follow in examining 

very young children. Because of this, a few State EPSDT staff question whether States 

should consume resources trying to find a dentist to examine children under age 3 unless 

they are at high risk or the general medical screening identifies an oral health problem. 

8

A few States are developing training programs and videotapes on techniques for detecting 

oral health problems of very young children. These materials are primarily for general 

dentists and non-dental health care providers. Dental experts in these and other States 

recognize the importance of careful oral examination in early infancy and oral health 

counseling to prevent conditions such as baby bottle tooth decay. They believe that 

pediatricians and other non-dental personnel are more likely than dentists to screen 

children who are less than 3 years old. They contend that with careful training non-dental 

health care providers are competent to detect oral health problems and refer children to 

dentists for diagnosis and treatment. They hope to change some providers’ attitudes about 

oral examinations, such as the physician who liked to boast, "Oral exams are no problem. 

I look past the teeth to the tonsils." 

STATE, LOCAL, AND PRIVATE AGENCIES ARE EXPERIMENTING TO 

IMPROVE ACCESS AND UTILIZATION 

State and local governments and private agencies have begun initiatives to improve the 

participation of dentists in Medicaid and to encourage children and families to use dental 

services. Their initiatives include: 

Increased reimbursement or other financial incentives 

In the past few years, more than half the States have increased dental reimbursement or 

taken steps to provide other financial incentives. Fifteen States raised fees significantly, 

and another 11 by smaller amounts. Several States are proposing additional financial 

incentives. For example, Georgia legislators introduced a proposal to authorize State tax 

credits to dentists and other providers who agree to serve poor children. 

Preliminary data from a few States that have raised fees show that initially access and 

utilization do not increase proportionally. Although Connecticut raised fees by 

80 percent, the overall increase in the number of services provided may not be substantial. 

California raised rates to 80 percent of the average amount billed in the previous year, but 

utilization still lags even though more dentists are available. Costs for Medicaid dental 

services in California have gone from about $150 million in 1991 to a projected 

$750 million in 1995. Other States report that fee increases have not been sufficient to 

bring fees close to the dentists’ usual and customary charges. Several respondents note 

that dentists who drop Medicaid are frequently reluctant to return even if States raise fees 

or eliminate red tape. 

A few States have restricted coverage of some dental procedures and used the savings to 

increase payments for the rest. For example, in response to a proposal from the State 

dental association, Indiana eliminated routine coverage for half of its children’s dental 

procedures and used the savings to increase fees for the remaining basic preventive and 

restorative services. The State will still cover these procedures for EPSDT children when 

medically necessary, but at a lower rate and subject to prior authorization to justify 

medical necessity. Other States have dropped or plan to drop most adult Medicaid dental 

services, some claiming this is necessary to keep children’s services fully funded. 

9 
Managed care arrangements 

To facilitate access and contain costs, almost all the States are establishing managed care 

arrangements for Medicaid beneficiaries. Only 22 States have set up some form of dental 

managed care, either statewide or pilot projects. The rest either explicitly exclude dental 

services or have not yet decided because their plans are at a preliminary stage. Those who 

are explicitly excluding dental services report they will reconsider at a future date. Some 

States attempted to contract for dental managed care benefits but did not get any 

satisfactory bids because the fees they could pay were too low. Respondents report that 

dentists’ resistance to managed care arrangements is a factor limiting implementation. 

Among the approaches States are using to acquire dental services under managed care 

plans are: capitated risk plans, primary care case management, fee-for-service programs, 

and a mixture of capitation and fee-for-service. None of these is mutually exclusive. In 

some States, a physician serves as a gatekeeper to medical and dental services. In Arizona 

and Tennessee, dentists contract with local or statewide health plans to provide services 

either through a capitated rate or a fee for service arrangement. Illinois has a statewide 

contract with Delta Dental to provide all EPSDT services at a fixed price. Several 

respondents are critical of plans that subcontract dental managed care arrangements 

through health plans, claiming that the extra administrative costs reduce funds available to 

dentists providing actual services and therefore limit access. States are just beginning to 

develop monitoring procedures for dental services under managed care arrangements. 

Streamlined claims processing 

Nineteen States report taking recent steps to streamline claims processing, speed up 

payment, and reduce denials. Many other States already have taken these steps. States 

are: 

replacing HCFA claims forms with universal forms issued by the American Dental


Association (ADA),


removing prior authorization requirements,


reducing denials,


setting up electronic billing, and


speeding up payments.


New Mexico, for example, is adopting the ADA claims forms and will supply dentists with 

the software for electronic claims processing. Florida has set up electronic billing but 

reports dentists are resistant to it. Arizona eliminated most prior authorization 

requirements. North Carolina worked with its dental association to establish use of ADA 

claims forms and electronic billing. Some respondents praise State steps to streamline 

claims processing but maintain this factor will not significantly improve access if States do 

not also raise fees and help families to make and keep appointments. 

10

Outreach and beneficiary education 

States report a wide range of new outreach and education efforts, either working directly 

with families or through dentists’ offices. The Alaska Head Start dental initiative funds 

indigenous staff to provide oral health education and outreach to rural, remote Alaska 

native communities. Illinois contracts with Delta Dental to educate beneficiaries about the 

importance of dental screening services. Coupling Medicaid and private funding, New 

Hampshire established an access-to-care project to increase public and provider acceptance 

of Medicaid and EPSDT and to assure that every eligible child gets needed medical and 

dental services. 

Mandated provider participation 

A few States are mandating provider participation directly or through State plans for 

provider distribution. Minnesota mandates that dentists treat Medicaid patients up to a 

specific threshold as a condition of participating as providers in health plans for State 

employees. As part of a statewide health improvement initiative, Washington established a 

Health Personnel Resource Plan for regulating the supply and distribution of dentists and 

other health personnel. 

Training general dentists and non-dental health providers 

A few States have begun pilot projects to train non-pediatric dentists and non-dental health 

providers about pediatric oral health problems. The Texas Medicaid program is developing 

a videotape for use by non-dental health workers who screen young children. The video 

will explain techniques for adequate oral screening, describe necessary elements for oral 

health counseling, and specify that each child should be referred to a dentist if any decay 

or abnormality is found. Washington is developing a pilot project to train non-pediatric 

dentists about new pediatric dental screening and treatment techniques. With the 

University of Iowa pediatric dental department, Iowa established an educational task force 

to educate general dentists on pediatric dental issues and to assure that at least one dentist 

in each county is willing to examine year-old children. Iowa has produced a monograph 

on children’s dental examinations and is reviewing data to determine how many children 

under age one dentists actually examine. 

Clinics for dental care 

Respondents from 20 States report efforts are under way to set up new dental clinics or 

expand existing ones to increase dental services available to Medicaid and other lowincome beneficiaries. Expansion of dental clinic capacity is underway in a variety of clinic 

settings, including Federally Qualified Health Centers, hospital-based clinics, and clinics 

operated by State and local health departments. In Delaware, for example, all Medicaid 

beneficiaries are served in State-operated clinics; almost no private practice dentists 

participate in Medicaid. In Alabama, some local health or primary care clinics make a 

block of time available for dental services and treat clients on a first-come, first-served 

basis. The New Mexico and Nevada legislatures decided to expand clinics to assure 

11 
greater availability of dental services to low-income clients. Some respondents point out 

that legislators and others see clinics as a way to expand or maintain services without 

significant dental fee increases. 

Voluntary efforts by dentists 

Several States, localities, and dental associations are encouraging dentists to serve their fair 

share of Medicaid children. Starting about 1990, California’s Contra Costa County dental 

society and EPSDT staff began a "share-the-care" project. Participating dentists agree to 

take one to three new Medicaid cases yearly or quarterly. County EPSDT staff make the 

referrals and ensure that participating dentists receive no more patients than they have 

agreed to. Other counties, not only in California but also in States such as Wisconsin, 

Colorado, and Texas, have started similar programs. North Dakota encourages dentists to 

accept a fair share of Medicaid patients and may provide non-monetary public recognition 

through "exemplary service" awards. Respondents report that while these voluntary 

programs are worthwhile, they usually reach only a small percentage of eligible children. 

While some States are planning to evaluate their projects, most do not yet have data to 

show whether they are effective. A description of selected projects to improve access and 

utilization is contained in appendix B. 

12

RECOMMENDATION


We recognize that there is significant legislation pending before Congress and the 

Administration that would alter the relationship between the Federal government and the 

States on matters discussed in this report. Nonetheless, we believe the following 

recommendation and the options discussed for implementing it remain relevant under the 

current or future Federal-State relationship. 

THE DEPARTMENT SHOULD CONVENE A WORK GROUP THAT, AT A 

MINIMUM, WOULD INCLUDE HCFA, HRSA, ACF, OPHS, AND ASPE TO 

DEVELOP AN INTEGRATED APPROACH TO IMPROVE DENTAL ACCESS 

AND UTILIZATION FOR EPSDT ELIGIBLE CHILDREN 

With expanded membership, the existing PHS Oral Health Coordinating Committee 

Working Group could fulfill this need. We suggest the work group consider the following 

issues: 

Should a special conference with State participants be convened to facilitate an 

exchange of ideas on existing and possible demonstrations, evaluation strategies, 

and dissemination protocols? 

Can a coordinated approach be developed to identify demonstration projects, grants, 

and other activities that would improve access and utilization? 

Are there ways to encourage professional volunteerism that would increase the 

availability of dentists to this underserved population? 

How can the Department support, promote, and improve education and outreach to 

Medicaid beneficiaries, their families, and the dental community? 

What incentives and demonstration projects can be developed or promoted at the 

State and local levels to increase provider participation? 

How can existing community organizations, many of which are supported by the 

Department, become involved in providing access to children’s dental services? 

13

AGENCY COMMENTS


We received comments on the draft report from the Assistant Secretary for Health, the 

Centers for Disease Control and Prevention, the National Institutes of Health, HRSA, and 

HCFA. Both the Assistant Secretary for Health and the National Institutes of Health 

suggested that the existing PHS Oral Health Coordinating Committee Working Group, with 

expanded membership, could adequately address our recommendation and obviate the need 

for a new Departmental work group. We agree that this is a viable alternative and have 

amended our recommendation accordingly. 

We also would like to draw the reader’s attention to the full text of the comments, which 

is contained in appendix C. In addition to some technical comments, they provide 

valuable information concerning issues that are not discussed in our report as well as other 

activities that the Department has undertaken to address children’s oral health. 

14

APPENDIX A


NUMBER AND PERCENT OF CHILDREN WHO RECEIVED


EPSDT PREVENTIVE DENTAL SERVICES


IN 1993, BY STATE1


STATE NUMBER OF 

EPSDT 

ELIGIBLE 

CHILDREN 

Connecticut 193094 

Maine 106828 

Massachusetts 404857 

Rhode Island 66136 

New Hampshire 40011 

Vermont 52251 

Region I Total 863177 

New Jersey 447272 

New York 1585786 

Region II Total 2033058 

Delaware 50585 

Maryland 229146 

Pennsylvania 880017 

Virginia 328090 

District of Columbia 73837 

West Virginia 135594 

Region III Total 1697269 

Alabama 279138 

Florida 1355013 

Georgia 643424 

Mississippi 470032 

Kentucky 293083 

North Carolina 550567 

South Carolina 302471 

Tennessee 534231 

Region IV Total 4427959 

NUMBER PERCENT 

WHO RECEIVED OF 

PREVENTIVE ELIGIBLES 

SERVICES 

52543 27.2 

36819 34.5 

139414 34.4 

21003 31.8 

17905 44.8 

17636 33.8 

285320 33.1 

101410 22.7 

283453 17.9 

384863 18.9 

6283 12.4 

33129 14.5 

185289 21.1 

64718 19.7 

11800 16.0 

41452 30.6 

342671 20.2 

31369 11.2 

222493 16.4 

161496 25.1 

56843 12.1 

27604 9.4 

75794 13.8 

37876 12.5 

129886 24.3 

743361 16.8 

1

This table is based on data from the HCFA-416 performance report on EPSDT 

program indicators for fiscal year 1993. 

A-1 
Illinois 

Indiana 

Michigan 

Minnesota 

Ohio 

Wisconsin 

Region V Total 

Arkansas 

Louisiana 

New Mexico 

Oklahoma 

Texas 

Region VI Total 

Iowa 

Kansas 

Missouri 

Nebraska 

Region VII Total 

Colorado 

Montana 

North Dakota 

South Dakota 

Utah 

Wyoming 

Region VIII Total 

Arizona 

California 

Hawaii 

Nevada 

Region IX Total 

Alaska 

Idaho 

Oregon 

Washington 

Region X Total 

TOTAL 

1027303 214810 20.9 

345751 144005 41.6 

823052 215885 26.2 

291466 73539 25.2 

948612 216584 22.8 

342664 77103 22.5 

3778848 941926 24.9 

207085 35062 16.9 

498389 128199 25.7 

133524 8290 6.2 

162598 30949 19.0 

1330465 160284 12.0 

2332061 362784 15.6 

169516 56210 33.2 

113286 40106 35.4 

403702 86619 21.5 

102285 34267 33.5 

788789 217202 27.5 

210749 44305 21.0 

57019 5119 9.0 

32799 2625 8.0 

47702 8543 17.9 

123966 19186 15.5 

34976 15157 43.3 

507211 94935 18.7 

413100 1153 0.3 

3583936 601451 16.8 

68008 503 0.7 

34845 5010 14.4 

4099889 608117 14.8 

51691 14468 28.0 

71269 14967 21.0 

206524 71661 34.7 

304257 89128 29.3 

633741 190224 30.0 

21162002 4171403 19.7 

A-2

APPENDIX B 

STATE AND LOCAL INITIATIVES TO IMPROVE 

DENTAL SERVICES FOR CHILDREN 

INTRODUCTION B-2


BENEFICIARY ACCESS, EDUCATION, AND OUTREACH 

Alaska Head Start Collaboration Project’s Dental Initiative B-2


Illinois Statewide Dental Contract B-3


Maryland Head Start Collaboration Project’s Dental Initiative B-4


Michigan Projects to Improve Dental Access B-4


New Hampshire Access to Care Project B-5


Washington Oral Health Improvement Plan B-5


PROVIDER PARTICIPATION 

California Dental Access Program B-6


Delaware Clinic Program B-7


Georgia Tax Credit B-7


Indiana Dental Procedure Priorities B-8


Minnesota Medicaid Provider Mandate B-8


New Mexico Patient Management Assistance B-9


North Carolina Clinic Program B-9


Wisconsin Access and Utilization Initiatives B-10


Wisconsin Fee Increases B-10


Contra Costa County (CA) "Share-the-Care" Dental Access Project B-11


PROVIDER TRAINING AND EDUCATION 

Iowa Pediatric Dental Education Program B-12


Texas Oral Health Video Project B-12


Spokane (WA) Dental Prevention Project B-13


B-1

INTRODUCTION 

The activities described in this appendix are representative of initiatives to improve 

children’s access to and utilization of dental services. Some are designed to increase the 

supply of available dentists by increasing fees or reducing red tape, while others are 

designed to help families with access, education, and outreach or to train professionals. 

Some were initiated by State Medicaid or public health agencies and others by professional 

and community organizations in cooperation with the States. 

The listing is not a complete catalog of all State or local initiatives or a complete 

description of each project. More detailed information can be obtained from the contact 

person listed. 

This listing does not constitute an OIG endorsement of any of the initiatives. While some 

States or other entities are planning to evaluate these projects, most do not yet have data to 

show whether they are effective. 

BENEFICIARY ACCESS, EDUCATION, AND OUTREACH 

Alaska Head Start Collaboration Project’s Dental Initiative 

The Alaska Head Start Health Improvement Initiative, which began in 1991, is designed to 

improve the dental health of children living in remote Alaskan villages across the State. 

Native Alaskan children have one of the highest rates of tooth decay in the United States. 

This is a result of factors such as infrequent and intermittent access to care, detrimental 

nutrition patterns, and child rearing traditions that do not include oral hygiene. 

Historically, Head Start programs serving rural Alaska communities have not been able to 

comply with the dental screening standard. 

The project (1) established a provider network of culturally-sensitive dentists who travel to 

the villages to screen and treat children and (2) trained community staff in the villages to 

provide oral health education and outreach to children and families. While the target 

population is primarily native Alaskan children, the project includes all Medicaid-eligible 

children from birth to age 6. 

The State Medicaid agency, the tribal health corporation in Nome, the State Head Start 

Association, and the State dental association have formed a coalition to work with the 

project and seek its continuation. The project will attempt to generate data showing that 

village-based care is cost effective and will distribute a manual for providers and others 

seeking to set up similar networks. 

B-2

For more information contact: 

Sally Mead, Director


Alaska Head Start Health Improvement Initiative


Prevention Associates


101 East 9th Avenue, Suite 10B


Anchorage, AK 99501


907-272-6925


Illinois Statewide Dental Contract 

Beginning in 1992, Illinois contracted for a fixed price with the Delta Dental Plan of 

Illinois to provide all EPSDT dental services statewide, including outreach, oral health 

education, screening, follow-up treatment, and tracking the children and families to assure 

they get the required services. Delta contacts all families who have children between the 

ages of 3 to 20 who have not been screened in the past year. Names and addresses are 

also provided to the local EPSDT offices for follow-up. Other outreach efforts include 

press releases, public service announcements, and messages about dental services targeted 

to specific communities. Delta will refer families to dentists and make appointments, if 

necessary, for the initial screening or follow-up treatment. 

Delta contracts with dentists, paying a fee based on the dentist’s usual and customary 

charges. Delta also contracts with schools, health centers, and other clinics to make 

dentists available for group screenings and preventive services. A Delta manual specifies 

provider responsibilities and a protocol for screening in schools. 

The contract requires Delta to provide services to at least one-half of the EPSDT-eligible 

children in Illinois. Delta must assure that screening goals are met, screening results are 

recorded, and referrals for treatment are issued. The State conducts compliance reviews 

and fiscal audits. 

For more information contact: 

Michael Berger, Vice President 

of Government Programs 

Delta Dental Plan of Illinois 

2001 Butterfield Road, Suite 900 

Downers Grove, IL 60515 

708-964-2400 

Deborah Saunders, Coordinator 

Illinois Department of Public Aid 

201 South Grand Avenue, East 

Springfield, IL 62763-0001 

217-524-7163 

B-3

Maryland Head Start Collaboration Project’s Dental Initiative 

The Maryland Head Start Collaboration Project was initiated in 1993 to eliminate barriers 

to health care for Head Start children. To identify problems and develop statewide 

solutions, the project formed a coalition of representatives from public and private 

agencies. The project is part of the governor’s office and, because of its location, project 

staff not only work closely with the Medicaid program but also have access to State 

policymakers. 

One of the project’s early initiatives was to survey Head Start grantee staff. The survey 

found that 38 percent of grantees have difficulty obtaining dental care for their children. 

According to grantees, only about 12 percent of dentists in their areas accept Medicaid. 

As a result of the survey, the project is recommending early outreach and oral health 

education for parents and children. 

Recruiting dentists for Medicaid has been very difficult largely because the Maryland 

Medicaid program pays lower fees than almost any other State. The project will initiate a 

survey to clarify dentists’ concerns about reimbursement and other issues. The survey will 

ask about dentists’ problems with the claims process and about difficulties they may have 

in examining and treating young children. Staff will work with Medicaid, other State 

agencies, and dentists to determine appropriate solutions. The project will then undertake 

educational efforts to encourage more dentists to treat 3- and 4-year-olds. 

For more information contact: 

Gayla Sanders, Head Start Collaborator


Division of Policy and Planning


Governor’s Office for Children, Youth, and Families


301 West Preston Street, 15th Floor


Baltimore, MD 21201


410-225-4160


Michigan Projects to Improve Dental Access 

Michigan funded eight oral health outreach projects in 1994 as part of its "Healthy Kids" 

program. The projects include such initiatives as: 

• utilizing mobile dental vans and portable equipment, 

• establishing county dental clinics, 

• coordinating efforts with schools regarding dental hygiene education, and 

• improving data collection and dissemination. 

Michigan formed a statewide oral health coalition to help generate legislative support for 

these projects and for other oral health improvement activities. 

B-4

For more information contact: 

Christine Cascaddan, Senior Policy Analyst


Medical Services Administration


Michigan Department of Social Services


Bureau of Policy and Management Information


400 South Pine Street


P.O. Box 30037


Lansing, MI 48909


517-335-5129


New Hampshire Access to Care Project 

New Hampshire established the Access to Care Project in 1992 to increase public 

acceptance of Medicaid and EPSDT and to insure that every eligible child receives needed 

medical and dental services. The project is jointly sponsored by the State Medicaid 

program, the New Hampshire Alliance for Children, and the New Hampshire Pediatric 

Society. Funding is provided by the Jessie B. Cox Charitable Trust in Boston and matched 

with New Hampshire Medicaid funds. 

The project (1) seeks support from the general public for increased children’s services 

through outreach and education about EPSDT, (2) insures that all eligible children have a 

primary care physician to serve as an oral health advocate for the child and family in 

addition to providing other care, and (3) explains EPSDT mandates and benefits to dentists 

and other health professionals and persuades them to participate. 

For more information contact: 

Carol Currier, Administrator


Division of Human Services


Office of Medical Services


6 Hazen Drive


Concord, NH 03301-6521


603-271-4350


Washington Oral Health Improvement Plan 

In 1993, Washington enacted the Public Health Improvement Plan to improve general 

health status in Washington through prevention and improved public health services 

capacity. Among other goals, the plan seeks to ensure universal access to needed health 

services for all State residents. Oral health is a key component of the health improvement 

initiative. The oral health component emphasizes that lack of access to dental care is at 

crisis levels, especially for low income and Medicaid-eligible children. Because of the 

lack of early preventive care and family education, hospital emergency rooms are handling 

cases of baby bottle tooth decay with charges up to $3000 per child. The Oral Health 

B-5

Improvement Plan has developed several strategies to address these problems. They 

include: 

• programs to screen children in the first year of life, 

• universal dental screening of school children, 

• increasing Medicaid dental fees, 

• training non-dental medical professionals to recognize oral health problems, 

• innovative interventions to prevent caries in infants and young children, and 

• increasing families’ willingness to see dentists by getting parents to understand that 

dental care is as important as medical care. 

One goal of the plan has been to sensitize doctors and nurses to begin to see dental issues 

in a medical framework. State dental staff say that getting health professionals to think of 

dental caries as a preventable infectious disease fits very well into their medical 

orientation. This also fits into the University of Washington dental school’s program to 

educate health professionals and make them more responsive about oral health issues. For 

example, staff designed an oral health training program for public health nurses so the 

nurses understand how to integrate oral health into their public health work. Ultimately, 

the State believes this understanding will result in better access to dentists and earlier 

intervention with dental problems. 

For more information contact: 

Elizabeth Hines, Oral Health Service Administrator


Community and Family Health


Washington Department of Health


P.O. Box 47880


Olympia, WA 98504-7880


360-753-5423


PROVIDER PARTICIPATION 

California Dental Access Program 

Beginning in 1992, the California EPSDT program conducted a statewide dental access 

improvement program which resulted in 40 county volunteer dental coalitions and the wide 

distribution of dental access resource manuals. The project established 9 regional 

workshops which were attended by more than 700 individuals representing private practice 

dentists, local public health programs, community clinics, professional organizations, 

universities and others concerned about children’s oral health issues. Community dental 

providers were introduced to their county EPSDT program, Head Start, and other local 

children’s programs. 

The local coalitions developed specific strategies and activities for improving access to 

dental care in their respective communities. The most widespread strategy has been the 

B-6 
establishment of volunteer share-the-care programs similar to those started in Contra Costa 

and other counties. Some coalitions have become involved with preventive strategies 

including baby bottle tooth decay, community water fluoridation campaigns, and the 

planning of community health fairs. 

For more information contact: 

Renee Nolte-Newton, Dental Hygienist Consultant


Children’s Medical Services Branch


California Department of Health Services


714 P Street, Room 400


Sacramento, CA 95814


916-653-4860


Delaware Clinic Program 

Because almost none of Delaware’s approximately 400 private practice dentists participate 

in Medicaid, nearly all EPSDT dental services are provided through clinics. For some 

years, the State has provided dental services to approximately 50,000 EPSDT-eligible 

children in 8 public health clinics. The State pays each clinic a monthly fee of $111 for 

each enrolled child to cover all medical and dental services. Each clinic is staffed with 

one dentist and one assistant. For specialized care, the clinic may refer children to a 

pediatric dentist and pay fee-for-service rates. In addition to the clinics, a few hospitals 

and a community college employ dentists who provide Medicaid services. 

For more information contact: 

David Mihalik, Social Service Senior Administrator


Delaware Department of Health and Social Services


1901 North DuPont Highway


New Castle, DE 19720


302-577-4900


Georgia Tax Credit 

Georgia legislators introduced a proposal in 1995 (House Bill LC-10-0948) to authorize 

State tax credits to dentists and other providers who agree to serve poor children. The bill 

would have given a credit of $50 against State income taxes due from physicians or 

dentists for each indigent patient treated in a public clinic and from whom no 

compensation is received. Providers could carry forward indefinitely unused credits. The 

proponents of the legislation believe that the amount of the credit is enough to partially 

overcome losses for treating indigent patients, but it is not high enough to cause providers 

to substitute non-paying for paying patients. The bill was not passed in 1995, but 

legislators plan to re-introduce it in the 1996 legislative session. 

B-7

For more information contact: 

Tim Burgess, Director


Office of Planning and Budget


254 Washington Street SW, Suite 614


Atlanta, GA 30334


404-656-3820


Indiana Dental Procedure Priorities 

In 1995, to retain participation of dentists in the EPSDT program, Indiana eliminated many 

adult dental services and reduced the number of children’s procedures that will be 

reimbursed routinely. With the savings, the State increased fees for the remaining 

procedures which are the most important preventive and restorative services for children. 

The State will continue to cover all procedures deemed medically necessary for EPSDT 

children but will require prior authorization and pay only current rates for any procedures 

that have been eliminated for adults. These actions were based on discussions with and 

recommendations from the State dental association. 

For more information contact: 

Carol Gable, Consultant


Office of Medicaid Policy and Planning


Indiana Family and Social Services Administration


402 West Washington Street, Room W382


Indianapolis, IN 46204


317-232-2091


Minnesota Medicaid Provider Mandate 

In 1994, Minnesota enacted legislation (Rule 101) requiring that dentists and other 

providers treat Medicaid beneficiaries as a condition of participation in health insurance 

and workers’ compensation plans for State employees. Minnesota EPSDT staff believe 

that Rule 101 has improved children’s access to dental services by increasing the supply of 

available dentists. 

Rule 101 requires that providers accept new Medicaid patients on a continuing basis, using 

the same acceptance criteria they would use for non-Medicaid patients, up to a threshold of 

20 percent. If a provider’s active Medicaid patient case load exceeds 20 percent, the 

provider may refuse to accept new beneficiaries. The rule includes a formula for 

determining this threshold. The formula includes such factors as active patient caseload, 

number of patient visits, and length of time enrolled as a Medicaid provider. Providers 

must notify the State when they have reached the threshold and will not take new 

Medicaid patients. 

B-8

For more information contact: 

Lawrence D. Grewach, Manager


Dental Demonstration Project


Minnesota Department of Human Services


444 Lafayette Road, 6th Floor


St. Paul, MN 55155


612-296-1481


New Mexico Patient Management Assistance 

New Mexico worked closely with its State dental association in 1994 and 1995 to 

streamline claims processing and help dentists better manage Medicaid families and 

children. For example, as part of a training program on improving claims processing, New 

Mexico offered suggestions to dentists on how to manage young children in the dental 

office. State officials also are seeking to allow dentists who participate in this training to 

receive continuing education credits. 

For more information contact: 

Dr. Ken Padilla, Planner


Ambulatory Care Section


Medical Assistance Division


New Mexico Human Services Department


P.O. Box 2348


Santa Fe, NM 87504-2348


505-827-3177


North Carolina Clinic Program 

North Carolina is enabling local health departments and other clinics to contract with local 

dentists for EPSDT services. In some localities, State staff believe this is the only way to 

assure the availability of dental services for EPSDT-eligible children. The State clinic 

program also will improve access for Head Start programs and initiate or expand dental 

services in rural, community, and migrant health centers. By enlisting the support of local 

dental societies, the State is hoping to attract dentists who might otherwise not participate 

to work full or part time in the clinics. 

For more information contact: 

Dr. C. Jean Spratt, Director


Division of Dental Health


North Carolina Department of Environment, Health and Natural Resources


P.O. Box 27687


Raleigh, NC 27611


919-733-3853


B-9 
Wisconsin Access and Utilization Initiatives 

In 1993, the Wisconsin Dental Association, in cooperation with State Medicaid and dental 

public health staff, initiated projects to help dentists deal with problems such as "no-show 

patients." By alleviating such problems, dentists may be more willing to participate in the 

EPSDT program. 

To formulate recommendations, the dental association and the State formed a task force of 

Medicaid staff and dentists who provide EPSDT services. The task force interviewed 

dentists and their support staff and developed suggestions to deal with "no-show patients." 

The suggestions include: 

• mailing reminders to patients and following up with phone calls a day in advance; 

• requiring patients to call the office and confirm their appointment 24 hours in advance 

or their appointment will go to someone else; 

• explaining why keeping appointments is important; 

• setting aside a specific block of time or certain days for Medicaid patients and treating 

patients on a first-come, first-served basis during those times; and 

• letting patients know where they can get help with transportation or child care so they 

can keep appointments. 

The dental association has prepared an informational pamphlet describing these suggestions 

and others. Other informational materials describe county dental society clinic and 

volunteer programs in Wisconsin. 

For more information contact: 

Maryann Dillon, Director of 

Dental Services 

Wisconsin Dental Association 

111 East Wisconsin Avenue, 

Suite 1300 

Milwaukee, WI 53202 

414-276-4520 

Wisconsin Fee Increases 

Dr. Warren LeMay, Oral Health Consultant


Bureau of Public Health


Division of Health


1414 East Washington Avenue


Madison, WI 53703


608-266-5152


In addition to general dental fee increases over the past few years, which have raised 

payments to approximately 61 percent of Statewide average charges, Wisconsin was paying 

a $3.50 "bonus payment" for 20 dental procedures most frequently performed on children 

under 21. Beginning in 1995, these additional payments have been folded into a further 

fee increase which applies only to claims for EPSDT services. These fees are now set at 

B-10 
approximately 75 percent of average charges. In part, these increases were possible 

because of the State’s decision to eliminate some adult dental benefits and hold the line on 

increasing fees for non-EPSDT dental services. 

For more information contact: 

Dr. Warren LeMay, Oral Health Consultant


Bureau of Public Health


Division of Health


1414 East Washington Avenue


Madison, WI 53703


608-266-5152


Contra Costa County (CA) "Share-the-Care" Dental Access Project 

In 1990, the county dental society and the EPSDT staff in Contra Costa County, 

California, initiated a voluntary "share-the-care" project. Participating dentists agree to 

take one to three new EPSDT cases, with the understanding that they will not be put on a 

list requiring them to see all referred children. County EPSDT staff insure that 

participating dentists receive no more patients than they have agreed to treat. Some 

dentists choose to bill Medicaid for services; others treat without charge. Some low-income 

patients who are not eligible for Medicaid are included. 

County staff provide education and outreach to insure that patients keep their 

appointments. Staff schedule initial appointments and provide transportation and 

translation, if needed. They instruct families about proper hygiene and behavior in the 

dentist’s office and strive to overcome any fear of dentists on the part of children or their 

parents. Some dentists will drop a family for breaking an appointment without calling to 

cancel. The Contra Costa program claims to have an 85 percent "kept-appointment" rate. 

County staff and the dental association continue to support the Contra Costa program. It is 

a model. Similar programs have been established in other counties in California and in 

other States, such as Colorado and Wisconsin. 

For more information contact: 

Robert Isom, Deputy Director


Child Health and Disability Prevention Program


Contra Costa County


595 Center Avenue, Suite 310


Martinez, CA 94553


510-313-6150


Dr. Colleen Zimmer 

1004 McHugh Street 

Fort Collins, CO 80524 

303-221-4500 

B-11

Maryann Dillon, Director of Dental Services


Wisconsin Dental Association


111 East Wisconsin Avenue, Suite 1300


Milwaukee, WI 53202


414-276-4520


PROVIDER TRAINING AND EDUCATION 

Iowa Pediatric Dental Education Program 

Staff from State Medicaid and dental public health programs are collaborating with the


pediatric dentistry department of the University of Iowa to develop training programs for


general practitioners. They plan to (1) train dentists about pediatric dental issues,


(2) determine how many dentists currently screen children under 3 years of age, and


(3) produce a monograph about what should be included in a child’s first dental exam.


The State will establish panels of dentists who are willing to treat very young or disabled


children. Iowa’s EPSDT screening schedule specifies an initial screening at 12 months of


age, but parents in many communities find that few dentists are willing to examine


children that young. In addition, few dentists are willing to serve children with disabilities.


The State has established a panel of dentists who are willing to treat disabled children and


hopes to set up a similar panel of dentists who are willing to see children before their first


birthday. Among other methods to improve access for this age group, the State will (1)


conduct a survey to find out how many children are screened before their first birthday, (2)


assess dentists’ attitudes about treating young children, and


(3) locate dentists willing to staff Iowa’s 25 child health clinics.


For more information contact: 

Dr. William C. Maurer, Chief


Dental Health Bureau


Iowa Department of Public Health


Lucas State Office Building


Des Moines, IA 50319-0075


515-281-4916


Texas Oral Health Video Project 

In 1995, the Texas Medicaid program began developing a videotape about oral health 

examinations for use by non-dental health workers who screen young children. The video 

will describe techniques for adequate oral screening, explain what should be included in 

oral health counseling, and specify that children should be referred to dentists if decay or 

abnormalities are found. To prepare the videotape, Texas staff consulted with the pediatric 

dental department of the University of Washington and others. 

B-12

For more information contact: 

Dr. Nana Lopez, Chief 

Bureau of Dental Services 

Texas Department of Health 

1100 West 49th Street 

Austin, TX 78756 

512-458-7323 

Spokane (WA) Dental Prevention Project: "Access to Baby and Child Dentistry" 

Spokane, Washington is the site of a demonstration project that (1) provides dental 

prevention services to young, at-risk children from birth through age 5 and (2) trains 

dentists on recent developments in pediatric dentistry. Initiated in 1995, the project 

established a coalition of pediatric dentists from the University of Washington dental 

school, dentists in Spokane, and State Medicaid and dental public health staff. The project 

will: 

• screen, diagnose and treat the children, 

• provide family oral health education, 

• calculate the direct costs and cost savings derived from the preventive program, 

• study factors that determine children’s utilization of dental services, 

• determine if improved access changes parents attitudes so that they will visit dentists 

more frequently, and 

• assess the cost effectiveness of a new technique to provide fluoride varnish. 

Pediatric dentists from the dental school will train participating dentists in recent pediatric 

dental techniques. According to project staff, training is needed because most general 

practitioners lack pediatric dental knowledge. The Washington Department of Health 

Services will pay participating Spokane dentists higher fees than dentists get for similar 

services in the rest of the State. 

Although the project will cost the State an estimated $3 million, project staff hope to 

demonstrate significant cost benefits. The project has submitted an application to the 

National Institute of Dental Research to fund a 4-year cost benefit and utilization study. 

For more information contact: 

Dr. Peter Milgrom, Director Elizabeth Hines, Oral Health Service


Dental Fears Research Clinic Administrator


Dental Public Health Sciences Community and Family Health


University of Washington School Washington Department of Health


of Dentistry P.O. Box 47880 

Box #357475 Olympia, WA 98504-7880 

Seattle, WA 98195 360-753-5423 

206-685-2453 

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APPENDIX C


AGENCY COMMENTS


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