Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

MOST CHILDREN WITH 

MEDICAID IN FOUR STATES 

ARE NOT RECEIVING 

REQUIRED DENTAL SERVICES 

Suzanne Murrin 

Deputy Inspector General for 

Evaluation and Inspections 

January 2016 

OEI-02-14-00490 
 

EXECUTIVE SUMMARY: MOST CHILDREN WITH MEDICAID IN FOUR STATES 

ARE NOT RECEIVING REQUIRED DENTAL SERVICES 

OEI-02-14-00490 

WHY WE DID THIS STUDY 

Medicaid is the primary source of dental coverage for children in low-income families and 

provides access to dental care for approximately 37 million children. However, access to dental 

care for children with Medicaid has been a longstanding concern. When children lack dental 

care, untreated decay and infection in their mouths can result in preventable emergency room 

visits or more complicated and expensive dental and medical interventions later in life. 

Medicaid provides dental services to children through the Early and Periodic Screening, 

Diagnostic, and Treatment program. Under this program, States are required to cover all 

medically necessary dental services and these services must be provided at the intervals specified 

in States’ pediatric dental periodicity schedules. 

HOW WE DID THIS STUDY 

This study focuses on four States: California, Indiana, Louisiana, and Maryland. We analyzed 

Medicaid dental claims with service dates in 2011 and 2012, analyzed Medicaid beneficiary 

enrollment files, and conducted structured interviews with State officials. We focused our 

analysis on three required dental services—biannual oral exams, dental cleanings, and fluoride 

treatments—for children continuously enrolled in Medicaid for 2 years. 

WHAT WE FOUND 

We found that three out of four children did not receive all required dental services, with one in 

four children failing to see a dentist at all. All four States reported that they do not routinely 

track whether children are receiving all the required services. In addition, two of the four States 

had policies that do not allow payment for particular services in accordance with their periodicity 

schedules. The States we reviewed reported facing shortages of participating dental providers 

and challenges in educating families about the importance of regular dental care. While the 

States reported that they employ a variety of strategies to address these problems and the Centers 

for Medicare & Medicaid Services (CMS) has taken some positive steps in this area, we continue 

to have concerns that children are not receiving required dental services. 

WHAT WE RECOMMEND 

We provided CMS with eight recommendations designed to monitor and ensure that children 

with Medicaid receive all of their EPSDT required dental services. Specifically, CMS should 

(1) develop a comprehensive plan to increase the number of children who receive required 

services; (2) develop benchmarks for dental services and require States to create mandatory 

action plans to meet them; (3) work with States to identify areas with limited providers and the 

barriers preventing providers from participating in Medicaid; (4) work with States to analyze the 

effects of Medicaid payments on access to dental providers; (5) work with States to educate 

families about the importance of dental care and to encourage ongoing relationships between 

children and their dentists; (6) work with States to track children’s utilization of required dental 

services; (7) identify and share effective strategies with States; and (8) ensure that States pay for 

services in accordance with their periodicity schedules. 
CMS concurred either fully or partially with all but one of our recommendations. With regard to 

our sixth recommendation—with which CMS did not concur—CMS does not agree that it is 

necessary to require additional data on dental services beyond the data collected on Form 

CMS-416. With regard to our second recommendation—with which CMS partially concurred— 

CMS does not agree that it is necessary to require mandatory action plans for meeting 

benchmarks for dental services. Also, in response to the first recommendation, CMS argued that 

children’s dental services are not “one size fits all” and that a child who receives an exam may 

not need a second one during the year. While we agree that services should be customized, we 

do not agree that children with Medicaid should receive services less frequently than at the 

minimum frequency set by States in their periodicity schedules, which for the four States we 

reviewed is twice per year. 
TABLE OF CONTENTS 

Objectives ....................................................................................................1 

Background..................................................................................................1 

Methodology................................................................................................4 

Findings........................................................................................................6 

In the four States we reviewed, 78 percent of children did not 

receive required dental services .......................................................6 

Two of the four States had coverage policies that may limit 

children’s ability to receive the required services ............................8 

The States we reviewed reported facing a shortage of 

participating dentists and challenges in educating families about 

the importance of regular dental care ...............................................9 

Conclusion and Recommendations ............................................................12 

Agency Comments and Office of Inspector General Response .....15 

Appendixes ................................................................................................18 

A: Detailed Data Sources and Analysis ........................................18 

B: Percentages of Children Who Did Not Receive Required 

Dental Services ..............................................................................21 

C: Percentages of Children Who Did Not Receive All Required 

Dental Services ..............................................................................23 

D: Agency Comments...................................................................24 

Acknowledgments......................................................................................29
 
 

 

 

 

OBJECTIVES 

1.	 To describe the extent to which children enrolled in Medicaid in four 

States received pediatric dental services in 2011 and 2012. 

2.	 To describe barriers and strategies to increase access in these States. 

BACKGROUND 

Tooth decay is one of the most common chronic diseases of children. The 

disease is almost entirely preventable through a combination of good oral 

health habits at home, a healthy diet, and early and regular use of 

preventive dental services. 

Medicaid is the primary source of dental coverage for children in 

low-income families, providing coverage to approximately 37 million 

children.1 However, access to dental care for children with Medicaid has 

been a longstanding concern. According to a Government Accountability 

Office (GAO) report, millions of children with Medicaid are estimated to 

be living with untreated tooth decay and other dental issues.2 In addition, 

the report found that inadequate receipt of services is a significant problem 

for children in Medicaid. 

A lack of access to dental care can lead to serious health consequences. 

Preventable dental conditions were the primary cause of more than 

850,000 emergency room visits in 2009.3 Notably, in 2007 the family of a 

12-year-old Maryland boy with tooth pain was unable to find a Medicaid 

dentist who would treat him. The family eventually sought treatment for 

the boy in an emergency room, but ultimately he died. Untreated dental 

disease has also been linked to various health issues such as ear and sinus 

infections, weakened immune systems, diabetes, and heart disease.4 

Medicaid Coverage for Children’s Dental Services 

Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment 

(EPSDT) benefit requires States to cover all medically necessary dental 

services for children 18 years of age and under, and States may choose to 

____________________________________________________________ 

1

 Thomas P. Wall, Dental Medicaid—2012, American Dental Association (ADA), 2012. 

Centers for Medicare & Medicaid Services (CMS), Annual EPSDT Participation Report, 

Form CMS-416 (National), Fiscal Year 2012, April 3, 2014. 2

 GAO, Extent of Dental Disease in Children Has Not Decreased, and Millions Are 

Estimated to Have Untreated Tooth Decay, GAO-08-1121, September 2008.
 3

 The Pew Charitable Trusts, A Costly Dental Destination: Hospital Care Means States 

Pay Dearly, February 28, 2012. 4

 The Kaiser Family Foundation, Children and Oral Health: Assessing Needs, Coverage, 

and Access, June 2012.
 

Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEI-02-14-00490) 1 
 

 

 

 

 

 

extend this benefit up to age 20. 5 Medically necessary services include a 

variety of services intended to prevent tooth decay and dental disease. The 

benefit covers diagnostic and preventive services, as well as needed 

treatment and follow-up care. Diagnostic services include oral exams and 

x-rays of the mouth; preventive services include cleanings, topical fluoride 

treatments, and dental sealants. Dental treatment covers a wide range of 

services, such as fillings and tooth extractions. 

The Social Security Act requires that EPSDT dental services be provided 

both (1) at intervals that meet reasonable standards of dental practice and 

(2) at other intervals as indicated by medical necessity.6 Further, CMS 

states in its State Medicaid Manual that “[d]ental services must be 

provided at intervals [that States] determine meet reasonable standards of 

dental practice.”7 To establish these standards of dental practice, each 

State must develop a dental periodicity schedule in consultation with 

recognized dental organizations involved in child health. In lieu of 

developing their own periodicity schedules, States may choose to adopt a 

nationally recognized periodicity schedule, such as the one developed by 

the American Academy of Pediatric Dentistry (AAPD). 

The four States in our study adopted the AAPD periodicity schedule. This 

schedule recommends that children receive a number of services at a 

minimum of every 6 months to maintain oral health. These services 

include oral exams, dental cleanings, and fluoride treatments, among other 

services. 

The Dental Home 

The AAPD and the American Dental Association (ADA) define a “dental 

home” as an ongoing relationship between a child and a dentist that 

includes all aspects of oral health care delivered in a comprehensive and 

continuously accessible way.8 According to the AAPD and ADA, a dental 

home assures continuity of care and assures that appropriate referral to 

dental specialists occurs when care cannot directly be provided by the 

dental home. They recommend that a child have a dental home no later 

than 1 year of age. Several studies found that dental visits at a very young 

age can improve health outcomes and reduce future dental costs.9

 ____________________________________________________________ 

5

 Social Security Act (SSA) § 1905(r)(3); 42 CFR § 441.56. All four States reviewed in 

this report provide coverage to children up to 20 years of age. California allows 

Medicaid coverage to continue until the last day of the month in which the child turns 21. 

See California Code of Regulations 22 CCR § 50193. 

6 SSA § 1905(r)(3)(A).
 7

 State Medicaid Manual, Pub. No. 45, ch. 5, § 5140(A).
 8

 AAPD Foundation, Dental Trade Alliance Foundation, and ADA, The Dental Home—
 

It’s Never Too Early to Start, February 2007. 9

 AAPD, Early Preventive Dental Visits, April 2014. 

Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEI-02-14-00490) 2 
 

 

Federal Initiatives 

Over the past several years, the Centers for Medicare & Medicaid Services 

(CMS) has worked to improve children’s access to dental care. In 

April 2010, CMS created its Oral Health Initiative with the goal of 

increasing the number of children receiving preventive dental care.10 As 

part of this initiative, CMS set State-specific goals for children’s use of 

preventive dental services for FY 2015. CMS asked States to voluntarily 

submit Oral Health Action Plans as a roadmap to achieving these goals. 

CMS offered technical assistance to States to develop and implement these 

plans. The Oral Health Initiative ended in September 2015. 

CMS also established the Core Set of Children’s Health Care Quality 

Measures. These measures help States to monitor and improve the quality 

of health care provided to enrollees in Medicaid and in the Children’s 

Health Insurance Program. The goals of this effort are (1) to encourage 

national reporting by States on a uniform set of measures and 

(2) to support States in using these measures to drive quality improvement. 

As a part of this initiative, CMS established two measures that track 

utilization of preventive dental services and sealants, respectively.11 

Related Work 

This report is a part of a series that also looked at Medicaid dental 

providers with questionable billing practices. 12 Our findings from those 

reports raise concerns that providers with questionable billing may be 

billing for services that are not medically necessary or were never 

provided, and the findings also raise concerns about the quality of care 

being provided. 

This report is also part of a body of work that looks at utilization of 

services by children with Medicaid. In one report, we found that three out 

of four children did not receive all required EPSDT medical, vision, and 

hearing screenings in 2007.13 In a followup report, we found that although 

____________________________________________________________ 

10 Specifically, CMS sets benchmarks for each State that, if met, would (1) increase by 

10 percentage points the proportion of children in Medicaid and the Children's Health 

Insurance Program (CHIP) who receive a preventive dental service; and (2) increase by 

10 percentage points the proportion of Medicaid and CHIP children ages 6 to 9 who 

receive a sealant on a permanent molar. 

11 A sealant is a plastic material applied to the surface of a tooth to help prevent cavities. 12 See OIG, Questionable Billing for Medicaid Pediatric Dental Services in New York, 

OEI-02-12-00330, March 2014; OIG, Questionable Billing for Medicaid Pediatric 

Dental Services in Louisiana, OEI-02-14-00120, August 2014; OIG, Questionable Billing 

for Medicaid Pediatric Dental Services in Indiana, OEI-02-14-00250, October 2014; and 

Questionable Billing for Medicaid Pediatric Dental Services in California, 

OEI-02-14-00480, May 2015. 

13 OIG, Most Medicaid Children in Nine States Are Not Receiving All Required
 

Preventive Screening Services, OEI-05-08-00520, May 2010. 

Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEI-02-14-00490) 3 
 

 

 

CMS disseminated strategies aimed at improving participation in EPSDT 

screenings and made efforts to improve the delivery of medical screenings, 

there was evidence that children continued to receive fewer medical 

screenings than required.14 

In another report, OIG found that nearly a third of children in foster care 

who were enrolled in Medicaid did not receive at least one required health 

screening in 2011 and 2012.15 Further, the reviews by the Administration 

for Children and Families (ACF) did not ensure that children in foster care 

receive the required screenings. OIG recommended that ACF identify and 

disseminate State strategies to ensure that all children in foster care 

receive required health screenings and that it expand the scope of its 

reviews to determine whether children in foster care receive these 

screenings. ACF concurred with the first recommendation and said that it 

was considering the second. 

METHODOLOGY 

Scope 

This study focuses on four States: California, Indiana, Louisiana, and 

Maryland. We selected a mix of States based on the following factors: the 

number of children with Medicaid per State, geographic location, and 

input from CMS staff. The four States serve approximately 19 percent of 

all children with Medicaid.16 

This report provides detailed information about dental services for 

children who were continuously enrolled in Medicaid for 2 years. The 

data in this report are not comparable to the data that States report 

annually to CMS about their utilization of services under the EPSDT 

benefit.17 Specifically, we provide a more comprehensive look at whether 

children were receiving required dental services over a longer period of 

____________________________________________________________ 

14 OIG, CMS Needs To Do More To Improve Medicaid Children's Utilization of 

Preventive Screening Services, OEI-05-13-00690, November 2014. 15 OIG, Not All Children in Foster Care Who Were Enrolled in Medicaid Received 

Required Health Screenings, OEI-07-13-00460, March 2015. 16 The percentage was derived from beneficiary enrollment data from the four States and 

from data collected from CMS’s Form-416. 

17 States report this information on CMS’s Form-416, which CMS uses to monitor 

EPSDT performance. The dental data collected are based on the number of children who 

were continuously enrolled in Medicaid for at least 90 days during the fiscal year of 

review. CMS does not collect information on the frequency of particular services. For 

further details on the data collected on Form-416, see 

http://www.medicaid.gov/medicaid-chip-program-information/bytopics/benefits/downloads/cms-416-instructions.pdf. 

Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEI-02-14-00490) 4 
 

time and also determine whether they received required services at the 

intervals specified in their respective States’ periodicity schedules. 

All four States in this review adopted the AAPD schedule, which specifies 

that children should receive—at a minimum—biannual oral exams, dental 

cleanings, and fluoride treatments. We focused our review on these 

services because they are essential to maintaining oral health. 

Data Sources 

We based this study on (1) Medicaid dental claims with service dates in 

2011 and 2012, (2) Medicaid beneficiary enrollment files, and 

(3) structured interviews with State officials. Appendix A provides a 

detailed description of the methodology. 

Limitations 

The study includes services paid for by Medicaid; it does not include 

services that these children may have received that were paid for by other 

sources. As a result, we may not be capturing all dental services that 

children received. 

Standards 

This study was conducted in accordance with the Quality Standards for 

Inspection and Evaluation issued by the Council of the Inspectors General 

on Integrity and Efficiency. 

Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEI-02-14-00490) 5 
 

 

FINDINGS 

In the four States we reviewed, 78 percent of children

did not receive required dental services 

All four States in this review adopted the AAPD schedule, which specifies 

that children should receive—at a minimum—biannual oral exams, dental 

cleanings, and fluoride treatments. Seventy-eight percent of children who 

were continuously enrolled in Medicaid in these four States did not 

receive these required services, representing 2.9 million children. See 

Chart 1. 

The percentage varied by State, with a low of 73 percent in Maryland and 

a high of 81 percent in Louisiana. See Appendix B for detailed 

information about children who did not receive required 

services. Receiving dental services to identify and prevent tooth decay 

and other dental problems is critical for ensuring children’s overall health. 

Chart 1: Percentage of Children Who Did Not Receive Required Dental 

Services 

22% received all 

required dental 

services 

50% received 

some but not 

all required 

services 

28% did not 

receive any 

dental services 

78% 

Source: OIG analysis of State Medicaid data, 2015. 

Note: Includes all children who were at least 1 year of age and were continuously enrolled in Medicaid in 2011 and 2012. 

 Required services include biannual oral exams, dental cleanings, and fluoride treatments. 

Over a quarter of children with Medicaid did not receive any 

dental services over a 2-year period 

In the four States we reviewed, 28 percent of children with Medicaid who 

were continuously enrolled received no dental services over a 2-year 

period. This amounted to over 1 million children in these four States. An 

Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEI-02-14-00490) 6 
 

 

 

 

additional 14 percent of children had only one visit to the dentist during 

the 2-year period. 

Children younger than 3 years old were the least likely to receive dental 

services when compared to children in the other age groups. Notably, 

41 percent of children under 3 received no dental care over a 2-year 

period, compared to 21 percent of children 6 to 9 years of age. 18 In 

addition, children in rural areas were slightly less likely than children in 

urban areas to receive dental services. 

Another 50 percent received some—but not all—of the required 

dental services over a 2-year period 

Fifty percent of children who were continuously enrolled in Medicaid over 

a 2-year period received some, but not all of the required dental services. 

These services include biannual oral exams, dental cleanings, and fluoride 

treatments. As shown in Chart 2, children most commonly did not receive 

fluoride treatments at the intervals specified in their State’s periodicity 

schedule, followed closely by dental cleanings and oral exams. See 

Appendix C for detailed information by State. 

Chart 2: Percentage of Children Who Did Not Receive All the Required 

Dental Services, By Type of Service 

50% 49% 46% 45% 

All required 

services 

Fluoride 

treatments 

Dental cleanings Oral exams 

Source: OIG analysis of State Medicaid data, 2015. 

Note: Includes all children who were at least 1 year of age and were continuously enrolled in Medicaid in 2011 and 2012. 

 Required services include biannual oral exams, dental cleanings, and fluoride treatments. 

This raises concerns about the States’ abilities to ensure that children are 

receiving the services they need. Although States have to report to CMS 

____________________________________________________________ 

18 Our analysis of children under the age of 3 included children from the age of 1 year to 

2 years. 

Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEI-02-14-00490) 7 
the number of children receiving at least one preventive dental service, 

they do not have to report data on the frequency of any services. Notably, 

all four States reported that they do not routinely track whether children 

are receiving services at the intervals specified in their periodicity 

schedules. As a result, States may not be capturing critical data or 

monitoring whether children are getting the care needed to prevent disease 

and promote good oral hygiene. 

Children who received required services appear to have a 

dental home 

A dental home is an ongoing relationship between a child and a dentist 

that includes all aspects of oral health care delivered in a comprehensive 

and continuously accessible way. Eighty-six percent of the children who 

received all the required services visited the same practice over a period of 

2 years.19 Children who received only some of the required services were 

more likely to visit multiple practices. This suggests that children in an 

established dental home are more likely to receive the required services. 

Two of the four States had coverage policies that may

limit children’s ability to receive the required services 

As noted earlier, States must provide certain dental services at the 

intervals specified in their periodicity schedules. All four States adopted 

the AAPD schedule, specifying that children should receive—at 

a minimum—biannual oral exams, dental cleanings, and fluoride 

treatments. However, two States had policies that do not allow payment 

for particular services in accordance with the established schedules. One 

State had a schedule specifying that children should receive biannual 

fluoride treatments and dental cleanings beginning at 6 months of age; 

however, the State’s coverage policy would pay for such services only for 

children 1 and older. Similarly, another State’s schedule specified that 

children 6 months and older should receive biannual fluoride treatments; 

however, the State’s coverage policy allowed payment for such treatment 

only for children up to 15 years of age.20

 ____________________________________________________________ 

19 Maryland was not included in this analysis. For more information, see Appendix A. 

20 Our analysis showed that despite its coverage policy, this State paid—at least in some 

cases—for fluoride treatments for children over 15 years of age. 

Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEI-02-14-00490) 8 
 

The States we reviewed reported facing a shortage of

participating dentists and reported challenges in 

educating families about the importance of regular 

dental care 

Officials in each of the four States identified a number of barriers that 

impeded access to Medicaid dental services in each of their States, as well 

as strategies to address these barriers. When children lack access to dental 

care, untreated decay and infection in their mouths can result in more 

complicated and expensive dental and medical interventions later in life.21 

Shortage of participating dentists: Officials in all four States expressed 

concerns about the lack of providers available to treat children with 

Medicaid, particularly very young children. They also reported shortages 

in certain geographic areas—typically, rural areas. Officials further noted 

a reluctance of some providers to participate in Medicaid because of low 

reimbursement rates and administrative burdens. They added that some 

providers are concerned that Medicaid patients are more likely to miss 

appointments, with providers in one State complaining of “no show” rates 

as high as 50 percent. 

Officials described several 

Pay-for-Performance Contracts strategies aimed at 

ameliorating these Maryland highlighted its contract with

problems. Officials in an administrative services organization 

one State reported that the (ASO) that focuses on building a robust 

State provides student network of dental providers. The ASO 

earns a significant additional payment if loan repayments to dental 

it meets specified targets in its contract, providers who serve such as increasing the number of dental children with Medicaid in 

providers in certain geographic areas. rural areas that have a To meet these targets, the ASO’s staff shortage of providers. visit dental providers to encourage them Providers can receive up to participate in Medicaid. to $30,000 annually for a 

3-year commitment, with 

a possible extension of 2 additional years. 

In addition, States have implemented other strategies to encourage 

providers to participate in Medicaid. In two States, officials reported that 

their States had previously increased provider reimbursement rates. One 

of these States targeted their rate increases to a limited set of dental 

services that are more often provided to children, such as sealants and the 

application of fluoride, so that dental providers who treat young children 

____________________________________________________________ 

21 CMS, Guide to Children’s Dental Care in Medicaid, October 2004. 

Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEI-02-14-00490) 9 
 

 

 

could particularly benefit. State officials also described efforts to reduce 

administrative burdens, particularly regarding their Medicaid enrollment 

process. For example, one State is creating a streamlined application form 

that automatically checks the provider’s credentials, thus reducing the 

amount of time it takes to become a Medicaid provider. In addition, 

officials in two States reported following up with families when providers 

alerted them that a child had missed an appointment, which can help 

reduce the States’ “no show” rates, thereby encouraging more providers to 

participate in Medicaid. 

In spite of these efforts, officials noted that in some areas, there was an 

extremely limited number of dentists. To combat this problem, two States 

are allowing midlevel dental providers and other nondentists (e.g., 

hygienists, medical providers) to provide certain dental services. One 

State recently passed legislation that allows for teledentistry services, 

which helps expand access to dental services in remote and underserved 

areas. The law also expands the types of procedures that dental hygienists 

and certain dental assistants can perform without a dentist onsite. The 

other State is allowing pediatricians and primary care providers to provide 

a limited set of diagnostic and preventive services. In addition, officials in 

this State reported working to set up a dental health “safety net” clinic in 

each county. 

To further combat provider shortages, another State analyzed how many 

providers submitted a high volume of Medicaid claims so that these 

providers could be targeted for outreach. Our analysis of providers in the 

four States showed that a small concentration of dentists served the 

majority of children with Medicaid in 2012. Notably, 896 dental 

providers in the 4 States served 55 percent of the children with Medicaid 

who received care. 

Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEI-02-14-00490) 10 
Connecting Families with Dentists 

California operates a call center that helps to 

make dental appointments for children with 

Medicaid. When a parent or caregiver of a 

child with Medicaid contacts the call center to 

obtain information about participating dental 

providers, the operator on the phone not only 

identifies a provider, but calls the provider’s 

office to make an appointment for the child 

while the family member is on the phone. 

California officials noted that they put this 

system in place because in the past—when the 

State only provided families with a list of dental 

providers—families often called back and 

reported that the providers on the list were no 

longer participating in Medicaid. By making 

appointments for children with Medicaid, the 

State not only ensures that more children are 

served, it is also able to track which providers 

are no longer serving children with Medicaid. 

Educating families about the 

importance of regular dental 

care: Officials in three States 

expressed concern that many 

caregivers were not aware of the 

importance of regular dental care. 

They highlighted particular 

concerns about a lack of 

awareness about the importance 

of dental care for children 

younger than 3. They noted that 

many families may not know that 

dental services are covered for 

children in this age group. 

At the same time, State officials 

reported having strategies in place 

to reach out to families. One of 

these strategies is to ensure that 

children with Medicaid have a 

dental home. Officials in one 

State reported that they assign a dentist to each child at a very young age. 

Officials in another State noted that they assign a local dentist to each 

child who is not already seeing a particular provider. The State sends out 

information and makes calls to families when they join Medicaid. 

Officials stated that they have seen an influx of calls from families who 

did not know that Medicaid covered dental services for children. 

Officials also emphasized the importance of tracking the number of 

children who are seeing dentists regularly. For example, one State 

identifies the children who have not seen a dental provider over the last 

12 months and reaches out to their families to encourage them to seek 

care. Another State particularly targets children under 3. The State 

identifies those children who are not receiving care and provides 

information on the importance of early oral health care. Officials added 

that they plan to make system changes to increase their ability to track the 

effects of these outreach efforts. 

Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEI-02-14-00490) 11 
 

 

CONCLUSION AND RECOMMENDATIONS 

Children’s lack of Medicaid dental care has been a longstanding concern. 

Tooth decay—an almost entirely preventable disease—is one of the most 

common chronic diseases of children, and children in low-income families 

experience more tooth decay than their peers in other income groups. 

When children lack dental care, untreated decay and infection in their 

mouths can result in more complicated and expensive dental and medical 

interventions later in life. The goal of the EPSDT program is to ensure 

that children with Medicaid receive needed dental care to combat a wide 

range of oral health problems. 

The EPSDT program requires each State to provide dental services to all 

children enrolled in Medicaid. However, we found that three out of four 

children with Medicaid in the four States are not receiving required dental 

services, with one in four children failing to see a dentist at all over a 

2-year period. The States we reviewed reported facing shortages of 

participating dental providers and challenges in educating families about 

the importance of regular dental care. While the States reported that they 

employ a variety of strategies to address these problems, they need to do 

more to ensure that children receive needed dental care. 

These findings pose a potentially larger problem, as the number of 

children with Medicaid is increasing as a result of the Affordable Care Act. 

CMS and States must work together to ensure that children receive the 

dental care they need. 

We recognize that CMS has already taken some steps towards addressing 

the issues we found in this report. It has developed materials to educate 

consumers and providers about positive oral health practices, and it has 

shared strategies with States to improve access to and utilization of dental 

care. However, we continue to have concerns that children are not 

receiving required dental services. 

We recommend that CMS take the following steps, in addition to those it 

has already taken: 

Develop a comprehensive plan to increase the number of 

children who receive required services 

CMS should develop a comprehensive plan for how it can help increase 

the number of children who receive required services, such as biannual 

exams, fluoride treatments, and cleanings. The plan should include 

strategies for working with States and cover short-term and long-term 

objectives, as well as timelines to meet these objectives. The plan should 

include the initiatives that CMS decides to pursue in response to the other 

Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEI-02-14-00490) 12 
 

recommendations in this report as well as other initiatives that it develops 

to increase the number of children receiving required dental services. 

Develop benchmarks for dental services and require States to 

create mandatory action plans to meet them 

CMS should set State-specific benchmarks to increase in future years the 

number of children who are receiving preventive dental care. CMS should 

require States to create mandatory action plans to meet these benchmarks 

and should require States to submit their plans to CMS. 

Work with States to identify areas with limited providers and 

the barriers preventing providers from participating in 

Medicaid 

To increase provider participation, CMS should help States identify where 

there are shortages of Medicaid providers and develop strategies to 

decrease barriers to participation. Such strategies could include provider 

outreach, improving the enrollment process, reducing the number of 

missed appointments, and evaluating whether certain dental services can 

be provided by other providers or in alternative settings. 

Work with States to analyze the effects of Medicaid payments 

on access to dental providers 

CMS should work with States to analyze Medicaid dental payments and 

ensure that States document whether their payment rates for providers are 

sufficient to encourage dental providers to participate in the program. To 

address this recommendation, CMS should work closely with States to 

effectively implement new regulations—finalized in November 2015— 

that are designed to assure access to covered Medicaid services, including 

dental care.22 Specifically, it should ensure that States have a process to 

monitor access to dental care and that they take these data into account 

when setting Medicaid payment rates for dental providers. 

Work with States to educate families about the importance of 

dental care and to encourage ongoing relationships between 

children and their dentists 

CMS should work with States to educate families about the importance of 

regular dental care. The outreach should focus on the importance of 

regular dental care, particularly for children under the age of 3. CMS 

should prepare materials and collaborate with States on media events. In 

addition, CMS should work with States to set up systems to pair children 

with participating dentists to help ensure that more children receive 

____________________________________________________________ 

22 42 CFR § 447.203; 80 Fed. Reg. 67575 (Nov. 2, 2015). 

Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEI-02-14-00490) 13 
regular dental care. Such systems should encourage the establishment of 

dental homes. The goal of these efforts is to increase the number of 

children receiving dental care. 

Work with States to track children’s utilization of required 

dental services 

Although the data in CMS’s Form-416 provide important information 

about the dental services that children with Medicaid receive, they do not 

include comprehensive information about whether children receive 

required services at the appropriate intervals. CMS should work with 

States to monitor their claims data to identify and track children with 

Medicaid who are receiving the required services according to each State’s 

periodicity schedule. One area of focus might be to look at children who 

have been continuously enrolled in Medicaid for an extended period of 

time, such as 18 months or 2 years, because these children in particular 

rely on Medicaid for these services. States should use the results of their 

tracking to target their educational and outreach efforts to the population 

of children who are not receiving required dental services at the intervals 

specified in States’ periodicity schedules. 

Identify and share effective strategies with States 

As shown in this report, States have implemented different strategies to 

increase assess to pediatric dental care. CMS should identify and review 

States’ strategies and share this information on an ongoing basis with all 

States. These strategies—which can encompass those identified in this 

report as well as others—should include ways to increase dental provider 

participation in States’ Medicaid dental programs as well as ways to 

encourage and increase children’s visits to the dentist. CMS could publish 

periodic reports or facilitate information sharing by creating a forum for 

States on its website. 

Ensure that States pay for services in accordance with their 

periodicity schedules 

CMS should ensure that States are paying for services in accordance with 

their periodicity schedules. As a part of this process, CMS should require 

that States review their periodicity schedules, and should ensure that 

States that adopted their schedules from professionally recognized 

associations (such as the AAPD) are relying on the most current 

guidelines. CMS should require States to conduct regular reviews to 

ensure that States are paying for services in accordance with their 

periodicity schedules. 

Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEI-02-14-00490) 14 
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 

RESPONSE 

CMS concurred with five of our recommendations, partially concurred 

with two recommendations, and did not concur with one recommendation. 

CMS partially concurred with our first recommendation—that it develop a 

comprehensive plan to increase the number of children who receive 

required services—and stated that it will update its current plan to identify 

both new and continuing opportunities for collaboration with States to 

improve the use of preventive dental services among children. This plan 

would include strategies that focus on managed care organizations or other 

contracted entities that provide dental services in States. 

CMS argued that children’s dental services are not a “one size fits all” 

requirement and stated that a child who receives an exam, a cleaning, and 

a fluoride treatment may not need an additional exam, cleaning, or 

fluoride treatment within a year. While we agree that services should be 

customized, we do not agree that children with Medicaid should receive 

services less frequently than at the minimum frequency set by States. As 

we note in the background of this report, the EPSDT benefit requires that 

all medically necessary services be provided at intervals that meet 

reasonable standards of dental practice, as determined in each State’s 

periodicity schedule. The four States we reviewed adopted the AAPD 

schedule, which sets as a reasonable standard of practice that oral exams, 

dental cleanings, and fluoride treatments be provided at a minimum of 

twice per year. 

CMS partially concurred with our second recommendation—that it 

develop benchmarks for dental services and require States to create 

mandatory action plans to meet them—and said that it has already set 

improvement benchmarks for utilization of preventive dental services as 

part of the Oral Health Initiative. It also believes that continuing to work 

collaboratively with States on current successful initiatives to improve 

dental access, instead of requiring mandatory action plans, is an effective 

way to increase the number of children receiving needed dental services. 

Given the findings of this report, we continue to recommend that CMS 

require States to create mandatory action plans to meet their benchmarks. 

CMS concurred with our third recommendation—that it work with States 

to identify areas with limited numbers of providers and the barriers 

preventing providers from participating in Medicaid—and said that it is 

currently working with States to identify such barriers. It also plans to 

work with States to address and decrease these barriers and to seek ways 

to increase the number of providers. 

Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEI-02-14-00490) 15 
CMS concurred with our fourth recommendation—that it work with States 

to analyze the effects of Medicaid payments on access to dental 

providers—and said that it issued a final rule (with comment period) titled 

Methods for Assuring Access to Covered Medicaid Services. This rule, 

which will take effect in 2016, requires States to submit Access 

Monitoring Review Plans that must include methodologies for measuring 

access to care. The plans must include a core set of five services, 

including primary care, which includes dental services. 

CMS concurred with our fifth recommendation—that it work with States 

to educate families about the importance of dental care and to encourage 

ongoing relationships between children and their dentists—and stated that 

it has already taken many steps in educating families about the importance 

of dental care, such as creating consumer education materials. It agrees 

that additional actions are needed to highlight dental homes as a successful 

strategy because the dental home is an effective tool for making sure that 

children are receiving dental services. 

CMS did not concur with our sixth recommendation—that it work with 

States to track children’s utilization of required dental services—and 

stated that States are already required by law to report a variety of dental 

utilization data to CMS every year on the Form CMS-416. CMS also said 

that it must balance the need for additional data with current reporting 

expectations for States. Currently, Form CMS-416 collects summary 

information, such as the number of children who received a dental service 

and what type of service it was (i.e., preventive, diagnostic, or treatment). 

However, States do not have to track whether children are receiving all 

required EPSDT services. Given the findings of this report, we believe 

that it is essential to track whether children are receiving services 

according to each State’s periodicity schedule to help States make 

improvements in this area. 

CMS concurred with our seventh recommendation—that it identify and 

share effective strategies with States—and stated that it has published 

Keep Kids Smiling, which details dozens of successful approaches 

developed by States. CMS also said that it has conducted and published 

summaries of reviews of Medicaid dental programs and has provided 

periodic technical assistance Webinars to States on strategies to improve 

their dental programs. 

CMS concurred with our eighth recommendation—that it ensure that 

States pay for services in accordance with their periodicity schedules—it 

stated that it will work with States to “crosswalk” their payment policies 

with the dental periodicity schedules and make any necessary adjustments 

to their payment policies. 

Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEI-02-14-00490) 16 
The full text of CMS’s comments is provided in Appendix D. 

Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEI-02-14-00490) 17 
 

 

 

 

 

 

APPENDIX A 

Detailed Data Sources and Analysis 

State Medicaid Data. From each State, we requested Medicaid dental 

claims for children up to age 20 from its Medicaid Management 

Information Systems. These claims included fee-for-service claims, 

claims from Federally Qualified Health Centers (FQHCs), and in one 

State—which covers the dental benefit through managed care in part of 

the State—managed care claims.23 They also included claims from 

nondental providers who are allowed to provide certain dental services, 

such as fluoride treatments. We also requested each State’s Medicaid 

beneficiary files for these years. 

Using information from the Medicaid beneficiary enrollment file for each 

State, we identified the children who were both (1) between the ages of 

1 and 20 years old and (2) continuously enrolled in Medicaid in 2011 and 

2012.24 In total, we identified 2,091,343 children in California, 

563,030 children in Indiana, 554,330 children in Louisiana, and 

454,669 children in Maryland. 

As a first step, for all four States, we calculated the total number and 

proportion of children who were continuously enrolled in Medicaid who 

did not receive required dental services in 2011 and 2012. This includes 

the proportion of children who did not receive any dental services and 

those who did not receive all the required services that we reviewed at the 

intervals specified in States’ periodicity schedules. The services that we 

reviewed were biannual dental cleanings, fluoride treatments, and oral 

exams.25 We considered a child to have not received all the required 

____________________________________________________________ 

23 California provided managed care claims from Los Angeles County and Sacramento 

County. For the other counties, the State provided fee-for-service claims. 24 For the purposes of this report, if a State offered a Medicaid expansion program under 

its Children’s Health Insurance Program (commonly referred to as M-CHIP), we 

considered children in this program to be children with Medicaid and included their 

claims and their enrollment data in our analyses. 

25 These services are distinguished from each other in the claims by their Healthcare 

Common Procedure Coding System codes. We also considered reviewing the use of 

sealants as another important preventive service that is included in State periodicity 

schedules. However, we were not able to analyze the use of sealants because the claims 

data did not have sufficient information to accurately measure whether children received 

sealants appropriately. 

Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEI-02-14-00490) 18 
 

 

 

 

 

 

 

 

APPENDIX A (CONTINUED) 

services if he or she did not receive all of these services at least three times 

in the 2-year period.26 

For the measures, we determined whether there were any differences by 

State. We also determined whether there were any differences by age 

group. We defined the age groups as follows: 1 to 2 years of age, 3 to 

5 years of age, 6 to 9 years of age, 10 to 14 years of age, and 15 to 

20 years of age.27 Lastly, we determined whether there were any 

differences between children in urban and rural areas. We defined urban 

and rural areas based on the ZIP Code associated with the child during his 

or her most recent enrollment period.28 

Next, we determined whether children who met the periodicity schedule 

appeared to have a dental home. To do this, we determined the proportion 

of children who received all the required services from the same practice 

(a likely indicator that a child has a “dental home”). For the purpose of 

this analysis, we used the billing provider identification number on the 

claim, rather than the rendering provider identification number, as an 

indicator that the child went to the same practice.29 The billing provider 

identification number is typically the same for all providers in the same 

practice. In addition, we determined the percentage of children who 

received all the required services who visited multiple practices and 

compared it to the percentage of children who received only some of the 

required services and visited multiple practices.

 ____________________________________________________________ 

26 In California and Maryland, FQHC dental claims did not include information on the 

specific services that were provided. For those who received services from FQHCs in 

these States, we considered a child to have received the required services if the child 

visited an FQHC three or more times or if the child visited an FQHC in addition to 

receiving required services in other practice settings at least three or more times. 27 For children who fell into two age groups during the 2-year period, we included the 

child in the category that he or she was in for the longest amount of time. For example, if 

a child was 6 years old for more days in the period than he was 5 years old, we included 

the child in the category of 6 to 9 years of age. 28 We matched ZIP Codes to the rural-urban commuting area codes (RUCAs), which 

classify counties using measures of population density, urbanization, and daily 

commuting distance. We defined an area as urban if 30 percent or more of its workers 

commute to or live within an area with 50,000 people or more. We considered all other 

areas to be rural. For further details on RUCAs, see the University of Washington’s 

WWAMI [Washington, Wyoming, Alaska, Montana, and Idaho] Rural Health Research 

Center at http://depts.washington.edu/uwruca/. 29 Almost all of Maryland’s claims had the same billing identification number, which 

represents the administrator for the dental program in the State. Therefore, we were not 

able to include Maryland in this analysis. 

Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEI-02-14-00490) 19 
 

 

 

APPENDIX A (CONTINUED) 

Lastly, we analyzed the 2012 dental claims and identified the dentists who 

provided services to 1,000 or more children with Medicaid.30 We 

considered this group to be high-volume dentists. We determined the 

number of high-volume dentists and the proportion of children with 

Medicaid that these dentists served in the four States. 

Comparison of coverage policies to periodicity schedules. We compared 

each State’s periodicity schedule to its coverage policy to determine 

whether there were any inconsistencies. We focused this analysis on the 

following required services: biannual oral exams, dental cleanings, and 

fluoride treatments. 

Structured Interviews with State Officials. We conducted structured 

interviews with officials in each State who were responsible for the State’s 

Medicaid pediatric dental programs. Our questions focused on any 

barriers that the State faced in increasing access to Medicaid pediatric 

dental services. We also asked about any strategies that the State had 

implemented to improve access to dental services. We conducted these 

interviews in September 2014. We analyzed the responses from each 

State and identified common themes across States regarding the barriers 

and strategies to improve access to services.

 ____________________________________________________________ 

30 For the purpose of this analysis, we used rendering provider identification numbers to 

identify the dentists and we excluded FQHCs in California and Maryland that submit 

their claims by facility, rather than by individual provider. 

Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEI-02-14-00490) 20 
 

 

APPENDIX B 

Percentages of Children Who Did Not Receive Required Dental 

Services 

Chart B-1: Percentage of Children Who Did Not Receive Required Dental 

Services, by State 

29% 31% 26% 23% 

49% 47% 55% 50% 

22% 21% 19% 27% 

California Indiana Louisiana Maryland 

Received all required dental services 

Did not receive all required dental services 

Received no dental services 

Source: OIG analysis of State Medicaid data, 2015. 

Note: Includes all children who were at least 1 year of age and were continuously enrolled in Medicaid in 

2011 and 2012. Required services include biannual oral exams, dental cleanings, and fluoride 

treatments. 

Chart B-2: Percentage of Children Who Did Not Receive Required Dental 

Services, by Age 

41% 

23% 21% 28% 39% 

46% 

51% 49% 

49% 

50% 

13% 

26% 30% 23% 11% 

Under 3 Ages 3 to 5 Ages 6 to 9 Ages 10 to 14 Ages 15 to 20 

Received all required dental services 

Did not receive all required dental services 

Received no dental services 

Source: OIG analysis of State Medicaid data, 2015. 

Note: Includes all children who were at least 1 year of age and were continuously enrolled in Medicaid in 

2011 and 2012. Required services include biannual oral exams, dental cleanings, and fluoride 

treatments. 

Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEI-02-14-00490) 21 
 

APPENDIX B (CONTINUED) 

Chart B-3: Percentage of Children Who Did Not Receive Required Dental 

Services, by Urban and Rural Areas 

30% 28% 

48% 50% 

22% 22% 

Rural Urban 

Received all required dental services 

Did not receive all required dental services 

Received no dental services 

Source: OIG analysis of State Medicaid data, 2015. 

Note: Includes all children who were at least 1 year of age and were continuously enrolled in Medicaid in 

2011 and 2012. Required services include biannual oral exams, dental cleanings, and fluoride 

treatments. 

Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEI-02-14-00490) 22 
 

APPENDIX C 

Percentages of Children Who Did Not Receive All Required 

Dental Services 

Chart C-1: Percentage of Children Who Did Not Receive All Required Dental Services, by 

Service 

49% 48% 45% 43% 

47% 47% 45% 44% 

55% 53% 

50% 48% 50% 49% 48% 47% 

All three services Flouride treatments Dental cleanings Oral exams 

California Indiana Louisiana Maryland 

Source: OIG analysis of State Medicaid data, 2015. 

Note: Includes all children who were at least 1 year of age and were continuously enrolled in Medicaid in 2011 and 2012. 

Chart C-2: Percentage of Children Who Did Not Receive All Required Dental Services, by 

Age 

44% 

51% 49% 49% 49% 

40% 

49% 49% 48% 46% 

53% 54% 52% 52% 

63% 

55% 

50% 48% 50% 51% 

Under 3 Ages 3 to 5 Ages 6 to 9 Ages 10 to 14 Ages 15 to 20 

California Indiana Louisiana Maryland 

Source: OIG analysis of State Medicaid data, 2015. 

Note: Includes all children who were at least 1 year of age and were continuously enrolled in Medicaid in 2011 and 2012. 

Required services include biannual oral exams, dental cleanings, and fluoride treatments. 

Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEI-02-14-00490) 23 
APPENDIX D 


Agency Comments 


.r~!>f.llVIClis ·~ 

( DEPAR:TMENTOFHEALTH&HUMANSERVICES Centers for Medfcare & Medfcald Services 

,~,... 200 Independence Avenue SW 

Washington, DC 20201 

DATE: NOV 1 6 2015 

TO: Daniel R. Levinson 

Inspector General 

FROM: Andrew M. Slavitt 

Acting Administrator 

SUBJECT: Office of Inspector General (OIG) Draft Report: "Most Children With Medicaid 

in Four States Are Not Receiving Services" (OEI~02~14~00490) 

The Centers for Medicare and Medicaid Services (CMS) appreciates the opportunity to review 

and comment on the Office oflnspector General's (OIG) draft report. CMS recognizes the need 

to continue and increase our focus on improving access to dental services for Medicaid~eligible 

children and to make sure children receive the full scope of services available under the Early 

and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. 

CMS is committed to improving access to dental and oral health services for children enrolled in 

Medicaid and the Children's Health Insurance Program (CHIP). CMS has made considerable 

progress in our efforts to make sure that low-income children have access to oral health care. 

From 2007 to 2014, sixty percent of all states achieved at least a ten percentage point increase in 

the proportion of children enrolled in Medicaid and CHIP that received a preventive dental 

service during the reporting year. 

To support continued progress, CMS launched the Children's Oral Health Initiative and set goals 

for improvement. To achieve those goals, CMS has adopted a national oral health strategy1 

through which CMS is working diligently with states and federal partners, as well as the dental 

provider community, children's advocates, and other stakeholders to improve children's access to 

dental care. 

To support state Medicaid and CHIP programs in achieving their improvement goals, CMS 

published Keep Kids Smiling: Promoting Oral .Health Through the Medicaid Benefit.for 

Children and Adolescents. It provides an overview ofthe children's dental benefit in Medicaid, 

examples of evidence-based policies at the state level, and details of successful strategies with 

state examples. 

In addition, CMS bas developed two learning collaboratives: one to support states in developing 

and implementing state oral health action plans, and the other for states to develop oral health 

1 National Oral Health Strategy can be found on http://www.medlcald.gov/Medlcaid-CHIP-Programlnformation/Bv~Topics/Qualitv-of-Care/Downloads/CM~-Qral-Health-Strategy.pdf 

Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEl-02-14-00490) 24 
Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEI-02-14-00490) 25 

 

APPENDIX D (CONTINUED)
 
Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEI-02-14-00490) 26 

APPENDIX D (CONTINUED)
 
Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEI-02-14-00490) 27 

APPENDIX D (CONTINUED)
 
Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEI-02-14-00490) 28 

APPENDIX D (CONTINUED)
 
Most Children With Medicaid in Four States Are Not Receiving Required Dental Services (OEI-02-14-00490) 29 

ACKNOWLEDGMENTS 

This report was prepared under the direction of Jodi Nudelman, Regional 

Inspector General for Evaluation and Inspections in the New York regional 

office, and Nancy Harrison and Meridith Seife, Deputy Regional Inspectors 

General. 

Judy Kellis served as team leader for this study. Other Office of Evaluation 

and Inspections staff from the New York regional office who conducted the 

study include Lucia Fort. Central office staff who provided support include 

Clarence Arnold, Meghan Kearns, and Christine Moritz. 
Office of Inspector General

http://oig.hhs.gov 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95452, 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 individuals served by those programs. 

This statutory mission is carried out through a nationwide network of audits, investigations, 

and inspections conducted by the following operating components: 

Office of Audit Services 

The Office of Audit Services (OAS) provides 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. These assessments help reduce waste, abuse, and 

mismanagement and promote economy and efficiency throughout HHS. 

Office of Evaluation and Inspections 

The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide 

HHS, Congress, and the public with timely, useful, and reliable information on significant 

issues. These evaluations focus on preventing fraud, waste, or abuse and promoting 

economy, efficiency, and effectiveness of departmental programs. To promote impact, OEI 

reports also present practical recommendations for improving program operations. 

Office of Investigations 

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

of fraud and misconduct related to HHS programs, operations, and individuals. With 

investigators working in all 50 States and the District of Columbia, OI utilizes its resources 

by actively coordinating with the Department of Justice and other Federal, State, and local 

law enforcement authorities. The investigative efforts of OI often lead to criminal 

convictions, administrative sanctions, and/or civil monetary penalties. 

Office of Counsel to the Inspector General 

The Office of Counsel to the Inspector General (OCIG) provides general legal services to 

OIG, rendering advice and opinions on HHS programs and operations and providing all 

legal support for OIG’s internal operations. OCIG represents OIG in all civil and 

administrative fraud and abuse cases involving HHS programs, including False Claims Act, 

program exclusion, and civil monetary penalty cases. In connection with these cases, OCIG 

also negotiates and monitors corporate integrity agreements. OCIG renders advisory 

opinions, issues compliance program guidance, publishes fraud alerts, and provides other 

guidance to the health care industry concerning the anti-kickback statute and other OIG 

enforcement authorities.