Children's Dental Services Under the

Medicaid Program

October 1990

OTA-BP-H-78

NTIS order #PB91-106708
Recommended Citation:

U.S. Congress, Office of Technology Assessment, Children’s Dental Services Under the

Medicaid Program-Background Paper, OTA-BP-H-78 (Washington, DC: U.S. Government

Printing Office, October 1990).

For sale by the Superintendent of Documents

U.S. Government Printing Office, Washington, DC 20402-9325

(order form can be found in the back of this report)
Foreword

A comprehensive set of dental services-encompassing certain preventive, restorative,

periodontal, endodontal, and sometimes orthodontic procedures-is especially important to

the future oral health of the Nation’s young people. Yet those children most at risk, e.g.,

children from low-income families, do not always receive the services they need, despite the

existence of a Medicaid program (particularly, the Early and Periodic Screening, Diagnosis

and Treatment program—EPSDT) whose mission includes diagnosing and treating the oral

health problems of these children.

Concerned about the oral health of children eligible for Medicaid, the House Committee

on Energy and Commerce and its Subcommittee on Health and the Environment requested

OTA to determine whether children eligible for Medicaid are provided at least a minimum

level of dental care. This study compares the dental manuals of seven State Medicaid programs

with a set of “basic’ dental services (which comprise shared components of various

well-accepted dental guidelines) to see if States allow these particular services. In addition,

OTA surveyed practicing dentists in each of these seven States to see if dentists provide these

“basic” services to children under the Medicaid program in their State and, if not, what

problems they encountered in trying to provide them.

iii
OTA Staff-Children’s Dental Services Under Medicaid

Roger C. Herdman, Assistant Director, OTA

Health and Life Sciences Division

Clyde J. Behney, Health Program Manager

Project Staff

Pamela Simerly, Study Director

Paula Chludzinski,l Research Assistant

Other Contributing Staff

Robert Guntow

Administrative Staff

Virginia Cwalina, Office Administrator

Eileen Murphy, P.C. Specialist

Carolyn Martin, Word Processor Specialist

Contractor

Selvin Sonken, DDS, MPH, Bethesda, MD

IF~m April 1989 to December 1989.

i v
Contents

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Figure Page

D-6. Responses to Questions About Selected Services: Periodic Oral Exam . . . . . . . . . . . . . . . . . . . . . . . 54

D-7. Responses to Questions About Selected Services: Counseling Child and Parent on Self-Care . . . 56

D-8. Responses to Questions About Selected Services: Prophylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

D-9. Responses to Questions About Selected Services: Topical Fluoride . . . . . . . . . . . . . . . . . . . . . . . . . 60

D-10. Responses to Questions About Selected Services: Sealants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

D-11. Responses to Questions About Selected Services: Bite-wing X-Rays . . . . . . . . . . . . . . . . . . . . . . . . 64

D-12. Responses to Questions About Selected Services: Pulp Therapy for Primary Teeth . . . . . . . . . . . . 66

D-13. Responses to Questions About Selected Services: Pulp Therapy for Permanent Teeth . . . . . . . . . 68

D-14. Responses to Questions About Selected Services: Restoration of Carious Lesions for

Primary Teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

D-15. Responses to Questions About Selected Services: Restoration of Carious Lesions for

Permanent Teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

D-16. Responses to Questions About Selected Services: Periodontal Scaling and Root Planing . . . . . . . 74

D-17. Responses to Questions About Selected Services: Gingival curettage . . . . . . . . . . . . . . . . . . . . . . . 76

D-18. Responses to Questions About Selected Services: Space Maintenance . . . . . . . . . . . . . . . . . . . . . . . 78

D-19. Responses to Questions About Selected Services: Prostheses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80

D-20. Responses to Questions About Selected Services: Orthodontic Treatment. . . . . . . . . . . . . . . . . . . . 82

D-21. information About Survey Respondents, California . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

D-22. information About A Sample of Respondents, California . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

D-23. Opinions About Medicaid Dental Programs, California . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

D-24. Responses to Questions About Selected Services, California, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

D-25. information About Survey Respondents, Michigan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

D-26. Information About A Sample of Respondents, Michigan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

D-27. Opinions About Medicaid Dental Programs, Michigan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

D-28. Responses to Questions About Selected Services, Michigan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

D-29. Information About Survey Respondents, Mississippi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

D-30. information About A Sample of Respondents, Mississippi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

D-31. Opinions About Medicaid Dental Programs, Mississippi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

D-32, Responses to Questions About Selected Services, Mississippi, .,.... . . . . . . . . . . . . . . . . . . . . . . . 100

D-33. information About Survey Respondents, Nevada... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

D-34, information About A Sample of Respondents, Nevada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103

D-35. Opinions About Medicaid Dental Programs, Nevada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104

D-36. Responses to Questions About Selected Services, Nevada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106

D-37. Information About Survey Respondents, New York . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

D-38.Information About A Sample o f Respondents, New York . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

D-39. Opinions About Medicaid Dental Programs, New York . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

D-40. Responses to Questions About Selected Services, New York . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112

D-41. Information About Survey Respondents, Ohio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114

D-42. Information About A Sample of Respondents, Ohio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115

D-43. Opinions About Medicaid Dental Programs, Ohio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116

D-44. Responses to Questions About Selected Services, Ohio ........... . . . . . . . . . . . . . . . . . . . . . . . . 118

D-45. information About Survey Respondents, Texas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120

D46. Information About a Sample of Respondents, Texas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121

D-47. Opinions About Medicaid Dental Programs, Texas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122

D48. Responses to Questions About Selected Services, Texas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124

Tables

Table Page

l. Major Differences Between the List of Core Components and State Medicaid Manuals . . . . . . . . . . . 4

2. Information About Sample States, 1986 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

3.HCFA State Medicaid Manual: Part 5-Early and P eriodic Screening,Diagnosis,and

Treatment April 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Chapter 1

Summary

Introduction

The oral health of the Nation’s children has been

improving steadily for over 10 years. Since 1979, the

number of children with no caries has increased, the

average number of decayed teeth per child has

shrunk, the average number of filled teeth per child

has increased, and each child averages fewer missing teeth (18) (see figure 1). While these numbers

suggest that, on average, fewer teeth are decayed in

the first place, they also reflect changes in utlization—

more decayed teeth are filled and fewer teeth are

extracted as a result of decay.

But some children have not experienced this oral

health phenomenon with the same intensity as others

their age. Specifically, nonwhite school children

Figure l-Changes in Caries Experience in U.S.

School Children, Ages 5 to 17,1979-80 and 1986-87

60

50

40

30

20

10

0

Caries-Free Mean DMFS Mean dmf

NOTE: DMFS refers to the mean number per person of decayed (D),

missing (M), and filled (F) surfaces of permanent teeth; dmf refers

to the mean number per person of decayed (d), missing (m), and

filled (f) primary teeth.

SOURCE: U.S. Department of Health and Human Services, Public Health

Service, National Institutes of Health, National Institute of Dental

Research, Oral Health of United States Children: The National

Survey of Dental Caries in U.S. School Children, 1966-87, NIH

publication no. 89-2247 (Washington, DC: U.S. Government

Printing Office, September 1989).

(ages 5 to 17) average fewer filled teeth and more

missing teeth due to decay than white school

children, though their average numbers of decayed

teeth do not differsignitlcantly(18) (see figure 2). In

addition, data on periodontal conditions (e.g., gingival bleeding and periodontal attachment loss) reflect

a similar pattern, where fewer white children (ages

14 to 17) experience problems than nonwhite

children (3,4) (see figure 3).

National data are collected only by age and race

(white or nonwhite) of school children. Though it

would appear from the data that the dental treatment

needs of nonwhite children are not being met, other

factors, such as socioeconomic status, may more

accurately describe children dental treatment needs

and their use of dental services.l

Most children below the Federal poverty level

receive dental care through the Medicaid program,

principally through its Early and Periodic Screening,

Diagnosis, and Treatment (EPSDT) program (Social

Security Amendments of 1967, Public Law 90-

248). 2 EPSDT is a comprehensive health care

program, including a dental component, for eligible

children. 3 In some States, the only Medicaid eligibles that are provided preventive and therapeutic

dental care are those children enrolled in the EPSDT

program (l), since the benefit is required for the

State to receive Federal funds.

Findings and Conclusions

OTA was asked by the House Energy and

Commerce Committee and its Subcommittee on

Health and the Environment to ascertain whether the

dental care programs for Medicaid beneficiaries,

particularly children eligible for the Early and

Periodic Screening, Diagnosis, and Treatment (EPSDT)

Program, conform to a minimum standard of dental

care and, if possible, to include some measure of the

actual dental care received under the State programs.

I For ~xmple, f~ly income and den~ imwanw coverage are associated with the utilization of dental semices (67). ~~ough tie ~~ do not

directly link socioeconomic status and race, children from low-income families and minority children (ages 12 to 17) are less likely to be covered by

private dental insurance than are children from higher income families and white children (15), and therefore, less likely to receive dental s-ices.

2Ch. 3 describes the Medicaid program and its EPSDT component more fully.

sAu~o~md by Congess ~ 1967, re@atio~ implementing he EpsDT pro~m did not take effect untd 1972, ~d specific dental guidelines WCE

not introduced until 1980 (19).

–l–
2 ● Children’s Dental Services Under the Medicaid Program

Figure 2—Percent of DMFSa and DMFTb Due to Deeayed, Missing, and Filled Surfaces and Teeth, 198&87

0% 25% 60% 76% 1 00% 0% 26% 50% 75% 100%

, 1 1 1 ~

White White

Mean DMFS

. 29 7

Mean DMFT

. 197

Nonwhite

Mean DMFS

Nonwhite

Mean DMFT

. 34 0 . 19 9

All All

Mean DMFS Mean DMFT

. 307 . 1.97

aDMFS refers to the mean number per person of decayed (D), missing (M), Wtd filled (F) permanent teeth.

b~~ refers t. the mean num~r pr prson of d~y~ (D), mi~ng (M), and Hl[d (F) SUrfm of permanent tAh.

SOURCE: U.S. Department of Heafth and Human Services, Public Health Service, National Institutes of Health, National Insthute of Dental Research, M

HedthofUnitedStates Chil&?n:7heNationa/S urveyofDental Cdhsin U.S. School Chil&en, 1986-87, NIHpublication no. S9-2247 (Washington,

DC: U.S. Government Printing Office, September 1989).

Figure 3-Periodontal Status of U.S. School Children, Ages 14 to 17, 1986-87

80%

60%

4 0 *

20%

on

Presence of gingival bleeding

72.1%

61.5%

56% 55.1%

68.8%

Periodontal attachment loss (2mm or more)

50%

40%

30%

20%

10%

0%

‘1

40.6%

23.6%

19.8%

21.7%

16.4%

Males Females White Nonwhite Prevalence Males Female. White Nonwhite Prevalence

SOURCES: M. Bhat, “Periodontal Attachment Loss in 14-to 17-Year-Old U.S. school Children.” Prooram and Abstrack. American Association for Public

Health ktktry, November 1989; M. Bhat, and J. Brunelle, “Gingivai Status of I&to I?-Year-Old U.S. school Children,” Jourrd of Denta/

Resear& 6S:965, June 1989.

This study looks at the dental care component of

Medicaid programs (including dental care provided

under EPSDT programs) in a sample of seven States ●

to answer whether “basic” dental services4 are

provided and whether programs impose barriers that

restrict eligible children’s access to these services.

Briefly, the study found in the States sampled that:

● there are significant differences among these

States in the dental services offered through

their Medicaid programs;

each of these programs failed (in varying

degrees) to adequately cover “basic” dental

services in their Medicaid program (specifically, though some services are universally

provided-particularly initial visits, x-rays,

and restorations, newer technologies (e.g., sealants) and many basic therapeutic services

(including periodontal, prosthetic, and ortho4@p. A lists these “basic” sewiccs, and the method of study (ch. 2) describes how they were identified.
Chapter l-Summary . 3

dontic services) are generally not covered, or

are of limited availability);5

there are some services that some dentists feel

they do not equally provide to their young

Medicaid patients under 18 compared to their

other young patients; and

a variety of barriers, identified by both State

representatives and private practice dentists,

restrict the low-income child’s access to dental

services under State Medicaid programs (e.g.,

low reimbursement rates for dental services

rendered under Medicaid may restrain provider

participation in the program).

The scope of this study is purposely narrow,

focusing on only a small part of the health care

system and only a handful of the population it serves.

Yet, the study raises some disturbing questions

about this system and the priority it gives to oral

health of low-income children. Although States are

ultimately responsible for defining their package of

dental services for children, Federal regulations

specify the provision of certain services. Nonetheless, some of these required dental services are not

available to children under Medicaid. Also, it is not

clear that any Federal action has been taken to ensure

the inclusion of these dental services. This raises

concerns about the accountability of State programs

and also about Federal enforcement of its own

policies and regulations.

Not unrelated, the priority of oral health care

within the Federal health care system is questionableMedicaid spends less than 1 percent of its payments

on dental care, for both adults and children. Although this study did not critique the effectiveness

of these basic dental services or their costs, the

inevitable next questions are: given that some basic

dental services are not routinely available to lowincome children, what are the oral health and other

impacts on these children and what are the short- and

long-term costs for the public health care system?

$Table 1 summarims and app. C specifically reports the comparison between the compiled list of basic services and the State Medicaid manuals.
Table l-Major Differences Between the List of Core Components and State Medicaid Manuals

Selected Service s Major Difference, by State

Preventiv e

● periodic exam CA:

TX:

● prophylaxis TX:

● fluoride treatment TX:

Only for developmentally disabled children

No billable procedure code for periodic exam

For patients 13 to 20 years, this procedure is intended for periodontal cases only.

Is included in fee

● counseling on self care ALL: No State specific a

● sealant s CA:

MI:

T X :

MS:

NV:

OH:

● space maintenance CA:

MI:

NV:

TX:

excluded separate

Not specified

Not specified

Not specified

or proph

ly requ

payment

ylaxis, is not required, and is not billable separately.

red that

for oral

these services be prov

hygiene instruction.

ided. One State (MI) specifically

Allowed for newly erupted first and second permanent molars or first and second premolars. Prio r

approval required for primary teeth. “

One sealant per primary tooth (ages 6-20).

One application per tooth per lifetime

Space maintainers are allowed "where there is sufficient roan for an unerupted permanent tooth to

erupt normally.” It is not covered to hold space for missing permanent teeth.

Space maintenance requires prior authorization, and is limited to the necessary maintenance of a

posterior space for a permanent successor to a prematurely lost deciduous tooth.

Prior authorization is required--not a routinely available benefit.

Limited to loss of primary second molar.

Therape uti c

● restoration s

-amalgam ALL

-othe r CA:

MI:

MS:

NV:

NY:

OH:

TX:

CA:

MI:

MS:

NY:

OH:

Tx:

● pulp therapy

: No major differences

For silicate, composite, and plastic restorations, but only on anterior teeth

For silicate, composite, and plastic restorations, but only on anterior teeth

Composites may be performed on both anterior and posterior teeth, primary and permanent

Acry(ic/plastic and composite resin, but only on anterior teeth

For anterior teeth onl y

For anterior teeth onl y

Higher fee for anterior teeth than posterior teeth

Included in

Direct pul p

No billabl e

Not covered

inclded i n

No billabl e

restoration fe e

cap is covered, not indirect pulp cap

procedure code

restoration fe e

procedure code
Chapter 1-Summury ● 5

.-

.-

“

-0

z

. . . . ,. ,. ., . . x

+

. .

● ● ● ● ●
Chapter 2

Method of Study

The narrow focus and exploratory nature of this

study shaped its method; basically, a sample of

States was selected and their Medicaid manuals

compared to a list of basic dental services, or ‘‘core

components. To ensure context and depth, however, another of the study’s elements was added;

specifically, identifying other factors, or ‘barriers, ’

that restrict or inhibit eligible children from receiving the dental care to which they are entitled. Two

methods were employed to identify these barriers: a

workshop attended by State representatives and

others, and a survey of dentists in the sample States.

State Sample

The study focuses on a sample of seven States:

California, New York, Michigan, Ohio, Mississippi,

Texas, and Nevada (see table 2). The sample was

chosen based on State Medicaid characteristics (e.g.,

the number of Medicaid beneficiaries, the number of

dependent children under 21, and the resources

devoted to the program). Although no two Medicaid

programs are the same, the sample provides examples of a range of programs, by size and resources.

Almost half (45 percent) of Medicaid’s total payments are represented in the sample as well as 43

percent of dependent children under 21 enrolled in

the program nationwide. (Nonetheless, the programs

in these States cannot be mistaken as representative

of the country as a whole.)

Each State’s dental provider manual for its

Medicaid program defines the dental services it

allows under the program. These manuals were

collected from each sample State to discern whether

each State pays for basic dental services provided to

children.

Core Components

For the purposes of this study, “basic dental

services” are defined as a set of services shared by

various dental care guidelines (see app. A), including those suggested by the Health Care Financing

Administration (HCFA), the Public Health Service

(PHS), and the American Dental Association (ADA).

In all instances, the most minimal aspect of a shared

component was selected (e.g., that a child should

receive an annual exam, rather than exams twice a

year) since the rationale behind compiling a common set of components is that such a set would

represent the core of a set of dental services that any

child should receive. The purpose for compiling this

set was to have a reference against which the level

of care provided for by State Medicaid programs

could be compared, and not to design an optimal

dental care program. Further, the set of core components is not an assessment of medical necessity by

OTA. But, a wide review of the set by experts in the

field indicated general acceptance of these core

components as “basic dental services” within the

scope of this study.

Comparison of Core Components to

State Medicaid Manuals

Each State’s provider manual was compared to

the set of core components to evaluate whether the

State was providing for “basic dental care.” The

findings of this comparison are presented below.

The draft comparison was sent to State Medicaid

officials in each State for their review.

Workshop on Other Barriers to Care

Although beyond the narrow scope of this study,

there are other factors that affect the delivery of

dental care to children under Medicaid. OTA held a

workshop on September 22, 1989, to identify some

of these barriers to care (see app. B for the list of

participants). People representing the Medicaid

program and the dental providers in each sample

State highlighted barriers in their State environment;

although some issues discussed were specific to a

particular State, there appear to be categories of

problems shared by most States (including low

reimbursement levels, low provider participation

rates, and high administrative burden associated

with participating in the program). Others attending

the workshop, representing the Federal Government

and groups interested in oral health, echoed these

concerns during the meeting. Chapter 4 considers

the outcome of this workshop in more depth.

Survey of Dentists

The comparison of the core components and the

State manuals assessed the level of dental care

offered by each State. The workshop identified a

number of issues viewed by officials at the State-
Table 2—information About Sample States, 1986

All Medicaid

State Payments All Medicaid EPSDT Eligible Dependent Kids Payments: Dependent All Medicaid Percent of Total

(Smill ) Beneficiaries Children (1987) Under 21 (1986) Kids Under 21 (Smill) Dental Services Payments for

[% of us] [x of us] ($thous) Dental Services

California %,&05 [11%] 2,466,100 [11X] 1,664,622 [68%1 1,375,980 [56%] $585 [13%] $84,913

Michigan 1,768 [4]

2x

1,119,724 [5] 587,530 [521 625,516 [561 290 [161

Mississippi 317 [1]

29,658 2

318,871 [1] 177,106 [561 126,920 [40] 38 [121

Nevada 79 [01

6,602 2

32,545 [01 12,130 [371 13,122 [40] 7 [91

New York 8,223 [201

1,446 2

2,322,628 [10] 971,691 [42] 989,349 [43] 685 [81 97,312

Ohio 2,050 [5]

1

1,078,851 [5] 516,198 [48] 574,811 [531 670 [331

Texas 1,628 [4] 878,985 [4] 372,639

28,165 1

[42] 369,634 [42] in [11 ] 14,389 1

California $7,596 81.7% 50.00% CN/MN 21 Y Y

MIchIgan 6,480 69.7

N

56.79 CN/HN 21 N NS

MIssIssIppl 4,416 47.5 78.42 CM

US

18 N

Nevada 3,420

N

36.8

Y

50.00 CN 21 N Y

New York 5,964 64.1

N

50.00 CN/MN 21 Y

Ohio 3,708

Y

39.9

N

58.30 CN 21 Y Y

Texas 2,208 23.7

N

53.56 CN/MN 21 N US US

aAFN:AkjtoFamfliesw~h Dependent Children

bCFUMN:@tegoricallyNeedyorMedcaNyNeedy

cfidu~ng regular programs based primarityonemqpmcy f=re.

dEnro~mentin EPsDT isnotr+r~forany Medicaid-eiigibie &fld under 180r21 in order to receiveservkes.

SOURCES: U.S. Congress, House of Representatives, Committee on Energy andtimmerm, Subcommittee on Health and the Environment, hfedicaidsour~~: &@rour)d~~~a andArrafysis,

prepared by the Congressional Research Service, Committee Print 1OO-AA (Washington, DC: U.S. Government Printing Office, 1988); and State Medicaid manuals.
Chapter 2-Method of Study . 9

level to be barriers to dental care. The beneficiary/ practice dentists in each sample State are included.

recipient’s perspective would have completed the The random sample of dentists, provided by the

picture regarding the dental care they receive under American Dental Association. was selected from a

the Medicaid program. Instead, as a more feasible list of all private practice dentists (not only ADA

approach, OTA surveyed dental providers directly;

10 percent (20 percent in both Mississippi and

members). See appendix D for the survey instrument

Nevada due to their small population size) of private

and results.
Chapter 3

Medicaid and the EPSDT Programs

Although dental care may be provided as an

optional service to Medicaid beneficiaries (and

many States do provide limited dental benefits to

their entire Medicaid population), all States must

provide dental services to Medicaid-eligible children under 21, as specified by the Early and Periodic

Screening, Diagnosis, and Treatment (EPSDT) program provisions (see the section below and table 3,

which outlines the Health Care Financing Administration (HCFA) regulations regarding EPSDT and

highlights sections specifically related to dental

services). Most publicly funded dental care for

low-income children under 21 is provided through

Medicaid or the EPSDT programs. Other federally

funded programs (such as Head Start, Community/

Migrant Health Centers, the Indian Health Service,

and the National Health Service Corps) and State

and local programs contribute to the oral health of

some of these children, but even these programs bill

Medicaid for services they provide directly to

eligible children (8). Out of the entire Medicaid

program’s payments, dental care accounted for only

1 percent (see table 2). Although Federal data do

describe the percentage that Medicaid spends on

dental care, the information is not routinely broken

down by age-i.e., it is unclear how much Medicaid

spends on dental care for children.l

This section briefly describes Medicaid and

EPSDT, focusing on components of those programs

particarly relevant to this study. There are other,

more detailed, descriptions of both programs elsewhere in the literature (e.g., 9,10,11).

Medicaid

The Medicaid program was authorized in 1965 by

the Social Security Act to provide medical assistance to low-income people.2 The Federal Government shares the cost of the program with States3 (see

table 2), but each State designs and administers its

program within broad Federal guidelines (10).

Interpretation of the guidelines and specific State

needs result in significant variations between programs, particularly in terms of eligibility requirements, covered services and limitations, and reimbursement policies.

Eligibility

Some groups must be covered by Medicaid

according to Federal mandate, and others may be

covered at the State’s option. States must offer

Medicaid services to those receiving benefits from

two cash assistance programs-Aid to Families with

Dependent Children (AFDC) and Supplemental

Security Income (SSI)-and to certain target groups.

States extend AFDC benefits based on family

income, family structure, and parent’s employment

status and SSI benefits to elderly, blind, and disabled

people. Pregnant women and children younger than

age 6 (born after Oct. 1, 1983) whose family incomes

fall below 133 percent of the Federal poverty level,

and children younger than 7 whose family incomes

fall within AFDC limits but who do not otherwise

qualify for AFDC support are also automatically

eligible for Medicaid. This group of people are

termed categorically needy.

States may classify other groups as categorically

needy at their option; children up to age 18 (or 19,

20, or 21) with family incomes within AFDC limits

but who do not otherwise qualify, children younger

than age 8 with family incomes within the Federal

poverty level, and pregnant women and children up

to age 1 with family incomes within 185 percent of

the Federal poverty level (9). State Medicaid programs may also include people who are medically

needy; i.e., those who qualify as a result of high

medical expenses that reduce their family incomes

to a level below the AFDC limits in that State.

Each State may set AFDC limits at their discretion. Table 2 illustrates the AFDC eligibility thresholds of the sample States in this study. The

variability in AFDC limits means that children of

similar circumstances but living in different States

are not equally eligible for Medicaid services.

IDa~ is ~v~able ~~ut the percen~ge spent on dent~ c~e under we ~DT pro-, but this information is confusing since dental ~tO C~dKZl

is not provided only under EPSDT and some States do not distinguish between payments under Medicaid and payments under EPSDT.

% FY89, there will be an estimated 25 million low-income people, of them over 11 million are children under age 21 (11).

3The Feder~ Government p~d 56 ~rmnt of to~ expen~tures in fis~ yea 198$), providing at least a 5(@ercent mdch for ~ch StNe. The f$Iilte’S

share of the match is based on the square of the State per capita income x the square of the National per capita income x 45 percent.

–11–
12 ● Children’s Dental Services Under the Medicaid Program

Table 3-HCFA State Medicaid Manual: Part 5-Early and Periodic Screening, Diagnosis, and Treatment;

April 1988

“This transmittal introduces Part 5: Early and Periodic Screening, Diagnosis, and Treatment

(EPSDT). It contains EPSDT program guidelines and implements Sections 2(a)(43) and

1905(a)(4)(B) of the Act, including revisions enacted by P.L. 97-35, the Omnibus Budget

Reconciliation Act of 1981, and P.L. 97-248, the Tax Equity and Fiscal Responsibility Act of

1982.”

Sections particularly relevant to dental care:

Sec. 5121. REQUIRED SERVICES--INFORMING FAMILIES OF EPSDT SERVICES

A. General Information.

B. Indi viduals to be I nformed.

c. ontent and Met hods.

Sec. 5123. DIAGNOSIS AND TREATMENT

A. Diagnosis.

B. Treatment.

1.

services included in the plan if a need is indicated by screen ing...

] An except ion (on\y to age 5) ui 1 [ be granted only i f shortage of dentists. [Note: The Onnibus Budge t

Reconc i 1 i at ion Act of 1989 el imi nated this except i on. ]

2 [Note: The Wmibus Budget Reconci [ iation Act of 1989 specifical Iy noted that, among older children, dental

examinations shouid occur with greater frequency than is the case with physical examinat ions.]
Chapter 3-Medicaid and the EPSDT Programs ● 13

Limit prior authorization to treatment services of high cost, or those to be

provided over extended periods of time.

2. Reaqu ired Vision and Hearing Treatment. Dental Care. and Immunizations .

Provide the following services, even if they are not included in the State

plan:

■ Dental care, at as early an age as necessary, needed for relief of

pain, infections, restoration of teeth, and maintenance of dental

health. Dental care includes emergency and preventive services

and therapeutic services for dental disease which, if left untreated,

may become acute dental problems or may cause irreversible

damage to the teeth or supporting structures. For further

information, consult HCFA’s Guide to Dental Care. EPSDT--

Medicaid, prepared in cooperation with the American Society of

Dentistry for Children and the American Academy of Pedodontics

(HCFA Pub. No. 24515).

a. Emergency Se rvic e s are those necessary to control bleeding, relieve

pain, eliminate acute infection; operative procedures which are

required to prevent pulpal death and the imminent loss of teeth;

treatment of injuries to the teeth or supporting structures (e.g.,

bone or soft tissues contiguous to the teeth); and palliative therapy

for periocoronitis associated with impacted teeth. Routine

restorative procedures and root canal are not emergency services.

b. Preventive Se rvices , provided either individually or in groups,

include:

 Instruction in self-care oral hygiene procedures;

■ Oral prophylaxis (cleaning of teeth), both necessary as a

precursor to the application of dental caries preventives where

indicated, or independent of the application of caries

preventives for patients 10 years of age or older;

■ Professional application of dental sealants when appropriate to

prevent pit and fissure caries.

c. Therapeutic Se rvices include:

■ PUlp therapy for permanent and primary teeth;

■ Restoration ‘of carious (decayed) permanent and primary teeth

with silver amalgam, silicate cement, plastic materials, and

stainless steel crowns;

Scaling and curettage;

Maintenance of space for posterior primary teeth lost

permanently;

Provision of removable prosthesis when masticator function is

impaired, or when existing prosthesis is unserviceable. It may

include services when the condition interferes with employment

training or social development; and

Orthodontic treatment when medically necessary to correct

handicapping malocclusion.

Sec. 5130. DISCRETIONARY SERVICES

Sec. 5140. PERIODICITY SCHEDULE

Sec. 5150. TRANSPORTATION AND SCHEDULING ASSISTANCE

Utilization of Providers and Cordination With Related Programs

Sec. 5210. REFERRAL FOR SERVICES NOT IN THE STATE PLAN

Continued on next page
14 ● Children’s Dental Services Under the Medicaid Program

Table 3-HCFA State Medicaid Manual: Part 5-Early and Periodic Screening, Diagnosis, and Treatment;

April 1988-Continued

--

Sec. 5220.

A.

B.

Sec. 5230.

A.

B.

c.

D.

E.

F.

G.

&C. 5240.

A.

B.

sec. 5310.

A.

B.

c.

D.

Sec. 5320.

A.

B.

Sec. 5330.

Sec. 5340.

A.

B.

c.

Sec. 5350.

A.

B.

SOURCE: U.S. Department of Health and Human services, Health Care Financing Administration, State Medidd Manual, Part =arty and Pedodk

Screening, Diagnosis, and Treatment (EPSD~, April 1988.
Chapter 3-Medicaid and the EPSDTPrograms ● 15

Nationally, less than half the children under age 13

living in poverty were covered by Medicaid for any

medical or dental services in 1986 (12).

Services

States are required to provide certain services4 to

categorically needy people and are allowed to

provide certain optional Services5 under the Medicaid program. Although they are not required to do

so, most States who cover medically needy people

provide them with the same range of benefits offered

to categorically needy people in their State. States

may also impose limitations on any of the services

offered, generally to reduce unnecessary use and

control Medicaid outlays. See chapter 4 for further

discussion on the relevance of service limitations to

this study.

Reimbursement Policies

Except for a few instances,6 States generally

design their own payment methodologies and develop payment levels for covered services. The only

two universal reimbursement rules are that Medicaid

providers must accept payment in full and that

Medicaid is the ‘payer of last resort’ (i.e., Medicaid

pays only after any other payment source has been

exhausted).

Institutions, such as hospitals and long-term care

facilities, are paid differently than individual practitioners. Payments to institutions are usually based

on either retrospective or prospective methodology. Individual practitioners are usually paid in one

of two ways: the lesser of their usual charge and the

State-allowed maximum, or based on a fixed fee

schedule. Reimbursement policies affect the access

of low-income children to dental care, as discussed

in chapter 4.

The Early and Periodic Screening, Diagnosis,

and Treatment Program (EPSDT)

The EPSDT program was legislated in 1967, and

implemented in 1972.9 The program is unique in that

it provides for comprehensive health care, including

preventive services, to children under Medicaid. The

five basic components of the program ensure its

comprehensiveness: informing, screening, diagnosis and treatment, accountability, and timeliness.

EPSDT is jointly administered and funded by

Federal and State Governments primarily through

the Medicaid program, although some States administer the programs separately.

The EPSDT program is structured on a case

management approach, to ensure comprehensiveness and continuity of care, though specific combinations of services and providers vary by State. In

addition, since 1985 States have been allowed to pay

a‘ ‘continuing care provider’ to manage the care of

EPSDT children. This means that this provider or

provider group is responsible for ensuring that each

child receives his or her entitled services. These

entitled services include notifying the child about

periodic screens and performing, or referring, appropriate services, as well as maintaining the child’s

medical records.

Informing

States must inform all Medicaid eligibles, generally within 60 days of eligibility determination, of

the EPSDT program and its benefits, particularly:

●

●

●

about the benefits of preventive health care;

about the services available under EPSDT,

where and how to obtain them;

that the services are without cost to those under

age 18 (or up to 21, agency choice) except for

any enrollment fee, premium, or other charge

imposed on medically needy recipients; and

4Sta[eS me ~qfied t. ~mvlde: ~patient ~d ~u~atient hospi~ ~~ices, physic~ sewices, EPSDT for children under age 21, ftily plq

services and supplies, laboratory and x-ray procedures, skilled nursing facilities for persons over 21, home health care services for those entitled to skilled

nursing care, rural health clinic services, and nurse midwife services (12). The EPSDT program includes dental services for children under 21.

Sstates ~ve tie Option of ~so provl~g ~ese ~rvi~s: clinic semices, including dental care; drugs; intermediate cue facilities; eYeglm*s; s~ll~

nursing facilities for those under age 21; rehabilitative semices; prosthetic devices; private duty nursing; inpatient psychiatric care for children or the

elderly; and physical, occupational, and speech therapies (12).

6PaPent ~les ~d tits~e es~blished by law for rural health chnics, hospices, and labo~tories.

7A re~o~Pctive system is @~d on he actu~ cost of pmvid~ tie se~i~s renderd, after they are provided.

8A Prospwtive system is based on a Pmdet ermined rate for defined units of service, regardless of the actual cost of providing the smice.

%e Sociat Security Amendments of 1967 (Public Law 90-248) added the EPSDT benefit and required implementation by July 1, 1969. Final

regulations became effective on Feb. 7, 1972.
16 ● Children’s Dental Services Under the Medicaid Program

 that transportation and scheduling assistance

are available on request.

Most States provide the information at the time of

application for welfare, though some States employ

additional outreach methods.

Screening

The program also requires that all eligible children who request EPSDT services receive an initial

health assessment. Generally, the screening should

be performed within 6 months of the request for

EPSDT services. This screening service should

include:

●

●

●

●

●

●

a health and development history screening,

including immunizations;

unclothed physical examination;

vision testing;

hearing testing;

laboratory tests, such as an anemia test, sickle

cell test, tuberculin test, and lead toxicity

screening; and

direct referral to a dentist for a dental screening.

Periodic medical examinations are based on th e

periodicity schedule recommended by the American

Academy of Pediatrics. The recent Omnibus Budget

Reconciliation Act of 1989 (Public Law 101-239)

specified that, among older children, dental examinations should occur with greater frequency than is

the case with physical examinations.

Diagnosis and Treatment

Further diagnosis of conditions indicated in exams

and their treatment are also components of the

EPSDT program. Specific diagnostic and treatment

services should be part of a State’s benefit package,

though States may provide a range of services to

children enrolled in EPSDT that go beyond the

scope of benefits for other Medicaid beneficiaries.

Accountability

States are required to prepare quarterly reports

which must contain utilization data by two age

groups, O to 6 and 6 to 21:

●

●

●

●

number eligible for EPSDT;

number of eligibles enrolled in continuing care

arrangements (and of these, the number receiving services and the number not receiving

services);

number of initial and periodic examinations;

and

number of examinations where at least one

referable condition was identified.

Initially, the Federal Government enforced the

EPSDT provisions by imposing a monetary penalty,

a l-percent reduction in AFDC payments, on States

not informing or providing care to eligible children

(see the Social Security Amendments of 1972

(Public Law 92-603)). This penalty was eliminated

in the Omnibus Budget Reconciliation Act of 1981

(Public Law 97-35) and, instead, the adherence to

the EPSDT provisions became a condition of

Federal finding for Medicaid. OTA was unable to

find any evidence that any State was penalized

before 1981 or that any State has lost Medicaid

Federal funding since that time as a result of not

complying with the EPSDT provisions.
Chapter 4

Barriers to Dental Care Under Medicaid and EPSDT

This study concerns the dental care that States

provide for under Medicaid, rather than the care that

may or may not be delivered through the program.

However, during the course of the study, many

expressed the opinion that the major problem may

not be the absence of dental services in State

manuals, but the lack of dental care that is actually

received. In other words, various barriers block

access to the dental care that low-income children

should receive under States’ Medicaid programs.

On September 22, 1989, OTA invited representatives from each of the States in the study sample and

other representatives from the public sector and

interested professional associations to identify some

of these barriers to access to dental care (see app. B

for a list of participants). The section below outlines

some of the opinions expressed by the workshop

participants; this list should be considered neither

exhaustive nor representative of in-depth analyses.

These brief descriptions attempt to capture some of

the more descriptive details, but what is clear is that

further study is necessary to identify, describe, and

eliminate the major deterrents to good oral health

among low-income children. Some examples of

further study include the relationship of Medicaid

fees to those of the real world and costs of operating

a dental practice, and a descriptive study of the types

of dental services provided through EPSDT, viewing it as a health care delivery system.

In January 1990, OTA surveyed a sampling of

private practice dentists in each of the seven States

in the study, which included nearly 4,500 dentists.1

In three parts, the survey asked the dentists about: 1)

themselves (e.g., age, race, specialty, whether they

participate in the Medicaid program, whether they

treat children, etc.), 2) their opinions about the

Medicaid program in their State (e.g., reimbursement issues, administrative issues, and scope and

limitations of covered services), and 3) about their

provision of certain services (those in app. A) to

children under Medicaid.2 The dentists’ responses to

the second and third sections identify aspects of the

Medicaid program that could be viewed as barriers

to children’s access to dental care. Some of their

responses echoed the opinions expressed by the

participants in the workshop.

Barriers Identified at the Workshop

The barriers, as discussed at the workshop, are

conveniently arranged below by topic, but are

complexly intercomected in real life. This simplistic approach and the lack of detail should not imply

that these problems are insignificant or small, only

that they have not been evaluated by OTA. Also,

although some topics seemed to be more fervently

emphasized during the workshop than others, the

order below is not based on any judgment of

importance. Since the purpose of the workshop did

not include reaching consensus, not all the topics

described below were expressed by every participant.

Topic: Structure of the Program—

Medicaid and/or EPSDT

Several types of structural problems were identified during the workshop, such as problems with

personnel, guidance, reporting requirements, quality

control, and eligibility requirements.

Personnel issues were generally about training:

e.g., that dental department consultants are usually

private practitioners rather than public health dentists, or that some welfare departments lack dental

expertise, or that inexperienced nondental providers

may control access to dental care under EPSDT.

Other personnel issues focused on process: e.g., that

State Medicaid offices and State dental directors

may not communicate well, or that a rivalry exists

between some State Medicaid agencies and public

health agencies, or that the State Medicaid office

could cooperate more closely with State licensing

boards.

The label ‘‘guidance” represents a diverse set of

problems. There was an opinion that guidance on a

national level is missing: that the goals and expectations of the program have dropped since its inception, as signified by the small percentage of the

l~e S~ple ~epreSent~ 10 ~rcent of tie dentis~ ~ c~o~~ ~c~g~, NW York (_)~o, and Te~ and 20 percent of the dentists irl NevA

and Mississippi.

%e survey instrument is provided in app. D.

–17 –
18 ● Children’s Dental Services Under the Medicaid Program

Medicaid budget spent on dental care, in spite of

evidence that these children have significant levels

of untreated dental disease (18); and that HCFA

regulations should be more clear and that standards

of dental care should be addressed. The results of the

lack of national guidance were expressed as a lack of

definition and consistency of available services, and

the inability or unwillingness of States to pay for the

services. There was also concern that there may be

increasing reliance on the program as the only source

of care by people who are least able to influence

change in the program.

Some participants felt that the lack of reliable and

comparable data was a barrier to evaluating the

program directly, and indirectly affected the quality

of care received by its beneficiaries. Quality control

as an issue itself was discussed during the workshop;

some observed that ‘‘Medicaid Mills,’ or the

practice of a sole provider or clinic treating very

large numbers of Medicaid beneficiaries, posed

questions about the quality of care received within

their programs. Also, although Medicaid is the

largest publicly funded dental program in the

Nation, many States have no mechanism in place for

monitoring the quality of dental care received by

recipients.

Lastly, some felt that another barrier restricting

the use of dental services for low-income children

was the Medicaid eligibility requirements for their

program.

Topic: Competition for Resources

Some participants suggested that the lack of data

about the oral health status of eligible children and

the adequacy of the program lead to policies, that, in

effect, lower the priority for the dental component of

Medicaid programs, losing the competition for

scarce State resources.

Topic: Low Provider Participation

A recurring observation throughout the workshop

was the universally low dental provider participation

rates in the programs. Fewer providers provide

services to fewer Medicaid beneficiaries, significantly lowering the accessibility of these dental

services. The services of specialists, such as periodontists and pediatric dentists, are also rarely

provided to children under Medicaid. The issue of

low participation is a prime example of the interrelated nature of these problems; many felt that low

fees and administrative burdens characterizing the

programs were the primary influences resulting in

low provider participation. (See below and app. D

for supporting information from OTA’s survey of

dentists.)

Topic: Low Fees/Reimbursement Issues

Though not all participants felt that low fees were

a primary problem in their State, most felt it was

significant; some fee levels were described as far

below the usual charges for services, others as not

even covering average overhead costs. In addition to

the impact of low fees on the accessibility of services

(noted above), there was concern that inadequate

fees may encourage inadequate treatment. Many

participants were concerned about small, untimely,

or nonexistent fee increases for dental services and

the incomparability of fees for dental services in

relation to other types of services under Medicaid.

Other reimbursement issues, such as late payments

or payment denials, are discussed below among

other administrative paperwork issues. (See below

and app. D for supporting information from OTA’s

survey of dentists.)

Topic: Paperwork Burden

Problems with paperwork were said to provide an

additional disincentive for dentists to participate in

the programs. In particular, three types of problems

were discussed: problems with filing claims, slow

payment, and denial; problems with prior authorization requirements; and problems with the fiscal

intermediary or Medicaid agency. (See below and

app. D for supporting information from OTA’s

survey of dentists.)

Topic: Perception of Program by

Dental Professionals

One participant noted that once providers leave

the program, they rarely reenter it. The unfavorable

perception of the program among those in the

profession certainly has an impact on current participation rates, and may continue to influence future

providers. (See below and app. D for supporting

information from OTA’s survey of dentists.)

Topic: Transportation

Although some allowance is provided for transportation in the HCFA regulations for EPSDT, some

participants felt that it remained a problem for some

recipients and resulted in missed appointments or

failure even to schedule one.
Chapter 4-Barriers to Dental Care Under Medicaid and EPSDT ● 19

Topic: Recipients

The recipients themselves may limit the dental

services they receive under Medicaid. For whatever

reasons, many of those who are eligible never use

their dental benefits. Some workshop participants

were concerned about the awareness of some Medicaideligible children (or their parents) about the dental

services offered by their program (discussed below).

The providers’ perception of the Medicaid patient

also seemed to be a problem; “missed appointments, “ “poor compliance and difficult to treat,”

‘‘negative impact on private-pay patients’ describe

some provider perceptions mentioned at the workshop.

Topic: Recipients’ Awareness of Program

As noted before, several participants were concerned that recipients were not being ‘reached’ and

made aware of their dental benefits or how to access

them (who could treat them or that transportation

may be available).

Topic: Recipients’ Perceptions About

Dentistry in General

Perhaps another cause of low dental benefit use by

those eligible is, as noted by one participant, due to

a widespread negative attitude about dentistry and

dentists, which is often related to prior experiences

of adult family members. The importance of the

educational component (both the child and their

parent) of treatment should be emphasized due to

recipients’ lack of knowledge about the benefits of

modern dental care, according to another participant.

Topic: State-Specific Barriers

Some participants felt that service limitations,

particularly the lack of effective provision of basic

services (e.g., those services listed in app. A), have

varying degrees of negative effect on oral health in

certain States (see below and app. D for supporting

information from OTA’s survey of dentists), Another barrier to improving oral health with minimal

public expenditure was felt to be the lack of

community water fluoridation for 45 percent of the

U.S. population (5).

Barriers Identified in Survey of Dentists -

Since State Medicaid programs can be very

different, the surveyed dentists’ responses were

grouped by State. The second section of the survey

asked the dentists their opinions about the Medicaid

program in their State. Detailed figures in appendix

D present their responses by State and by their

participation in the Medicaid program. In general,

those who do not participate in the Medicaid

program appeared to have a more negative opinion

about the program. Although responses varied by

State, some aspects of Medicaid programs—

reimbursement level, timeliness of payment, the

criteria on which payment or denial of claims are

based, prior authorization process, and conformity

with community standards of practice-were often

rated poorly by the surveyed dentists.

The third section of the survey asked dentists3

about the provision of certain services to children

under Medicaid. Again, responses varied by service

and

●

●

●

●

by State. Dentists were asked:

Do you feel Medicaid allows you to provide the

following services as they are necessary to your

young Medicaid patients under age 18?

For each service you responded ‘no’ to above,

please indicate any or all of the possible reasons

(i.e., a) service not covered, b) service is not

allowed frequently enough, c) benefit excludes

use of appropriate materials, d) circumstances

allowing service are too narrow, and e) prior

authorization is difficult to obtain).

For each service, do you feel that any other

difficulties significantly compound the problem, if any, of providing that service appropriately to your young Medicaid patients (responses: g) no; h) yes, Medicaid reimbursement for this service is insufficient; i) yes, the

administrative process for this service is particularly burdensome; j) yes, Medicaid requirements regarding this service were not clearly

communicated)?

For each service, do you feel that young

Medicaid patients in your practice receive the

same intensity of care as other young patients

in your practice?

According to some dentists, the Medicaid program did not adequately allow some services they

Whia aection waa dirceted only to those dentists who both participate in the Medicaid program and treat children under age 18.
20 ● Children’s Dental Services Under the Medicaid Program

felt were necessary to Medicaid patients, particu- Problems cited by dentists are often reflected in

larly counseling children and parents on self care, the State Medicaid manuals, e.g., many dentists in

sealants, pulp therapy for permanent teeth, periodon- Texas felt that children under Medicaid did not

tal scaling and root planing, ginigival curettage, receive topical fluoride treatments with the same

removable prostheses, and orthodontic treatment.

Their reasons are very mixed and are presented in

intensity as their other patients and, in fact, the State

does not cover that service for older children.

appendix D, but very often insufficient reimbursement was one reason that significantly compounded

the problem of providing that sex-vice.

These same services, many dentists felt, were not

received by young Medicaid patients with the same

intensity as their other young patients.
References

1. American Dental Association, Council of Dental

Care Programs, Dental Programs in Medicaid: The

2989 Survey (Chicago, IL: American Dental Association, 1989).

2. American Dental Association, Council on Dental

Care Programs, Policies on Dental Care Programs,

1988 (Chicago, IL: American Dental Association,

1988).

3. Bhat, M., “Periodontal Attachment bss in 14- to

17-Year-Old U.S. School Children,” program and

absfracts, American Association for Public Health

Dentistry, November 1989.

4. Bhat, M., and Brunelle, J., ‘‘Gingival Status of 14-to

17-Year-Old U.S. School Children, ” Journal of

Dental Research 68:955, June 1989.

5. Gift, H. C., and Corbin, S. B., “Year 2000 Draft Oral

Health Objectives for the Nation, ” Mar. 27, 1989.

6. Grembowski, D., Conrad, D., Milgrom, P., “Dental

Care Demand Among Children with Dental Insurance,” Health Services Research 21:755, 1987.

7. Jack, S., and Bloom, B., Use of Dental Services and

Dental Health United States, 1986, DHHS Publication No. (PHS)88-1593. Vital and Health Statistics;

Series 10, No. 165 (Hyattsville, MD: National Center

for Health Statistics, 1988).

8. Johnson, K. and M. Siegal, “Resources for Improving the Oral Health of Maternal and Child Populations, ’ Public Health Service Workshop on Oral

Health of Mothers and Children: Background Issue

Papers, J.E.M. Steffensen and J.P. Brown (eds.)

Department of Health and Human Services, Public

Health Service, Health Resources and Services Administration, Bureau of Maternal and Child Health

and Resources Development (Washington, DC: National Center for Education in Maternal and Child

Health, September 1989).

9. U.S. Congress, Congressional Research Service,

“Health Care for Children: Federal Programs and

Policies, Mar. 17, 1988.

10. U.S. Congress, Congressional Research Service,

“Medicaid: FY90 Budget and Child Health Initiatives,” June 14, 1989.

11. U.S. Congress, House of Representatives, Committee on Energy and Commerce, Subcommittee on

Health and the Environment, Medicaid Source Book:

Background Data and Analysis, prepared by the

Congressional Research Service, Committee Print

1OO-AA (Washington, DC: U.S. Government Printing Office, 1988).

12. U.S. Congress, Office of Technology Assessment,

Healthy Children: Investing in the Future, OTA-H345 (Washington, DC: U.S. Government Printing

Office, 1988).

13. U.S. Department of Health and Human Services,

Food and Drug Administration, Selection of Patients

for X-ray Examinations: Dental Radiographic Examinations (Washington, DC: U.S. Government Printing Office, October 1987).

14. U.S. Department of Health and Human Services,

Health Care Financing Administration, State Medicaid Manual, Part 5--Early and Periodic Screening,

Diagnosis, and Treatment (EPSDT), April 1988.

15, U.S. Department of Health and Human Services,

Public Health Service, National Center for Health

Statistics, Use of Dental Services and Denta!Health,

1986, DHHS Publication No, (PHS)88-1593 (kVashington, DC: U.S. Government Printing Office, October, 1988).

16. U.S. Department of Health and Human Services,

Public Health Service, Healthy Children: Eflective

Public Health Practices for Improving Children’s

OraZ Health (Washington, DC: U.S. Government

Printing Office, May 1980).

17. U.S. Department of Health and Human Services,

Public Health Se~ice, NationaI Institutes of Health,

National Institute of Dental Research, Oral Health of

United States Children: The National Survey of

Dental Caries in U.S. School Children, 1986-87,

NH-I Publication No. 89-2247 (Washington, DC:

U.S. Government Printing Office, September 1989).

18. U.S. Department of Health and Human Services,

Public Health Se~ice, National Institutes of Health,

National Institute of Dental Research, National

Caries Program, The Prevalence of Dental Caries in

U.S. School Children, 1979-80, NIH Pub. No.

82-2245 (Washington, DC: U.S. Government Printing Office, 1981).

19. U.S. Department of Health, Education, and Welfare,

Health Care Financing Administration in cooperation

with The American Society of Dentistry for Children

and The American Academy of Pedodontics, A Guide

to Dental Care for the Early and Periodic Screening,

Diagnosis, and Treatment Program (EPSDT) Under

Medicaid, February 1980.

–21–
DIAGNOSIS

treatment

o for patients with caries or in a

00210

00220

00230

00240

00250

00260

00270

00272

00274

00275

00290

00315

00320

00321
24 . Children’s Dental Services Under the Medicaid Program

.-

.

“

L

0

.- n

ii

“

0

u

●
VI. Prosthodontics

Restoration of caricws lesior?s (primary

and permanent) with silver amis[gam,

plastic materials, c~ite resin

restoration, and stainless steel crowns

(on primary teeth)

Scaling and curettage arWor root p~aning

Removable prosthesis: at (east

function inpsird or exis t

unserviceable, inc(uling repa

the prosthesis

EPSDT, PHS, HCFA, ADA

HCFA, ADA

when mastication HCFA, EPSDT, PHS, ADA

ing prosthesis is

r and rebasing of

02110-02161 Ama[gam restorations

(including po~ishing)

02330-02387 Fi(Led or mfi~~ed resin

restorations

02930 Prefabricated stain(ess stee~ crown

-primary tooth

04341 Periodontal sca~ing and root p~anlng

-per quadrant

04220 Gingival curettage, by re~rt

x. Orthodontics Orthodontic treatment: at (east when medically HCFA, PHS, ADA

necessary to correct handica~ing malocclusion

Additional procdures suggested by core component reviewers:

Oral Surgery

Extractions-includes [ccal anesthesia ad rcwtine postoperative care:

07110 Sing~e tooth

07120 Each additlona~ tooth

07130 Root removal-exposed roots

Other surgica( procedures:

07285 Biopsy of ora[ tissue-hard

07286 Biopsy of ora~ tissue-soft

aManYrevieWers indicated thatafirstvlsit by age 1 is more approptiatethan byage3.

bThOse athigh fiskinclude th~sedem~nstra~ng: highlevel of~~iesexpe~ence, historyofrecurrent ~ries, poor qua~tyexlsting restoration, poor orai hygiene, inadequate fluortde ex~sure,

prolonged nursing, dtet with high sucrose, poor family dental health, developmental enamel defects, developmental dlsabihty, xerostomia, genetic abnormabty of teeth, many multisurface

restorations, chemokadiation therapy.

CSl]icate ~ement ~estorationS Whfch are spe~fiCa\ly included in the HCFA Guidelines, are excluded from this ~re ~mponent IIst because most reviewers indicated that Si!lCate CetTIent restorations

have been replaced by newer materials. Also, many rewewers suggested that stainless steel crowns for permanent teeth should be inciuded in a list of basic dental services.

SOURCES: ADA: Amerman Dental Association, Council on Dental Care Programs, Policies on Derrfa/ Care Programs, 1988 (Chicago, IL: American Dental Association, 1988). These guidehnes

describe a model dental benefit plan. EPSDT: U.S. Department of Health, Education, and Welfare, Health Care Financing Administration in cooperation with The American Society of

Dentistry for Chddren and The American Academy of Pedodontics, A Guide to Dental Care for the Early and Periodic Screening, Diagnosis, and Treafment Program (EPSD’1) Under

Medicaid, February 1980. This guide was prepared to assist those involved with implementing the dental care component of EPSDT. FDA: U.S. Department of Health and Human

Services, Food and Drug Administration, Selection of Patients for X-ray Examinations: Dental Radiographic Examinations (Washington, DC: U.S. Government Printing Office, October

1987). HCFA: U.S. Department of Health and Human Services, Health Care Financing Administration, State Medicaid Manual, Part fiEarfy and Pericdic Screening, Diagnosis, and

Treatment (EPSD7) April 1988. These are the Federal EPSDT program guidelines to which each State program must adhere. Thase guidelines cite the EPSDT dental guidelines above

for further information. PHS: U.S. Department of Health and Human Services, Public Health Service, Heatthy Chikfren: Effective Public Health Practices for Improving Children’s Oral

Hea/th(Washington, DC: U.S. Government Printing Office, May 1980). This document presents PHS guidelines regarding the most acceptable dental public health practices for improving

children’s oral health.

●
Appendix B

Workshop To Identify Barriers to Dental Services Experienced

by Children Under Medicaid, September 22, 1989

California

Richard Iniguez

Chief, Medical Care Services

Department of Health Services

714 P St., Rm 1640

Sacramento, CA 95814

List of Participants

Selvin Son ken, Chair

8200 Wisconsin Avenue, NW

APt. 1703

Bethesda, MD 20814

Dale F. Redig

Executive Director

California Dental Association

P.O. Box 13749

Sacramento, CA 95853

Michigan

Bruce C. Huckaby

Assistant Director

Medical Services Administration

Michigan Department of Social Services

400 S. Pine Street

Lansing, MI 48910

Bill Burke

Assistant Executive Director

Michigan Dental Association

North Washington Square

Lansing, MI 48933

Mississippi

J. Clinton Smith

Director, Division of Medicaid

Suite 801

Robert E. Lee Building

239 North Lamar Street

Jackson, MS 39201-131 I

Horton Giffin

P.O. BOX 2 4 8

Louisville, MS 39339

Dale Capurro

Nevada Medicaid

2527 N. Carson St.

Carson City, NV 89710

Patricia Craddock

820 South 7th Street

Las Vegas, NV 89101

New York

William Reynolds

Director, Bureau of Standards Development

Division of Health Care Standards and

Surveillance

Office of Health System Management

New York State Department of Health

Empire State Plaza, Corning Building

Albany, NY 12237

Ohio

Robin Colby

Ohio Department of Human Services

Bureau of Medicaid Policy

30 E. Broad, 31st Floor

Columbus, OH 43215

Edward Kozelek

Ohio Dental Association

1370 Dublin Road

Columbus, OH 43215

Texas

Bridget Cook

EPSDT Program Director

Texas Department of Human Services

Mail Code 522-E

P.O. Box 149030

Austin, TX 78714-9030

William D. Steinhauer

706 SW 24th St

Suite 103

San Antonio, TX 78207

List of Participants (cont. )

–26-
Appendix B-Workshop to Identify Barriers To Dental Services Experinced by Children Under Medicaid September 22, 1989 . 27

Myron Allukian, Jr.

Community Dental Programs

818 Harrison Avenue

Boston, MA 02118

Robert Collins

Indian Health Service, HRSA

5600 Fishers Lane

Room 6A-30

Rockville, MD 20855

Washington, DC 20036

Stephen Corbin

NIH, NIDR

Westwood Bldg

Rm 536

5333 Westbard Ave.

Bethesda, MD 20892

Burton L. Edelstein

190 Hempstead Street

New London, CT 06320

David Greenberg

Health Care Financing Administration

Rm 281

EHR, BQC

P.O. BOX 26678

Baltimore, MD 21207

Rockville, MD 20857

Bill Hall

USPHS

17th Floor

105 W. Adams St.

Chicago, IL 60603

Scott Litch

American Association of

Dental Schools

1625. Massachusetts Avenue, NW

Linda Niessen

P.O. BOX 167

Terry Point, MD 21902

John F. O’Donnell

Director of Legislation and

Legislative Policy

American Dental Association

1111 14th St., N.W.

Washington, DC 20005

John Rossetti

Health Resources and Services Admin.

Bureau of Maternal and Child Health

Parklawn Bldg, Rm 9-3 I

5600 Fishers Lane

Robert Isman

Secretary-Treasurer

Association of State and Territorial

Dental Directors

P.O. BOX 942732

Sacramento, CA 94234-7320

Clyde J. Behney, Program Manager for Health

Roger Herdman, Director, Division of Health and Life Sciences

Pamela Simerly, Study Director

Paula Chludzinski, Research Assistant
Appendix C

Comparison of State Medicaid Manuals to Core Components

0

u)

x

●

>

(n

x

●
● indivitilized radiographic ● xamination

for periodontal disease and a growth ad

develofxnent assessment

●
Footnotes:

1 k! i ch i gan r-i res prior authorization for at 1 treatment plsm for beneficiaries tir 21 hi ch r~i re more than S200 of denta~ services (according to the

dentist’s USUSL end custcmary f=). ALSO al ( authorized work mat be provided wi thin 6 months.

2 In Mississippi, beneficiaries mder 21 are ● t igible for ● mxi- of S2S0 in dentat services (exclusive of ● xtractiooa). Recipients over 18 are responsible

for a S2.00 copayment per visit.

3 In Texas, EPSOT recipients are ● t igib(e for dental services once in ● 12-~th period, +ich i!

date of service. Those r-i ring additional services mat obtain an Exception to Periodic

services mat receive prior euthor i zat i on.

4 NY: Specified in Part S08 of the Chi td/Teen Health Plen r~lstiona, 18 NYCRR S08.

5 TX: An Exception to Periodici ty form needs to be obtained by the dentist in waler to provide S(

6 C A: u/o radiographs; one ● xam per bmef iciary per provider.

7 HI : Not inctding rediogre@s, fiich are b{ t Led separately .

8 PK: Hay be claimed on the first visit for EPSO’

are ● ( loud in conjmct i cm.

9 NV: Al (owed once per beneficiary per provider,

character i zed as the 12 mnth period fo~ Lowing the last paid

ty. Any treatment plen r+i ring more than S300 of dental

rv{ ces to ch i ldren mder 3.

pat ients mder 21 and is 1 imi ted to me per fiscal year. Ooes not inc ude radi ogra@s, but other procedures

● xcludi ng radiographs.

10 OH: The ini tint ora( ● xam does not speci fica( (y inc(de rediogrefdm. Rsdiogra@s are bi L (able separately.

11 TX: Ini t i at ● xam may onty be bi [ ted then no radiographs ● re taken.

12 CA: Only deve[opmntal ly disabled children smy receive ● periodic ● xax, according to the manual.

●
13 HI : Covered service once ● very 6 months.

14 MS: The periodic ● xmn is (irni ted to r=ipients mder 21 who have space maintainers. Al Lowed once per year and incldes pro@ylaxis and f~uoride treatment.

The clinical oral ● xam for other EPSOT recipients is describd md referred to above in the initiat ora~ ● xrrn.

15 NV: A perialic orat ● xam is all- ● very 12 sunths for al( children mder 21.

16 Oli: Periodic ora( ● x~ are a~lowed once ● very 6 months.

17 TX: There iS no procedme cde or pqment s~if{ca((y for a periodic ● x m . tl~ver, a patient nust uait 12 mcmths after services outlined in a treatment

plan have beerI perforwed before ● neu treatment plan for rtiine semices cm be authorizd. Prior authorization is recpird for a treatment plan

rwiriw over $300 of services or if MY Pmcedmes in the treatment plm require prior authorization.

18 CA: Amuatly for beneficiaries 13 and over.

19 HI: A&Its are defind as those aged 14 ad older. B~ficiaries tinder 21 tit ● t

20 TX: Prophylaxis for recipients 13-20 =y be provided once evety 12 months, md my

Oniy.

21 M: Amus(iy for beneficiaries 12 and wtder.

22 Ml: Bmeficiaries mder 14 may receive prophylaxis once in s 6-nxmth pericd.

23 !4S: Pro@y(axis is a(lowd for a(t recipients uder 21 orue per 12 stcmth period .

● ast 14 my receive prc@ylaxis m mre than once in a 6-month pericd.

or may not include f(uoride. Proce&re intended for periodontal cases

24 NV: Pro@y(axis is covered for chiidren 10 through 20 years once ● very 12 months; prophylaxis ad f

● very 6 months.

25 NY: ‘Child w is defined as beneficiaries @r age 21.

26 OH: Prophylaxis is alloued for recipients through age 20 cmce ● very 6 mnths.

uoride treatment is a~(owd for chiidr~ 9 and mder onc e

27 TX: Prc@ylaxis for recipients 3-12 may be provided once ● very 12 mnths, inctdes s~ingival scaling, and msy or NY not inctude fluoride.

28 CA: In adiition to prc@ylaxis, for beneficiaries 5 and u-der.

29 HI: FLuoride treatment is a benefit only for recipients mder 18, wust be preceded by a coq(ete oral pro@y[axis, ard may be provided only once in a 12-

month period.

30 MS: Topical application of ftuorick inclu5es prqhylaxis, ailcwed once pr year for EPSOT recipimts.

31 NV: Chf[dren w to 9 my receive fluoride treatments (including prophylaxis) ● very 6 wmnths; chi [dren 10 through 20 IMY receive f[uoride treatments

(exclusive of prc@ytaxis) once ● very year.

32 OH: Fluoride treatnamt, fol[ouing ccaplete pro@ylaxis, is alloud once ● very 6 months for beneficiaries tit- 21.

33 TX: F\uoride treatmmt is included in the fee for prophylaxis, although its provision is not required and it may not be bi~[ed for separately.

34 CA: In addition to prc@ylaxis, for beneficiaries 6 through 17.

35 OH: A(though rmt spcifial in the smrmsl, an (Mio State PMicaid officia( noted that both dietary p[aming for control of denta[ caries and ora~ hygien e

instruction should be inc~ded as part of the periodic ● xm and prc#yiaxis procedures.

36 HI: Not a covered service since 1981.

37 HS: CoverA for recipients @r 21 for newly ● r~ted first and aecond p rS9nefK smlars or for first and seccd premolars. Prior a~rova( is rquired fo r

prifmry teeth.

38 NV: Chi(dren 6-20 are altoued one sealant per prirmry tooth. ●
39 OH: Sea[ants ● re pe~itted on Pm?man t f$rst molars for recipients uder age 9 and on permment second molars for recip

application of sealant per tooth per Lifetime is a(toual.

40 CA: Space maintainers are aliowd WAere there {S sufficient rocm for an mertqted permanent tooth to ● rtqx normstty.w

missing permanent teeth.

41 ml: Space maintena-e recpires prior authorization, and is limited to the necessary maintenance of a posterior space for

prmturety lost deciduous tooth.

42 MS: Space maintenance is provided for decickmus or pe rmanent dentition.

43 NV: Prior authorizat{cm required -- not a routinety ● vai(able benefit.

44 TX: Limited to loss of primary second sm(ar.

mts tir age 15. On[yOne

t is not covered to hotd space for

a Pe-nent successor to a

45 TX: Attouabte onty for the (0ss of tbm or mre pr{smry smlars in a sing(e ● rch, me of which sust be a prismry second mlar.

46 CA: For beneficiaries 13 ● nd over, ● c~(ete series once ● very 3 years.

For beneficiaries @r 13. fever intraoral radiographs comrise a comlete ser{es and msy be a~toued ‘ccxnmms urate with sirans, svmtoms. and age of th e

Patien t

a (a(though Sec.-51307(d)(ll) specifica~ly” denies” full muth’radiogra@ coverage for beneficiaries 12 and mder).- - -

47 Ml:

48 MS:

49 NV:

50 OH:

51 TX:

52 C A:

53 MI:

54 Ms:

55 TX:

56 OH:

57 CA:

58 OH:

59 NY:

@ OH:

61 CA:

Ccq(ete mouth survey ● benefit only once every 3 years.

Allouab[e on~y once ● very 2 years. Shou(d include 10 to 14 intraorat filmz ad biteuings.

Hedicaid acceptable x-rays are not to be taken with ● xcessive fr~y.

A c~lete series wi~t consist of ● nini- of 12 or more films ad is allowed only once ● very 3 years, mless prior authorized.

Aiiouable once every 3 years by the smne dentist.

A total of 11 films are ● iicwed in ● serfes.

Reca(t radiogr~s are covered onty cmce ● very 6 months, and ● re (imited to biteuings and necessary periapica( radiographs.

tity 7 intraoral fi\sc3 are coverd per clafn.

Not to ● xceed payment for fu[l smuth series.

ExtraoraL fi~m is al~oued as an adjmct to complex treatment.

Sqp(enentary biteuings are a benefit no more than once ● very 6 months

Biteuing radiogra~s, inccmbination oraione, areal[oudat6month

Three fi(ms mininun.

Prior authorization is r~ired.

Single radiographs are a benefit utven necessary to a msx mm of 11 films.

ntervals.

AILouad as part of futt mouth series, with periapica( radiogra@s of anterior teeth and at least 2 biteuings, once every 3 years for beneficiaries 13 and

rcunstances.

over. Panogra@ic radiogra@s ● lorw are ● limited benefit.

62 MI: Require prior authorization then they ● re the only type of radiograph taken, which is al(oud uider limited c

63 HS: Not covered in conjmction with full-smuth intraoral series.

64 NV: Panorex or Panelipse x-rays r-ire written prior authorization if more fr+t than within 90 days.

65 OH: Panoramic radiogra~s are attcwed once every 3 years (and 3 years ~t ● lapse betueen panoramic radiographs and ccqlete series of radiogra~s) and are

iimited to beneficiaries 6 ● nd otder, mtess prior authorized.

h

N

%&

g.

CL
66 TX: Limitd to one during the ages 0-9 @r’xl me during the ages 10-20 by the same dentist.

67 RI: Prior authorization rqired.

68 NV: Wedicaid acceptable x-rays are not to be taken ~ith ● xcessive fr~y.

69 OH: Prior authorizaticm is required .

70 MS: Amalgam shou~d be used on a(~ teeth dista~ to cuspids for beneficiaries fir 21, primary or permanent.

71 CA: Benefit i~(~ Silicate, Ccapoaite, and Ptastic restorations, but only on anterior teeth.

72 HI: Benefit includes Silicate, Composite, and Plastic restorations, but only cm anterior teeth.

73 MS: Ccaposites IMY be performed on both anterior and posterior teeth, prismry and permanent.

74 NV: Restorations with acrylic/plastic, ccmposite resin, limited to anterior teeth.

75 NY: Although the fee schechte does not specify, corresponding AOA Codes i~~y that resin restorat

76 OH: For anterior t~th on(y.

77 TX: The fee for restoring ● nterior teeth With resin is higher than for posterior teeth.

ons are al owed for anterior teeth oniy.

78 HI: Preformed stainless steel crome ● re authorized on[y for decidmua teeth and first permanent nmlars and on~y for recipients 15 and tir. Other crouns

● re for aoterior teeth only and r~ire prior authorization.

79 CA: According to the California Smnua(, ~lp capping ia covered ● s pert of restorative services, &t it is specifically a ‘not covered” service according to

Section 51307(d)(ll).

80 OH: A(though there is no coda for pJLp therm, &t IXio State Medicaid officiat notd that these proce&res shou(d be inc~uded as pert of restorativ e

proc*res if necessary.

81 CA: Therapeutic ~tpotonry for deci&ous teeth only. Vita( puipotcmry for vitat permment teeth onty.

82 HI: A vital ~(pot~ is covered for a vital decic&oua tooth or ● vitat pemnent tooth with incmp(ete(y formal roota, and r~ires prior authorization.

63 MS: Putpotomy for primary teeth does not recpire prior authorization.

64 TX: Therapeutic pulpot~ with base.

8S CA: A limited benefit for posterior ad anterior pa rmanent teeth for beneficiaries though age 17.

06 MI: Prior authorization is racpired for any root CUU1 therapy.

87MS: Rootcanais forpe rmanant teeth r~ires sdxaission of titanti{

M NV: Prior authorization re+ired -- not ● routinely ● vailable benefi’

890H: Rootcanei ther~ is atloued on[yonpermmn t teeth.

90 TX: Root canal payments are Limited to four permanent teeth for ● a c h

91 NY: Prior epprova( rqired.

92 C A: Periodontal services are Limited to benef

93 MI: R~ires prior ~thorization.

94 OH: Although the manual specifically does not

necessary sca(ing ati that pericxjonta( sca

ciaries 18 and over.

ting x-rays.

.

recipient ad x-rays are required.

cover periodcmta( seating, an tiio State Hedicaid off

ing should be prwided if necessa~. There is no bil

cia( noted that the defnition of pro@y axis inc~udes

abie code for periodontal sca[lng.
9S 1X: Altho@ the fee for pro@y(axis for recipients 3-12 inciudes s~ingival sca~ing, neither pericdcmta( sca(ing and root planing nor gingival curettage

● re specificat[y covered services.

% MS: Gingival curettage and gingivectomies mill & ccxtsidered cwtly for patients on Di(antin ther~.

97 NV: Prior authorization rwirtd -- not ● routine(y ● vailable benefit.

96 NY: However, gingivectcmy or gingivop(asty is ● lloud .

W ON: However, gingivwctowy or gingivoplasty sometimes (though not ususlty) al(owed and prior authorization is r~ired.

10D CA: Reable prostheses ● re ● benefit with limitations (e.g., only *en necessary for the balance of a complete dmture) and cmty once in a 5

101 ml: A partial denture witl be authorized for beneficiaries *r 21 cmly if one or more incisor is missing or fewer than 6 teeth are in occtus

year period.

on in

posterior ● reas. Ccmp(ete or partial dentures will oniy be authorized then mssticatory deficiencies will impair generai health and Mm ● xisting denture s

camot be smde serviceable. Replacement &tures ● re not ● benefit if the originsi dentures were placed uithin 5 years.

AL( dentures r~ire prior authorization.

102 MS: Prosthodontics ● re (imitd to -r ad louer rwab(e bridges. Prior approvat is r+ired.

103 NV: Prior authorization r~ired -- not ● routinely ● vai1s4(e txmefit.

104 NY: Prior authorization is reqired.

10S ON: Ali dentures -t be prior authorized; partia( dentures ● re authorized 4wn severat teeth ● re missing in the arch and mssticatory fmction

impaired. Ati dentures camot be repiaced or rti uithin 8 years ● xcept for very musuat circumstances.

106 TX: Partia( dentures may be authorized for recipients 9-20 if the reciBient has missino anterior teeth or (sss than 8 occidim oosterior teeth

palate and partial ar&ontia cases (age 3-20)” sIsY be ● xceptai.

107 CA: Orthodontic treatment is lix!ited to beneficiaries uith cleft

Program.

108 HI: Orthodontic procedmes are ~~ovided to children medicat

● (igib(e) and reqire prior authorization.

s severely

-. Cleft

palate deformities who are mder case ~gement of the California Children Services

y ● ligib(e for the Cri~lecl Children Program (Medicaid recipients are a(resdy financs[ly

109 MS: For permnen t dentition only, ad sust receive prior approval.

110 NV: Orthodontic coverage is liaitd to only those chitdren with the most severe handicapping conditions.

111 NY: Prior approva[ rqired.

112 ON: Orthodontic coverage is Limitd to onty those children with the most severe hatiicapping conditions.

113 TX: Orthodontic coverage is Iimittxl but smy be authorized for children with the smst severe handicapping conditions.

114 NY: The only emergency service listed in the lieu York progr~~s fee sche&le is palliative care; there is no procedre code for an emergency visit nor any

sfx?cific parmueters regarding the provision of ~rg~ services.

115 In California, ~rgency dentai services do not ned prior authorization. There is no specific mrgency ● xcm proc~re code (except in the case of

emergency periodmtic service); providers shou(d bitt for the services redered. From the ● xanples in the manus[, it uouldagpear that the emergency

situations covered in California ● re consistent with those specified in this (ist of core caponents.

116 in?lichigan, one visit is attoud for ● ach specific ~rgertcy for all recipients ad dws not rqire prior authorization. SomaE services rerdered (such as

emergency oral surgery, rechction of dislaations of TMJ, treatment of ce[(u(itis, ad single, si!!p[e ● xtraction) do not r+ire prior authorization for

billing . Al( other emergmcy services do rqire prior authorization, ht it SMy be obtained by @one by the end of the next working day. Routine

restorative procedmes, root cana( therapy, eiectivesurgery, anddenture services are not awrgencyproce&res.

●
117 In 14ississippi, emsrgency denta~ care is provided to relieve pain and/or infection. Emergency is defined as a condition which requires treatment and there

exists pain and/or infection of the dental ~ratus and/or contiguous structures *ich, in the opinion of the dentist, ui~~ require ● xtraction of the

tooth or teeth. WI mnergency ● xms is bi[~abte on(y if no other procdres, other than x-rays, are performed that same day.

118 The Nevada progrars definition of emergency care is ~ite simi(ar to the e(ements Iistd here. Treatment measures include emergency prosthetic repair,

repiacemen t of missing teeth in a prosthesis, dmture adjustments, routine restorative procedures, endodontics (cm anterior teeth on(y) and extractions.

Emergency services ned no prior authorization.

119 There are no Proc-re codes in the CN!io handmok for either Paiiiative etra?rg-y care or an emergency ● xam. Indeed, there is rm discreet secticm

● xplaining the po~icies on emergency services at all in the hamboo k, a(tho@ scme guidance is provided regarding specific services (e.g.,

rendering the patient edentutous -t be prior awoved, ● xcept in abaotute emergency). The billing form does offer ‘emergency rcw+’ as a

service. An Utio Medicaid officiat noted that providers should bill for the actual services redered.

120 There is m orocecbre coda for an eawrwmcv ● xrn. ● tthowh there is one for oa[(iative emermncv treatment. Prior authorization is recwired

121 M

extractions

ocation of

denta[ aer~ices poyab[e ● t sure than-S80i Aich may be-obtaind by calting’an %00- rsmbe~.

or efnergency

Routine restorative procechmes are not considered as

emergency proce&rea. The Texas mrwmt &finitiori of am?rgency services is aimilar to the ● lements in this list of core coqxments.

: Extraction of -r@ than one t~th r~irea prior authorization.

122 CA: Not payable to provider receiving pyment for tooth extraction.

123 MI: Requires prior authorization.

124 CA: But not ● banefit in COnjWtCtiOtI with ● XtrSCti~.

125 RI: A biopsy performed in conjmction uith another surgicat Proc-re is considered part of that surgica( procedure.

126 NV: Prior authorization r~ired -- not ● routinely ● vai~abte benefit.

s

●
Appendix D

Survey Instrument

Contents

Page

Survey Instrument . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Results Page

D-l. Information About the Survey Respondents, by State . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

D-2. information About a Sample of Respondents, by State . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

D-3. Opinions About Medicaid Dental Programs, by State and by the Respondents’

Medicaid Participation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

D-4. Opinions About Medicaid Dental Programs, State Summary . . . . . . . . . . . . . . . . . . . . . . . 50

D-5. Responses to Questions About Selected Services: Initial Oral Exam . . . . . . . . . . . . . . . . . 52

D-6. Responses to Questions About Selected Services: Periodic Oral Exam . . . . . . . . . . . . . . 54

D-7. Responses to Questions About Selected Services: Counseling Child and Parent on

Self-Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

D-8. Responses to Questions About Selected Services: Prophylaxis . . . . . . . . . . . . . . . . . . . . . . 58

D-9. Responses to Questions About Selected Services: Topical Fluoride . . . . . . . . . . . . . . . . . 60

D-10. Responses to Questions About Selected Services: Sealants . . . . . . . . . . . . . . . . . . . . . . . . . 62

D-n. Responses to Questions About Selected Services: Bite-wing X-Rays . . . . . . . . . . . . . . . . 64

D-12. Responses to Questions About Selected Services: Pulp Therapy for Primary Teeth... 66

D-13. Responses to Questions About Selected Services: Pulp Therapy for Permanent

Teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

D-14. Responses to Questions About Selected Services: Restoration of Carious Lesions for

Primary Teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

D-15. Responses to Questions About Selected Services: Restoration of Carious Lesions for

Permanent Teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

D-16. Responses to Questions About Selected Services: Periodontal Scaling and

Root Planing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

D-17. Responses to Questions About Selected Services: Gingival Curettage . . . . . . . . . . . . . . . 76

D-18. Responses to Questions About Selected Services: Space Maintenance . . . . . . . . . . . . . . . 78

D-19. Responses to Questions About Selected Services: Prostheses . . . . . . . . . . . . . . . . . . . . . . . 80

D-20. Responses to Questions About Selected Services: Orthodontic Treatment . . . . . . . . . . . 82

D-21. information About Survey Respondents, California . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

D-22. information About A Sample of Respondents, California . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

D-23. Opinions About Medicaid Dental Programs, California . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

D-24. Responses to Questions About Selected Services, California . . . . . . . . . . . . . . . . . . . . . . . 88

D-25. information About Survey Respondents, Michigan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

D-26. information About A Sample of Respondents, Michigan . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

D-27. Opinions About Medicaid Dental Programs, Michigan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

D-28. Responses to Questions About Selected Services, Michigan . . . . . . . . . . . . . . . . . . . . . . . . 94

D-29. information About Survey Respondents, Mississippi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

D-30. information About A Sample of Respondents, Mississippi . . . . . . . . . . . . . . . . . . . . . . . . . 97

D-31. Opinions About Medicaid Dental Programs, Mississippi . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

D-32, Responses to Questions About Selected Services, Mississippi . . . . . . . . . . . . . . . . . . . . . . 100

-36-
Appendix D-Survey Instrument . 37

Page

D-33. Information About Survey Respondents, Nevada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

D-34. Information About A Sampleof Respondents, Nevada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103

D-35. Opinions About Medicaid Dental Programs, Nevada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104

D-36. Responses to Questions About Selected Services, Nevada . . . . . . . . . . . . . . . . . . . . . . . . . . 106

D-37. Information About Survey Respondents, New York . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

D-38. Information About A Sample of Respondents, New York . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

D-39. Opinions About Medicaid Dental Programs, New York . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

D-40. Responses to Questions About Selected Services, New York . . . . . . . . . . . . . . . . . . . . . . . 112

D41. Information About Survey Respondents, Ohio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114

D-42. Information About A Sample of Respondents, Ohio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115

D-43. Opinions About Medicaid Dental Programs, Ohio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116

D-44. Responses to Questions About Selected Services, Ohio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118

D-45. information About Survey Respondents, Texas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120

D-46. Information About a Sample of Respondents, Texas.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121

D-47. Opinions About Medicaid Dental Programs, Texas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122

D-48. Responses to Questions About Selected Services, Texas . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
19
Scope and Limitations of Covered Services:

●
40 ● Children’s Dental Services Under the Medicaid Program

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Section IV. Additional Comments

1 f aIf you have comments about particular questions, please record them below .

1. Background Information -- Additional Comments

1. a.

b.

c.

d.

2.

3

4.

5.

6

,

8.

I I . Opinions About the Medicaid Dental Program in Your State -- Additional Comments

Administrative Requirements:

1.

2.

3.

4.

5.

6.

7.

8.

9.

Reimbursement Issues:

Scope and Limitations of Covered Services:

10.

11.
111. A Closer Look at selected Services -- Additional Comments

1.

2. and 3. Ques. 2: f. other Ques 3: k. other

- initial oral exam f . k.

- periodic oral exam f . k.

- counsel child and parent

on self care (oral

hygiene, reduce cariogenic

food, etc.) f . k.

- prophylaxis f . k.

topical fluoride f . k.

pit and fissure sealants f . k.

- posterior bitewings f . k.

- provide pulp therapy for

primary teeth f . k.

- pulp therapy for

permanent teeth f . k.

- restoration of carious

Lesions for primary teeth f . k.

- restoration of cariou s

lesions for permanent teeth f . k.

- Periodontal scaling and

root planing (ADA Code 04341) f . k.

- gingival curettage

(ADA Code 04220) f . k.

- provide space maintainers for

posterior primary teeth which

are lost prematurely f . k.

- provide removable prosthesis

when mastication function is

impaired or the existing

prosthesis is unserviceable f . k.

- provide medically necessary

orthodontic treatment to

correct handicapping

malocclusion f . k.
111. (cult. )

4.

5.

Additional Comments about the Survey in General:
44 ● Children’s Dental Services Under the Medicaid Program

I

I
Medicaid Participation of Respondents

California

Michigan

Mississippi

Nevad a

New York

Ohio

Texas

California

Michigan

Mississippi

Nevad a

New York

Ohio

Texas

I

75% 100%

by State

Treatment Patterns of Medicaid

Patients by Participating Dentists

California

Michigan

Mississippi

Nevad a

New York

Ohio

Texa s

Past Participation Behavior

of Nonparticipating Dentists*

o% 2 5 % 50% 7 5 % 1 00%

40

30

20

1 0

0

r

California Michigan

● The sample contains those dentists responding to the survey who treat

Medicaid patients and children under age 18.
California

Michigan

Mississippi

Nevada

New York

Ohio

Texas

California

Missiissippi

Michigan

Nevada

New York

Ohio

Texas

Figure D-2-information About a

Sex of Survey Sample, by State

o% 25% 50%

Percent of sample, by

No answer Mal e

75% 100%

State

 Femal e

Race of Survey Sample, by State

of Respondents, by State

Age of Survey Sample, by State

California

Michigan

Mississippi

Nevada

New York

Ohio

Texas

o% 25%

 No ● nswe r

 46-5 5

Specialties of Survey Sample, by State

California

Michigan

Mississippi

Nevada

New York

Ohio

Texas

o% 25% 50% 75% 1 00% o%

Percent of sample, by State

Hispanic origin
Appendix D-Survey instrument ● 47

: :. : :5 . ,.
48 ● Children’s Dental Services Under the Medicaid Program —
Appendix D-Survey Instrument ● 49

I II II II

I

0

0
50 ● Children’s Dental Services Under the Medicaid Program
New York

Survey questions by Medicaid participation

Texas

Survey questions by Medicaid participation

Ohio

Survey questions by Medicaid participation

Opinions of Surveyed Dentists on Certain

Aspects of the Medicaid Dental Program in Their

State:

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

Timeliness of payment for submitted claims

Communication of requirements

Format of billing forms

Reimbursement levels for covered services

Criteria upon which payment or denial

of claims are based

Consistency of payment or denial of claims

Selection of covered services

Selection of services requiring prior authorization

Process for receiving prior authorization

Criteria for approval or denial of

prior authorization

Conformity with community standards of practice

Responses of Both Those Dentists who Participate i n

Medicaid and Those Who Do Not.
52 ● Children’s Dental Services Under the Medicaid Program

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64 ● Children’s Dental Services Under the Medicaid Program

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Appendix D-Survey Instrument ● 67

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Appendix D-Survey Instrument ● 71

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Appendix D-Survey Instrument ● 77

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84 ● Children’s Dental Services Under the Medicaid Program

Figure D-21—lnformation About Survey Respondents, California

Female 7

No answe

Sex

White/Not Hisp 7 5 %

White/Hlap Orig 3%

Asian/Pac.ls. 14%

No answer 8%

Race

Yea 40$ No

Age

36-45 32 %

26-35 21 %

No answer 1%

68%

Have

----- -

Specialty

have 27%

o answer 3%

In

. . .

past

---- -

No answer 2%

Medicaid participation Past participation behavior

of nonparticipating dentists

KEY: Raca American Indian/Alaska Native; AsiarVPaafic Islander; BlacidHispanic origin; Blacidnot Hispanic origin; White/Hiepanic origin; White/not Hispanic

ofiginm

S#a/ty Endodontics; General practice; Oral surge~; Orthodontics; Pedodontics (Pediatric dentistry); Periodontics; Prosthodontics.

SOURCE: Office of Ttinology Assessment, 1990.
Appendix Wurvey Instrument ● 85

Figure D-22—lnformation About a Samplea of Respondents, California

No answer 4%

~66 6%

68-66 131b

46-66 20%

36-46 32 %

26-36 23 %

No answe r 2%

Sex Age

Race Specialty

Others

61%

\

‘\\

.

Sample*

3 9 %

eat ● ll

22%

No ● na

1%

pts

we r

Only current pts

46%

Survey respondents Treatment patterns of Medicaid

in the sample* patients by sample* dentists

KEY: flace:/lmerican Indian/Alaska Native; AsiarJPaoific Islander; Black/Hispanic origin; Black/not Hispanic origin; White/Hispanic origin; Whhe/not Hispanic

origin.

Specialty Endodontics; General practice; OreJ surgery; Orthodontics; Pedodontics (Pediatric dentistry); Periodontics; Pmsthodontica.

~he sample contains those dentists responding to the survey who treat Medicaid patients and children under age 18.

SOURCE: Office of Technology Assessment, 1990.
86 ● Children’s Dental Services Under the Medicaid Program

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88 ● Children’s Dental Services Under the Medicaid Program

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90 ● Children’s Dental Services Under the Medicaid Program

Figure D-25-information About Survey Respondents, Michigan

White/Not HisP 87%

Gen prac

Black/Hisp Orig 1%

Amer lnd/AL Nat 1% Black/Not Hisp 3%

no answer 8%

Race Specialty

69%

38-46 36%

26-96 21%

Sex Age

have 27

● n.war

‘%

2%

No 49%

Have in past

----------------- -

Medicaid participation Past participation behavior

of nonparticipating dentists

KEY: Raoa Amerkan lndian/Ataaka Native; Aalan/PaMlc Islander; BlacWHiapank orlghr; Black/not Hispanic origin; White/Hiapankorigin; White/not Hlapank

*in .

~Endodontka; General practice; Oral surgery; Orthodontics; Padodontica (Pediatric dentistry); Periodontka; Proathodontica.

SOURCE: Offke of Technology Aaaeaamont, 1990.
Appendix D-Survey Instrument .91

Figure D-26-lnformation About a Samplea of Respondents, Michigan

Female 6%

No ● nswer 8%

Sex

White/Not Hisp 88 %

Others 49%

)65 6%

68-86 17%

48-66 18%

36-45 1 8 %

28-96 24%

Age

on.

ho.

ral

Race Specialty

------------------ - No answer 6%

Treat ● ll pts 32%

Sample 61%

Emergency only 6%

‘r. at sore. pt. 3

Only our rent pts 28%

Survey respondents Treatment patterns of Medicaid

in the sample* patients by sample* dentists

KEY: Fhace:American lndlatiAlaska Native; AsiarVPacific Islandsr; Black/Hispanic origin; Biack/not Hispanic origin; White/Hispanic origin; Whits/not Hispanic

origin.

-~En_t~; General Practi@; ~~ surgery; ~h*nti=; peddti= (Pediatric dentistry); Periodontics; Prosthodontics.

~he sampie contains those dentists responding to the survey who treat Medicaid patients and chiidren under age 18.

SOURCE: Office of T-noiogy Assessment, 1990.
92 ● Children’s Dental Services Under the Medicaid Program

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Appendix D-Survey Instrument . 93

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94 ● Children’s Dental Services Under the Medicaid Program

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96 ● Children’s Dental Services Under the Medicaid Program

Figure D-29—lnformation About Survey Respondents, Mississippi

Female 5%

No answer 5%

Sex

White/not Hisp 88%

Black/not Hisp 7 %

. . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . .

No answer 5%

Age

 65 12%

66-66 17 %

46-66 29 %

36-46 26%

26-36 17%

/ \

No ● newer 2%

Perio. 2%

edodon. 7%

surg. 5%

Race

Yea 84%

Specialty

Never have 6 0 %

Have in past 60%

Medicaid participation Past participation behavior

of nonparticipating dentists

KEY: /?aca Amerkan lndiarVAlaska Native; Asian/Paafic Islander; BlacldHispanicorlgin; Biacldnot Hispanic origin; White/Hlspanlcodgln; White/not Hlapanio

origin.

Spea”atty Endodontics; General practice; Oral surgery; Orthodontics; Pedodontics (Pediatric dentistry); Periodontics; Pmsthodontka.

SOURCE: Office of Technology Assessment, 1990.
Appendix D-Survey Instrument . 97

Figure D-30-information About a Sam plea of Respondents, Mississippi

Sex Age

36-45 29 %

26-36 20 %

Race Specialty

Othe r

17%

Treat al I

8 0 %

Sample=

8 3 %

Only current

3 %

at some p t s

14%

Emergency only

Survey respondents Treatment patterns of Medicaid

in the sample* patients by sample* dentists

pts

KEY: Race: American Indian/Alaska Native ;Asian/Pacific Islander; Black/Hispanic origin; Black/not Hispanic origin; White/Hispanic origin; White/not Hispanic

origin.

Spedis/ty Endodontics; General practice; Oral surgery; Orthodontics; Pedodontics (Pediatric dentistry); Periodontics; Prosthodontks.

%e sarnpie contains those dentists responding to the survey who treat Medicaid patients and children under age 18.

SOURCE: Office of Technology Assessment, 1990.
98 ● Children’s Dental Services Under the Medicaid Program

0

.-

L

— L

0

0

z

—

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● ✍

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0 0

0

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. .
Mississippi

Survey questions by Medicaid participation

Q1

Q2

Q3

Q 4

Q 5

Q6

Q7

Q8

Q9

yes

no

yes

no

yes

no

yes

no

yes

no

yes

no

yes

no

yes

no

yes

no

1

0% 2 5 % 50% 75% 100%

Percent of respondents, Mississippi

good Fair

or opinion

KEY: Race: American lndIwAIaska Native; kian/Pdfk blander; BlackMbanic origin; BkuWnot Fftspmk origin; WhiteJH&panic origin; WhiWnot I+sptmk origin,

%=dtJc Erldodontics; General practim; msum; Orthodonlks; Ped@Xmcs‘ (PecsatJicdentistry); Pedodonb; Proethodontics.

SOURCE: OlficO (d T~notogy ~tnent 1990.
100 . Children’s Dental Services Under the Medicaid Program

o —

c

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0
Appendix D-Survey Instrument ● 101

0

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o

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102 ● Children’s Dental Services Under the Medicaid Program

Figure D-33-Information About Survey Respondents, Nevada

Female 3%

No ● nswer 3%

9 4 %

36-46 62%

26-96 10%

Sex Age

Race Specialty

Yes 69% No 31%

Never

------ -

67

---

ave In past 3 3 %

Medicaid participation Past participation behavior

of nonparticipating dentists

KEY: RaoEAmorioan Indian/Alaska Native; Asian/PacMc islander; B14dWpank origin; Black/not Hispanic origin; Whtta/Htspank origin; White/not Hiepank

origin.

-

Endodontics; General practice; Oral surgery; Orthodontics; Pedodon tica (Pedatllc derlttatly); Periodontke; Proethodonth

SOURCE: Offloa of Ttindogy Aseeaement, 1990.
Appendix D-Survey Instrument . 103

Whi

No

Figure D-34-information About a Samplea of Respondents, Nevada

● nswer 6%

Sex

No ● nswer 6%

96%

Age

n. 20%

the. 10%

80%

surg. 10%

Race Specialty

Other@

31%

Survey respondents Treatment patterns of Medicaid

in the sample* patients by sample* dentists

Sample*

69%

Treat ● ll

66%

nt pts

reat some pt.

35%

KEY: F&xx Anwtcan lndiadAlaska Native; Aaian/Padfic Islander; BkWHlapanic orfgln; Black.hot Hispanic origin; White/Hispanic orfgin; White/not H4apank

dgln.

W* Endodontics; Ganerd ptiCO; Oral surgery; Orthodontb; Pedodon tks (Pedlatrlc dentistry); Periodontics; Prosthodontks.

~. aempla cmtains thoeo dontiata reepondng to the survey who treat Medicaid patients and children under age 18.

SOURCE: ~ of Tdmdogy Aaaeaament, 1990.
104 ● Children’s Dental Services Under the Medicaid Program

0

m

0

z

L

0

0

n

0

n

——.- 0 a

c

.-

L

E

— .-

.- .- 0 . .

-u
Nevada

Survey questions by Medicaid participation

Q1

Q2

Q3

Q4

Q 5

Q 6

Q7

Q8

Q9

Q10

Q11

yes

no

yes

no

yes

no

yes

no

yes

no

yes

no

yes

no

yes

no

yes

no

yes

no

yes

no 1 1 0% 2 5 % 5 0 % 759(0 100?40

Percent of respondents, Nevada

Fair

opinion

KEY: Race: American lrKSadAiaska Native; Asian/Padfic Islander; BiackHispanic origin; Black/not HiSpank origin; White/Hispan.k origin; White/not Hispank origin.

*-. 13dodontics; General practk9; Oral surgery; Orthodontics; Pedodontks (Pediatric dentistry); Periodontics; Prosthodontks.

SOURCE: Office of Technology Assessment 1990.
106 ● Children’s Dental Services U nder the Medicaid Program

0

—

.-

3

0

0

co

.

—

c

(u
Appendix D-Survey Instrument ● 107

I

I

.

o

-i I

t
108 ● Children’s Dental Services Under the Medicaid Program

Figure D-37—lnformation About Survey’s Respondents, New York

Fema

No ● n

Sex

White/Not Hisp 8 3 %

Gen prac

White/Hlsp Orig. 1%

Amer Ind/AL Nat. 1%

Age

Yes 42%

48-65 22%

36-46 31 %

26-35 16%

No answer

Prostho. 1%

. . . . . . Pedodon. 2%

,..

Never

No 68%

No answer 11% Asian/Pac.Is. 4%

Race Specialty

No answer 1%

1%

Medicaid participation Past participation behavior

of nonparticipating dentists

KEY: Race: American lndian/Alasla Native; Asian/Pacific Islander; BIAdHispanic origin; Black/not Hispanic origin; White/Hispanic origin; White/not Hispanic

origin.

W* Endodontica; General practice; Oral surgery; Orthodontics; Pedodontics (Pediatric dentistry); Periodontics; Prosthodontica.

SOURCE: Office of T*nology Assessment, 1990.
Appendix D-Survey Instrument ● 109

Figure D-38-information About a Samplea of Respondents, New York

Female 6 8%

No ● newer 1 1%

93 93%

Whito/Not Hi sP 7

Others 60%

Sex Age

Gen prac

Amer lnd/AL Nat. 2%

Race

Sample

40%

56-65 19 %

46-55 19%

30-46 2 0 %

26-35 24 %

3%

Endodon. 3%

Specialty

ly

curre

28%

Treat come pts

31%

Survey respondents Treatment patterns of Medicaid

in the sample* patients by sample* dentists

nt pts

KEY: Race: Arnerkan lndiar@aa&aNatlvo; Adan/Padtic Islander; Black/Hispanic origin; Blacidnot Hispanic origin; White/Hispanic origin; White/not Hispanic

origin.

mm En&dontics: General practice; Oral surgery; Orthodontics; Pedodontics (Pediatric dentistry); Periodontics; Prosthodontics.

~esample containe those dentists responding to the survey vvho treat Medicaid patients and chiidren under age 18.

SOURCE: Otfice of Ttindogy Assessment, 1990.
110 ● Children’s Dental Services Under the Medicaid Program

0

u)

C

0

u) L c 0

n n

0

.-

.-

C U ,- c

, 0 L

Z

.- 0 m 0

m

0

0

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—

Q

. .

.
Appendix D-Survey Instrument ● 111

.-

c

Q

0
112 . Children’s Dental Services Under the Medicaid Program

—

E

.-

—

.

to

a ) *

.-

- .—
Survey Question 1 Survey Question 2

Selected services

Initial exam

Periodic exam

Counselling

Prophylaxis

Topical fluoride

Sealanta

Bitewing x-rays

Pulp therapy (prim.)

Pulp therapy (perM.)

Restoration (prim.)

Restoration (perm.)

Perio. scaling

Gingival curettage

Space maintenance

Prostheses

Orthodontia

Selected services

Initial exam

Periodic exam

Counseling

Prophylaxis

Topical fluoride

Sealants

Bitewing x-rays

Pulp therapy (prim.)

Pulp therapy (perm.)

Restoration (prim.)

Restoration (perm.)

Perio. scaling

Gingival curettage

Space maintenance

Prostheses

Orthodontia

Survey Question 3

Selected services

Initial exam

Periodic exam

Counseling

Prophylaxis

Topical fluoride

Sealants

Bitewing x-rays

Pulp therapy (prim.)

Pulp therapy (perm.)

Restoration (prim.)

Restoration (perm.)

Perio. scaling

Gingival curettage

Space maintenance

Prostheaea

Orthodontia

Selected services

Initial exam

Periodic exam

Counseling

Prophylaxis

Topical fluoride

Sealants

Bitewing x-rays

Pulp therapy (prim.)

Pulp therapy (Perm.)

Restoration (prim.)

Restoration (perm.)

Perio. scaling

Gingival curettage

Space maintenance

Proathesea

1

I

o 20 40 60 80 100 120 140

Percent sample responses, New York

Survey Question 4

o% 25% 50% 7 5 % 100 %

Percent sample respondents, New York

KEY: Race: American Indian/Alaska Native; AsiarVPacifii Islander; Blaclvliispanic origin; Black/not Hispanic origin; Whitd+spanic origin; Whitehot Hbpenic origin.

Sp- Endodontics; General practice; Oral surgery; Orthodontics; Pedodont~cs (Pediatric dentistry); periodontics; Prosthodontics,

SOURCE: Office of Technology &sessrnen~ 1990.
114 ● Children’s Dental Services Under the Medicaid Program

Figure D-41—information About Survey’s Respondents, Ohio

Female 6%

No ● newer 2%

Sex

92% 66-66 12%

48-66 24%

38-46 33%

26-36 24%

Age

White/Not Hisp 89%

Amer lnd/AL Nat 1%

no answer 6%

Yes 45%,

Race Specialty

64%

Never have 67%

.-------- -

Have in pat 4 3 %

No answer 1%

Medicaid participation Past participation behavior

of nonparticipating dentists

KEY: Race: American lndlan/Alaska Native; AsiarVPacMc lsiander; BlacWHispanic origin; Blacidnot Hispanic origin; White/Hispanic origin; White/not Hispanic

origin.

SPCJX Endodont~; Gener~ practica; Oral surgery; Orthodontics; Padodontica (Pediatric dentistry); Periodontics; Proethodontks.

SOURCE: Office of Technology Assessment, 1990.
Appendix D-Survey Instrument . 115

Figure D-42-information About a Samplea of Respondents, Ohio

Female

No ans

Sex

36-45 4

46-66 26%

Age

White Hisp Orig. 2%

Black/Not Hisp 6%

Amer lnd/A at. 2% l

No ● nswer 7%

Gen prac

White/Not Hisp 84%

Others

56%

8

Race

Treat ● ll

43%

Sample*

4 4 s

26%

2%

6 6%

Specialty

wer

Treat come pt.

33%

Survey respondents Treatment patterns of Medicaid

in the sample* patients by sample* dentists

only

only

KEY: Race: AmertcarI lndlan/Aiaska Nattve; AsiarVPadtlc Islander; BlackA+ispanic origin; Blacldnot Hispanic otigin; White/Hispank origin; whitdnot Hiep~k

origin.

Specf@c Endodcmtks; General practics; Oral surgery; Orthodontics; Pedodontks (Pediatric dentistry); Periodontks; Prosthodontke.

-O sample contains those dentists responding to the survey who treat Medkaid patients and children under ags 18.

SOURCE: Offke of Technology Assessment, 1990.
116 ● Children’s Dental Services Under the Medicaid Program

0 L

0

E

L 0

.-

L 0

.-

C

.- 0

0 .- 0 Q 0 L

0

0

0

*= b.titio
Ohio

Survey questions by Medicaid participation

Q1 yes

no

1

KEY: Race: American lndadAlaska Native; AsiarVPacific Islander; Black/Hispanic origin; BlacWnot Hispanic origin; WhiteMspanic origin; Whitehot Hispanic origin.

~-Emiodontics; General practti; Oral surgery; Orthodontics; Pedodontics (Pediatric dentistry); periodontics; Prost&tib.

SOURCE: Offb of Twhnobgy Asseasmen~ 1990.
118 . Children’s Dental Services Under the Medicaid Program

o

: —— .-

---

L

o

a)

—

c

u) 0

c

(/2 (d

● ✎✌

q
Appendix D-Survey Instrument . 119

I

.

I

0

04

o

t *

11111111111111111

N

0
120 . Children’s Dental Services Under the Medicaid Program

White

Figure D-45-Information About Survey Respondents, Texas

Female 7%

No ● nswer 4%

/Not Hisp 85%

Yes 26%

No ● nswer

Sex Age

30-46 30 %

26-36 23%

No answer 1%

Gen prac 79%

White/Hlep Orig 4%

No answer 6%

Black/Not Hisp 2%

Amer lnd/AL Nat 2% Pedodon. 5%

Oral surg. 2%

Race Specialty

No answer 3%

NO 72%

Never have 6

ave in pact 34%

Medicaid participation Past participation behavior

of nonparticipating dentists

KEY: Race: Arnetican lndierWUaake Native; AsiarVPaafic Islander; BlacidHispanic origin; Blacidnot Hispanic origin; White/Hispanic origin; White/not Hispanic

origin.

we Endodontics; Generai practice; Orei surgery; Orthodontics; Pedodontics (Pediatric dentistry); Periodontics; Prosthodontics.

SOURCE: Office of Technology Aeaesernent, 1990.
Appendix D-Survey Instrument . 121

Figure D-46-lnformation About a Sam plea of Respondents, Texas

26-36 23%

Sex Age

Others

74%

nt pts

Treat some

33%

Survey respondents Treatment patterns of Medicaid

in the sample* patients by sample* dentists

pts

KEY: RaIxx American Indian/Alaska Native; AsiarVPaafic Islander; BlacldHispanic origin; Blacldnot Hispanic origin; White/Hispanic origin; White/not Hispanic

origin.

Speda/t~ Endodontics; General practice; Oral surgery; Orthodontics; Pedodontks (Pediatric dentistry); Periodontics; Prosthodontics.

%re sample oontains those dentists responding to the survey who treat Medicaid patients and children under age 18.

SOURCE: Office of Technology Assessment, 1990.
122 ● Children’s Dental Services Under the Medicaid Program

c.9

L

0

3

L 4- C

0

z

w

U

.-

.

0 0

w

0 c w--

● -0 0

4 -

0

.- 0

4- c

u)

c

0

.- 0 .-

t- 0 ● m
Texas

Survey questions by Medicaid participation

Q1

Q2

Q3

Q4

Q5

Q6

Q7

Q8

Q9

Q10

Q11

yes

no

yes

no

yes

no

yes

no

yes

no

yes

no

yes

no

yes

no

yes

no

yes

no

yes

50% 75% 1 009(0

respondents, Texas

Good Fair

No answer or opinion

KEY: /?ace: American ln&n/AJ~~ N~ve; ~kw@dfic~,~oriain: BlacWnot -k origin; White/Hispank origin; White/not Hbpmk oriain.

spa. -ntics; General practb; C&al surgefy; CkthrxiMc8; Pedodo&s”(Pe<ric -);p~. ;P&t ho&ics.

SOURCE: Office d Tschnokgy~~ 1990.
124 ● Children’s Dental Services Under the Medicaid Program

o

C

g) .-

a)

0

<

0

in

c

CD
Appendix D--Survey Instrument ● 125

I

1-

-L I 1

u

I

I

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0