GAO 

United States Government Accountability Office

Report to Congressional Requesters

MEDICAID

State and Federal 

Actions Have Been 

Taken to Improve 

Children’s Access to 

Dental Services, but 

Gaps Remain 

September 2009 

GAO-09-723 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

September 2009

MEDICAID

State and Federal Actions Have Been Taken to 

Improve Children’s Access to Dental Services, but 

Highlights of GAO-09-723, a report to Gaps Remain 

congressional requesters 

Children’s access to Medicaid 

dental services is a long-standing 

concern. The tragic case of a 

12-year-old boy who died from an 

untreated infected tooth that led to 

a fatal brain infection renewed 

attention to this issue. He was 

enrolled in Medicaid—a joint 

federal and state program that 

provides health care coverage, 

including dental care, for 30 million 

low-income children—but, like 

many children in Medicaid, he 

experienced difficulty finding a 

dentist who would treat him. At the 

federal level, the Centers for 

Medicare & Medicaid Services 

(CMS), an agency within the 

Department of Health and Human 

Services (HHS), oversees Medicaid. 

In this report, GAO examined 

(1) state strategies to monitor and 

improve access to dental care for 

children in Medicaid and (2) CMS 

actions since 2007 to improve 

oversight of Medicaid dental 

services for children. GAO 

surveyed all state Medicaid 

programs and interviewed state 

and federal officials, and dental 

researchers and associations. 

What GAO Recommends

GAO recommends that CMS 

develop a plan to review dental 

services in states with low 

utilization rates, ensure that states 

found to have inadequate managed 

care provider networks strengthen 

their networks, develop additional 

guidance, and identify ways to 

improve sharing of promising 

practices among states. CMS 

generally concurred with GAO’s 

recommendations. 

State Medicaid programs reported that they use multiple strategies to monitor 

and improve access to dental services for children, but problems persist. Most 

states responding to our survey use a variety of tools, such as examining 

claims and utilization data, to monitor the provision of dental services to 

children in Medicaid. Although all 21 states that provide Medicaid dental 

services through managed care organizations (MCO) reported that they set 

measurable access standards for MCOs, 14 states reported that MCOs do not 

meet all of the state’s dental access standards. Almost all states described 

initiatives to improve access to dental services, including simplifying claims 

processing, increasing reimbursement rates, recruiting providers, and 

educating beneficiaries. Nonetheless, access rates remain low and states 

reported that long-standing barriers hinder further improvement. 

Number of States Reporting Barriers to Children Receiving Medicaid Dental Services and 

Barriers to Dental Providers Serving Medicaid Beneficiaries

Since May 2007, CMS has taken steps to strengthen its oversight of Medicaid 

dental services for children, but gaps remain. For example, CMS reviews of 

Medicaid dental services in 17 states identified a number of concerns and 

made recommendations for improvement. Nonetheless, at the time of our 

review CMS did not plan to perform more reviews, even though other states 

had utilization rates well below HHS’s 2010 target for low-income children 

receiving a preventive dental service. CMS also provided guidance to states 

and facilitated collaboration among stakeholders, but states reported needing 

more CMS support, including guidance on setting dental payment rates, on 

quality initiatives, and on promoting outreach. States also reported wanting 

more information on other states’ efforts to improve dental utilization.

View GAO-09-723 or key components.

For more information, contact Alicia Puente 

Cackley, (202) 512-7114, cackleya@gao.gov. 
Page i GAO-09-723 

Contents 

Letter 1

Background 4 

State Medicaid Programs Reported They Employ Multiple 

Strategies to Monitor and Improve Access to Medicaid Dental 

Services, but Problems Persist 8 

CMS Has Taken Action to Improve Federal Oversight of State 

Medicaid Dental Services for Children, but Gaps Remain 17 

Conclusions 23 

Recommendations for Executive Action 23 

Agency Comments 24 

Appendix I Methods Used by State Medicaid Programs to 

Monitor the Statewide Provision of Dental Care 

to Children 26 

Appendix II Statewide Utilization Goals for the Provision 

of Dental Care to Children in State Medicaid 

Programs 28 

Appendix III Access Standards Set by the 21 States That 

Provide Dental Services through Managed Care 

Organizations (MCOs) 30 

Appendix IV Extent to Which Managed Care Organizations 

(MCO) Meet State Standards and State 

Verification of MCO Networks 31 

Appendix V CMS Promising Practices and State Reported 

Best Practices 32 

 Medicaid Dental Services for Children 
Appendix VI Comments from the Department of Health and 

Human Services 35 

Appendix VII GAO Contact and Staff Acknowledgments 41 

Related GAO Products 42 

Tables 

Table 1: Number of State Medicaid Programs Employing Certain 

Methods to Monitor the Provision of Medicaid Dental 

Services to Children 9 

Table 2: Number of State Medicaid Programs Employing Certain 

Measures to Monitor Children’s Access to Dental Services, 

by Service Delivery Method 10 

Table 3: Number of State Medicaid Programs That Reported Setting 

Statewide Utilization Goals for the Provision of Dental 

Services to Children 11 

Table 4: MCO Access Standards Set by the 21 State Medicaid 

Programs That Provide Dental Services to Children under 

Managed Care 12 

Table 5: Outreach Actions Taken to Educate Families on the 

Importance of Dental Care, as Reported by State Medicaid 

Programs 14 

Table 6: Actions to Recruit Dental Providers since 2000, as 

Reported by State Medicaid Programs 15 

Table 7: Barriers That Hinder State Initiatives to Improve Access to 

Medicaid Dental Services, as Reported by State Medicaid 

Programs 16 

Table 8: Description of State-Reported Best Practices for 

Improving Dental Care for Children in Medicaid 33 

Page ii GAO-09-723 Medicaid Dental Services for Children
Figure 

Figure 1: Barriers to Children Seeking Medicaid Dental Services 

and Barriers to Dental Providers Serving Medicaid 

Beneficiaries, as Reported by State Medicaid Programs 17 

Abbreviations 

AAPD American Academy of Pediatric Dentistry 

CMS Centers for Medicare & Medicaid Services 

EPSDT Early and Periodic Screening, Diagnostic, and Treatment 

HHS Department of Health and Human Services 

MCO managed care organization 

NASMD National Association of State Medicaid Directors 

SCHIP State Children’s Health Insurance Program 

This is a work of the U.S. government and is not subject to copyright protection in the 

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Page iii GAO-09-723 Medicaid Dental Services for Children
Page 1 GAO-09-723 

 

United States Government Accountability Office

Washington, DC 20548 

 

September 30, 2009 

The Honorable Dennis Kucinich 

Chairman 

Subcommittee on Domestic Policy 

Committee on Oversight and Government Reform 

House of Representatives 

The Honorable Elijah Cummings 

House of Representatives 

Dental disease is a significant problem for children in Medicaid, a joint 

federal and state program that provides health care coverage, including 

dental care, for low-income children. Although dental services are a 

mandatory benefit for the 30 million children served by Medicaid,1

 these 

children often experience elevated levels of dental problems and have 

difficulty finding dentists to treat them. Attention to this subject became 

more acute after the widely publicized case of a 12-year-old boy who died 

in 2007 as a result of an untreated infected tooth, even though he was 

entitled to dental coverage under Medicaid. In testimony before the 

Subcommittee on Domestic Policy of the Committee on Oversight and 

Government Reform2

 last year, we reported that children in Medicaid were 

almost twice as likely to have untreated cavities as children with private 

insurance.3

 We also reported that the percentage of children in Medicaid 

ages 2 through 18 who received any dental care—37 percent according to 

national survey data—was far below the Department of Health and Human 

Services’ (HHS) target of having 66 percent of low-income children under 

age 19 receive a preventive dental service. 

Concerns about low-income children’s poor oral health and inadequate 

access to dental services, low payment rates for dental services, and 

1

Low-income children eligible under a state Medicaid plan generally are entitled to 

coverage of screening, diagnostic, and treatment services—including dental services—

under Medicaid’s early and periodic screening, diagnostic, and treatment (EPSDT) benefit. 

2

We refer to the Subcommittee on Domestic Policy, Committee on Oversight and 

Government Reform, House of Representatives, as the Subcommittee throughout this 

report. 

3

GAO, Medicaid: Extent of Dental Disease in Children Has Not Decreased, GAO-08-1176T 

(Washington, D.C.: Sept. 23, 2008). 

 Medicaid Dental Services for Children 
insufficient federal and state efforts to address oral health access 

problems are long-standing. Our reports dating back to 2000 highlight the 

problem of chronic dental disease and the factors that contribute to low 

use of dental services by low-income populations, including children in 

Medicaid.4

 A major concern has been the adequacy of the network of 

dental providers who serve low-income populations, particularly for 

children who receive Medicaid dental services under managed care. This 

concern stems in part from investigations by the Subcommittee that found 

that some managed care organizations (MCO) did not have adequate 

provider networks—that is, a sufficient number and mix of dental 

providers—to provide timely access to covered Medicaid dental services. 

In September 2000, we reported that while several factors contributed to 

the low use of dental services among low-income persons who had 

coverage, the major factor was difficulty finding dentists to treat them.5

During a Subcommittee hearing in May 2007, concerns were raised about 

federal oversight of state Medicaid dental services for children by the 

Centers for Medicare & Medicaid Services (CMS), the agency that oversees 

Medicaid at the federal level. 

You expressed concern about the state and federal actions taken to ensure 

children in Medicaid receive recommended dental services. This report 

examines (1) the strategies that state Medicaid programs employ to 

monitor and improve access to dental services for children in Medicaid 

and (2) CMS actions since 2007 to improve oversight of state Medicaid 

dental services for children. To identify state strategies to improve 

children’s access to Medicaid dental services, we conducted a Web-based 

survey of state Medicaid directors in all 50 states and the District of 

Columbia.6

 The survey included both closed-ended and open-ended 

questions regarding dental services for children, the methods states have 

used for promoting and monitoring dental utilization (the use of dental 

services), statewide goals for the delivery of dental services, and the 

federal support provided to states for the provision of dental services. To 

establish the reliability of our survey data, we consulted with 

knowledgeable state officials in developing the survey and pre-tested the 

 

4

A list of related GAO products can be found at the end of this report. 

5

GAO, Oral Health: Factors Contributing to Low Use of Dental Services by Low-Income 

Populations, GAO/HEHS-00-149 (Washington, D.C.: Sept. 11, 2000). 

6

We refer to the District of Columbia as a state and refer to the Medicaid director’s survey 

response as the state Medicaid program’s response or as the state’s response throughout 

this report. 

Page 2 GAO-09-723 Medicaid Dental Services for Children
survey questions with Medicaid officials from two states. The survey was 

conducted from December 8, 2008, through January 30, 2009. We received 

responses from all 50 states and the District of Columbia. We reviewed 

survey responses for internal consistency and in certain cases where 

responses were absent, unclear, or inconsistent, we contacted state 

officials for clarification. We did not independently verify specific aspects 

of responses or the effectiveness of programs reported through the survey. 

We determined that the data submitted by states were sufficiently reliable 

for the purposes of our engagement. In addition to the Web-based survey, 

we reviewed studies and reports on state Medicaid dental-related 

initiatives and conducted a review of current literature to obtain 

information on these initiatives and on barriers to providing dental care in 

Medicaid. To describe contractual provisions between states and MCOs 

concerning network adequacy and timely access standards related to 

dental services for children, we obtained and reviewed a non-generalizable 

sample of contracts from the MCOs that covered dental services and that 

served the most Medicaid beneficiaries in 9 states, including 5 states 

whose dental programs had been reviewed by CMS in 2008.7

To examine CMS’s oversight of state Medicaid dental services for children, 

we interviewed CMS officials; reviewed federal laws, regulations, and 

guidance that CMS provides to states; and interviewed key stakeholders, 

including the Medicaid/SCHIP Dental Association,8

 the National 

Association of State Medicaid Directors (NASMD), and experts involved 

with pediatric dental issues. We also reviewed data used by CMS to 

monitor provision of dental services to children in state Medicaid 

programs, including information in annual reports submitted by states on 

the provision of dental and other services provided under Medicaid’s early 

and periodic screening, diagnostic, and treatment (EPSDT) benefit. We 

also examined CMS’s reviews of Medicaid dental programs in 17 states. To 

obtain states’ perspectives of CMS oversight, we included several 

questions about CMS’s guidance and activities in our survey of state 

Medicaid programs. We conducted this performance audit from July 2008 

through August 2009 in accordance with generally accepted government 

 

7

We reviewed only those dental provisions that were specified in the contracts under 

sections titled network adequacy, covered services, access standards, or similar. We also 

searched each contract using key terms, such as network and access, to identify additional 

related provisions. 

8

The State Children’s Health Insurance Program (SCHIP) provides health care coverage to 

children in low-income families who are not eligible for traditional Medicaid programs. 

CMS now refers to SCHIP as the Children’s Health Insurance Program (CHIP). 

Page 3 GAO-09-723 Medicaid Dental Services for Children
auditing standards. Those standards require that we plan and perform the 

audit to obtain sufficient, appropriate evidence to provide a reasonable 

basis for our findings and conclusions based on our audit objectives. We 

believe that the evidence obtained provides a reasonable basis for our 

findings and conclusions based on our audit objectives. 

In 2000, the Surgeon General noted that tooth decay is the most common 

chronic disease among children.9

 Left untreated, the pain and infections 

caused by tooth decay can lead to problems in eating, speaking, and 

learning. Proper dental care can prevent tooth decay and associated 

problems that can lead to dental disease and even death. Research has 

shown that preventive dental care is cost effective and can make a 

significant difference in health outcomes. For example, a 2004 study found 

that, over a 5-year period, low-income children who had their first 

preventive dental visit by age 1 had average dental-related costs of $262, 

compared to $546 for children who received their first preventive visit at 

age 4 through 5.10

Background 

The American Academy of Pediatric Dentistry (AAPD) recommends that 

each child see a dentist when the child’s first tooth erupts and no later 

than the child’s first birthday, with subsequent visits occurring at 6-month 

intervals or more frequently if recommended by a dentist. The early initial 

visit establishes a “dental home” for the child, creating an opportunity to 

build an ongoing relationship with a dental provider who can ensure 

comprehensive, continuously accessible care. Comprehensive dental visits 

can include both clinical assessments, such as for tooth decay and the 

need for sealants,11 and appropriate discussion and counseling for oral 

hygiene, injury prevention, and speech and language development, among 

other topics. Because resistance to tooth decay is determined partly by 

genetics and partly by behavior, delaying the onset of tooth decay may 

also reduce long-term risk for decay. 

 

9

U.S. Department of Health and Human Services, National Institute of Dental and 

Craniofacial Research, National Institutes of Health, Oral Health in America: A Report of 

the Surgeon General (Rockville, Md.: 2000). 

10Matthew F. Savage, Jessica Y. Lee, Jonathan B. Kotch, and William F. Vann Jr., “Early 

Preventive Dental Visits: Effects on Subsequent Utilization and Costs,” Pediatrics, 114 

(2004). 

11Dental sealants, a plastic material put on the chewing surfaces of back teeth, have been 

shown to prevent decay on tooth surfaces where food and bacteria can build up. AAPD 

recommends sealants for 6-year and 12-year molars as soon as possible after eruption. 

Page 4 GAO-09-723 Medicaid Dental Services for Children
Recognizing the importance of good oral health, HHS in 1990 established 

oral health goals as part of its Healthy People 2000 initiative; and in 2000 

updated these oral health goals for 2010. These include goals related to 

oral health in children, for example, reducing the proportion of children 

with untreated tooth decay. Another goal relates to the Medicaid 

population: to increase the proportion of low-income children and 

adolescents under the age of 19 who receive any preventive dental service 

each year to 66 percent in 2010.12

At the federal level, CMS oversees Medicaid, which provides health care 

coverage for low-income families and aged, blind, and disabled people. 

CMS oversight includes monitoring state Medicaid programs, issuing 

guidance to states, and facilitating communication and collaboration 

among stakeholders. Medicaid provided health coverage for over 

30 million children under 21 in fiscal year 2008.13 The states operate their 

Medicaid programs within broad federal requirements and may contract 

with MCOs to provide Medicaid benefits. CMS estimated that in 2006 about 

65 percent of Medicaid beneficiaries received benefits through some form 

of managed care.14 State Medicaid programs are required to cover certain 

populations and services under federal law. For instance, under the 

Medicaid EPSDT benefit, state Medicaid programs generally must provide 

coverage of dental screening, diagnostic, and related treatment services 

for all eligible Medicaid beneficiaries under the age of 21. Other federal 

requirements for the EPSDT benefit that are related to dental services 

include the following: 

 

12The Healthy People 2010 goal was increased from 57 percent when it was first established 

in 2000 to 66 percent during a mid-course review in the mid-2000s. The goal defines 

preventive dental care to include examination, x-ray, fluoride treatment, cleaning, or 

sealant application. See U.S. Department of Health and Human Services, Public Health 

Service, Progress Review: Oral Health (Feb. 7, 2008). 

13The 30 million children represent the 2008 unduplicated annual enrollment (the total 

number of children, each child counted once, who were enrolled in Medicaid at any point 

in federal fiscal year 2008) reported by CMS. See http://www.cms.hhs.gov/CapMarket 

Updates/02_CMSStatistics.asp#TopOfPage (accessed May 18, 2009). 

14CMS’s statistics include the Medicaid population enrolled in capitated plans (typically 

defined as plans that contract with states to receive a prepaid payment per enrollee for 

coverage of Medicaid services) and primary care case management models. 

Page 5 GAO-09-723 Medicaid Dental Services for Children
• Developing dental periodicity schedules. State Medicaid programs 

have some flexibility in determining the frequency and timing of dental 

screenings covered for children under the EPSDT benefit. Under federal 

law, however, state Medicaid programs must provide these dental services 

at intervals that meet reasonable standards of dental practice as 

determined by the state after consultation with recognized dental 

organizations involved in children’s health care.15 According to CMS 

guidance, as an alternative to developing a state-specific periodicity 

schedule, a state may adopt a nationally recognized dental periodicity 

standard, such as the schedule recommended by AAPD. CMS considers 

AAPD’s periodicity schedule a model for comparison and it is published in 

CMS’s Guide to Children’s Dental Care in Medicaid.

16

• Reporting on delivery of EPSDT services. Federal law requires states 

to report annually on the provision of EPSDT services, including dental 

services.17 The annual EPSDT participation report, Form CMS-416 

(hereafter called the CMS 416), is the agency’s primary tool for gathering 

data on the provision of dental services to children in state Medicaid 

programs. It captures data on the number of children who received a 

preventive dental service, a dental treatment service, or any dental service 

each year. Information on the CMS 416 report is used to calculate a state’s 

dental utilization rate—the percentage of children eligible for EPSDT that 

received any dental service in a given year. 

Inadequate access to dental services for low-income children has been a 

longstanding concern. In April 2000, we reported that Medicaid 

beneficiaries and other low-income people had low rates of dental visits 

and high rates of dental disease relative to the rest of the population.18 In a 

 

15Dental services must also be provided as medically necessary to identify a suspected 

illness or condition and must include, at a minimum, relief of pain and infections, 

restoration of teeth, and maintenance of dental health. 42 U.S.C. § 1396d(r)(3). 

16CMS, Guide to Children’s Dental Care in Medicaid (Washington, D.C.: October 2004). 

Under contract with CMS, AAPD developed the guide as a resource for states on clinical 

practice, evolving technologies, and recommendations in dental care. 

17State Medicaid programs must annually report to the Secretary of HHS information on 

EPSDT services, including the number of children provided EPSDT screenings, the number 

of children referred for corrective treatment as a result of the screenings, the number of 

children receiving dental services, and the states’ results in meeting annual goals for 

children’s receipt of EPSDT services established by HHS. 42 U.S.C. § 1396a(a)(43). 

18GAO, Oral Health: Dental Disease Is a Chronic Problem among Low-Income 

Populations, GAO/HEHS-00-72 (Washington, D.C.: Apr. 12, 2000). 

Page 6 GAO-09-723 Medicaid Dental Services for Children
September 2000 report, we identified factors influencing the access that 

low-income groups have to dental care: a primary factor was limited 

dentist participation in Medicaid.19 As part of its oversight of state 

Medicaid dental services for children, in January 2001 CMS issued a letter 

to state Medicaid directors indicating that, through a series of state 

reviews, CMS would increase its oversight activities and assess state 

compliance with statutory requirements. CMS highlighted four areas for 

review: outreach and administrative case management, adequacy of 

Medicaid reimbursement rates, increasing provider participation, and 

claims reporting and processing. CMS did not complete this initiative. In 

September 2008, we reported that the extent of dental disease in Medicaidenrolled children had not decreased between 1988 through 1994 and 1999 

through 2004.20 We also reported that millions of Medicaid-enrolled 

children were estimated to have untreated tooth decay, and that children 

in Medicaid were often not receiving dental services. 

The American Recovery and Reinvestment Act of 2009 (Recovery Act) 

authorized an estimated $87 billion in additional federal Medicaid funding 

for states in the form of a temporary increase in the funds that the federal 

government contributes toward state Medicaid programs, including the 

provision of Medicaid dental services for children. The Recovery Act 

provides this money to states through a temporary, 27-month increase in 

the federal medical assistance percentage formula—the formula that 

determines the federal share of a state’s Medicaid service expenditures.21

In July 2009, we reported that the receipt of an increased federal share 

may reduce the states’ share of expenditures for their Medicaid program, 

and states have reported using these available funds for a variety of 

 

19GAO/HEHS-00-149. 

20Although dental disease in the overall Medicaid population aged 2 through 18 did not 

decrease, the trends vary somewhat among different age groups. Younger children—those 

aged 2 through 5—had statistically significant higher rates of dental disease in the more 

recent time period examined as compared to earlier surveys. By contrast, data for 

adolescents—children in Medicaid aged 16 through 18—show declining rates of tooth 

decay, although the change was not statistically significant. GAO, Medicaid: Extent of 

Dental Disease in Children Has Not Decreased, and Millions Are Estimated to Have 

Untreated Tooth Decay, GAO-08-1121 (Washington, D.C.: Sept. 23, 2008). 

21See Pub. L. No. 111-5, div. B, tit. V § 5001, 123 Stat. 115, 496 (Feb. 17, 2009) (codified at 

42 U.S.C. § 1396d note). 

Page 7 GAO-09-723 Medicaid Dental Services for Children
purposes, such as maintaining program eligibility, covering increased 

Medicaid caseloads, and maintaining local health care reform initiatives.22

In response to our survey, most states reported using multiple strategies to 

monitor and improve access to Medicaid dental services, but they also 

reported that persistent barriers hinder improvements. All 21 states that 

provided Medicaid dental services under managed care arrangements 

reported that they set measurable access standards for MCOs, however 

more than half also reported that MCOs in their state do not meet any, or 

only meet some, of the state’s dental access standards. Further, some 

states reported that they do not routinely verify the adequacy of MCO 

provider networks. Almost all states described initiatives to recruit dental 

providers and enhance outreach to beneficiaries’ families, but barriers 

persist and access rates remain low. 

State Medicaid 

Programs Reported 

They Employ Multiple 

Strategies to Monitor 

and Improve Access 

to Medicaid Dental 

Services, but 

Problems Persist 

State Medicaid Programs 

Reported They Use a 

Variety of Methods to 

Monitor Dental Services 

In response to our survey, all 51 states reported that they monitor the 

provision of dental care to Medicaid-enrolled children, but how they do so 

varies. The majority (39 states) reported that they use multiple methods—

often three or more—to monitor the provision of dental care. These 

methods included surveys of oral health, monitoring dental claims, and 

collecting utilization data (see table 1). See appendix I for a list of the 

monitoring methods reported by each state. 

 

22GAO, Recovery Act: States’ and Localities’ Current and Planned Uses of Funds While 

Facing Fiscal Stresses, GAO-09-829 (Washington, D.C.: July 8, 2009). 

Page 8 GAO-09-723 Medicaid Dental Services for Children
Table 1: Number of State Medicaid Programs Employing Certain Methods to Monitor the Provision of Medicaid Dental 

Services to Children 

Monitoring method 

Number of states

(51 states)

Track utilization by collecting CMS 416 data 50

Use claims data and/or encounter data provided by MCOs 23

Collect and analyze data from phone calls to the state or MCOs regarding concerns with dental care 16

Collect and analyze data from beneficiary satisfaction surveys 16

Use survey data to monitor problems obtaining needed dental services 11

Use survey data to monitor oral health of children 7

Other monitoring methodsa19

Source: GAO (Survey of state Medicaid directors conducted between December 2008 and January 2009). 

Note: States could select more than one monitoring method and may be counted in more than one 

category. 

a

States reported using other methods to monitor the provision of Medicaid dental services, including 

generating ad hoc reports on various dental procedures and analyzing monthly budget reports by 

procedure code to monitor utilization trends. 

States also reported using various measures to monitor children’s access 

to Medicaid dental services. The most common reported measure—used 

by 40 (of 51) states for their fee-for-service programs and by 18 (of 21) 

states that also used managed care23—was the percentage of children who 

had a dental visit in the previous year (see table 2). In the 21 states where 

both fee-for-service and managed care programs are used to provide 

dental services to Medicaid-enrolled children, state monitoring can vary by 

service delivery method. For example, one state reported that it monitors 

the percentage of dentists who treat children through its managed care 

program, but does not monitor the percentage of dentists who treat 

children through its fee-for-service program. Conversely, another state 

reported the opposite—that it monitors this percentage for its fee-forservice program, but not for managed care. 

 

23Twenty-one of the 51 state Medicaid programs reported using both managed care and feefor-service to deliver dental services to Medicaid beneficiaries in their state. For our 

survey, we defined managed care as arrangements where the state pays an MCO a 

capitated (per member per month) payment and the MCO uses this payment to provide 

care. We defined dental care organizations as managed care organizations that provide only 

dental benefits. 

Page 9 GAO-09-723 Medicaid Dental Services for Children
Table 2: Number of State Medicaid Programs Employing Certain Measures to Monitor Children’s Access to Dental Services, 

by Service Delivery Method 

Measure 

Fee-for-service

(51 states)

Managed care

(21 states)a

The percentage of children who had a dental visit in the previous year 40 18

The percentage of dentists who treat children in Medicaid 36 14

The extent to which provision of dental services is concentrated among a small number 

of providers 27 7

The percentage of children who did not visit a dentist in the last three years 12 5

Other analyses of claims data, utilization data, or both 19 8

Other monitoring efforts 6 4

Source: GAO (Survey of state Medicaid directors conducted between December 2008 and January 2009). 

Note: States could select more than one monitoring measure and may be counted in more than one 

category. 

a

Twenty-one of the 51 state Medicaid programs reported using both managed care and fee-forservice to deliver dental services to Medicaid beneficiaries in their state. 

States reported setting statewide dental utilization goals related to the 

provision of children’s dental services. In response to our survey, 42 states 

reported that they have set at least one statewide utilization goal related to 

the provision of children’s dental care in Medicaid and about half of these 

42 states (20 states) have set three or more statewide goals (see table 3). 

Nine states reported they had no goals related to children’s dental care. 

See appendix II for a list of the utilization goals reported by each state. 

Page 10 GAO-09-723 Medicaid Dental Services for Children
Table 3: Number of State Medicaid Programs That Reported Setting Statewide Utilization Goals for the Provision of Dental 

Services to Children 

Statewide dental utilization goal 

Number of states

(51 states)

The percentage of children receiving any dental care in a given time period exceeds a certain threshold 31

The percentage of children receiving dental preventive services, such as sealants, exceeds a certain threshold 25

The ratio of participating dental providers to Medicaid children (provider to beneficiary ratio) exceeds a certain 

threshold 17

The percentage of children receiving restorative procedures for oral health problems, such as tooth decay, 

exceeds a certain threshold 14

The percentage of children who report difficulty finding dental care falls below a certain threshold 11

Other state goalsa16

Total number of states that set at least one statewide utilization goal 42

Source: GAO (Survey of state Medicaid directors conducted between December 2008 and January 2009). 

Note: States could select more than one statewide dental utilization goal and may be counted in more 

than one category. 

a

States reported other goals, including a target percent of children who are continually enrolled in 

Medicaid and receive appropriate follow-up care, and increasing levels of provider participation. 

All States with Managed 

Care Programs Reported 

They Set Measurable MCO 

Access Standards and 

about Half Routinely 

Verified Provider 

Networks 

All of the 21 states that reported using managed care programs to deliver 

Medicaid dental services reported that they had established one or more 

measurable MCO access standards specific to each MCO dental network, 

such as specifying maximum waiting times for scheduling appointments 

or a minimum ratio of available providers to Medicaid beneficiaries (see 

table 4). However, more than half—14 of the 21 states—reported that the 

MCOs either did not meet any, or only met some, of their standards. 

Seventeen states reported that they used incentives or penalties to 

encourage the MCOs to meet or exceed state standards. However, 

potential incentives or penalties did not always produce the desired result. 

For example, one state reported MCOs had not met any of the established 

standards even though MCOs could be paid a bonus if they met some or all 

of the standards. Similarly, other states reported that only some standards 

were being met, despite potential financial penalties if MCOs did not meet 

all of the state’s standards. 

Page 11 GAO-09-723 Medicaid Dental Services for Children
Table 4: MCO Access Standards Set by the 21 State Medicaid Programs That Provide Dental Services to Children under 

Managed Care 

Dental access standards specific to MCO provider networks 

States using MCOs 

(21 states) 

Maximum waiting times when scheduling dental appointments 17

Maximum waiting times when scheduling emergency dental appointments 16

Maximum travel distances from beneficiaries’ residences to the dental provider’s office 15

Maximum travel times from beneficiaries’ residences to the dental provider’s office 11

Minimum provider to patient ratios (minimum number of dental providers for a given enrollment) 6

Other state standardsa 10

Total number of states that established one or more MCO dental access standard 21

Source: GAO (Survey of state Medicaid directors conducted between December 2008 and January 2009). 

Note: States could select more than one MCO access standard and may be counted in more than 

one category. 

a

States reported other standards, such as identifying and managing beneficiaries who use emergency 

room facilities to obtain dental services. 

State oversight of MCO provider networks varied. Approximately half of 

the states using managed care—12 of 21 states—reported contacting a 

selection of providers in their MCO provider networks on a regular basis 

to determine if they accept new Medicaid patients. Eighteen states using 

managed care reported that they examined the adequacy of their dental 

networks in response to a complaint or concern.24 Two of the 21 states 

using managed care did not report taking any action to verify MCO 

provider networks in their state. See appendix III for a list of MCO 

standards set by states and appendix IV for a description of the extent to 

which MCOs meet state standards and the methods states use to verify 

that MCO dental providers accept children in Medicaid. 

State Medicaid agencies also set expectations for MCOs related to 

provider networks and access to services through the contracts they 

establish with the MCOs. We reported in 2001 that specific and 

comprehensive contract language helps ensure that MCOs know their 

responsibilities and that they can be held accountable for delivering 

covered services.25 Our review of contracts between states and nine large 

 

24Five of the 18 states reported that examining MCO networks in response to a complaint or 

concern was their only method to verify MCO networks, 13 states do so in combination 

with other verification methods. 

25GAO, Medicaid: Stronger Efforts Needed to Ensure Children’s Access to Health 

Screening Services, GAO-01-749 (Washington, D.C.: July 13, 2001). 

Page 12 GAO-09-723 Medicaid Dental Services for Children
MCOs that provide Medicaid dental services illustrate variations in the 

specificity of the standards that states established in their contracts 

concerning network adequacy and access measures. Regarding one 

measure of network adequacy—the maximum number of beneficiaries per 

dental provider—some, but not all, contracts specified a maximum 

allowed number of Medicaid enrollees per dental provider. One contract, 

for example, specified a county-level maximum of 486 enrollees per dental 

provider, while other contracts did not specify any maximum. Standards 

related to timely access also varied; for example, one contract required 

that routine dental appointments be scheduled within 30 calendar days, or 

sooner if possible, while another contract required that routine dental 

appointments be scheduled within 90 days of a formal request. Finally, the 

specificity of the contracts with regard to standards for the proximity of 

dental providers to beneficiaries varied. One contract, for example, 

specified a maximum travel time of 30 minutes to a provider, while 

another contract had no proximity standards. 

State Medicaid Programs 

Reported Efforts to 

Improve Access, but Also 

Reported That Persistent 

Barriers Hinder Further 

Improvement in Children’s 

Access to Dental Care 

Many of the 51 states we surveyed reported efforts to improve children’s 

access to dental care, including efforts to provide outreach to the families 

of children in Medicaid and recruit dental providers. Forty-eight states 

reported that they have taken one or more actions to facilitate or 

encourage parents to take their children to a dentist, including publishing 

literature about the importance of oral health and establishing a hotline 

that families can call for help in finding a dentist (see table 5). Studies in 

the published literature have reported some successes in outreach 

programs. One such study reported on a state program where dental 

hygienist services provided in three schools resulted in an increase in the 

percentage of children who had seen a dentist at least once a year from 

59 percent to 78 percent in the first year of the program.26

 

26Christina Melvin, “A Collaborative Community-based Oral Care Program for School-age 

Children,” Clinical Nurse Specialist, vol. 20, no. 1 (2006): 18-22. 

Page 13 GAO-09-723 Medicaid Dental Services for Children
Table 5: Outreach Actions Taken to Educate Families on the Importance of Dental Care, as Reported by State Medicaid 

Programs 

State actions to provide outreach to families 

States responding

(51 states)

Issued literature to Medicaid families discussing the importance of oral health 39

Established a hotline that families in Medicaid can call for help in finding a dental provider 35

Translated literature about the importance of oral health into other languages 29

Distributed an up-to-date list of dental providers who accept children in Medicaid 24

Required MCOs to assist families in finding a dental provider for their children 20

Launched a Web site for Medicaid families providing information about oral health care 18

Required MCOs to provide literature to their beneficiaries about the importance of oral health 18

Provided incentives to Medicaid families to bring their children to dental providers 5

Paid for advertisements aimed at Medicaid families that promote the importance of oral health 5

Other state actionsa 17

Total number of states that have taken one or more outreach action 48

Source: GAO (Survey of state Medicaid directors conducted between December 2008 and January 2009). 

Note: States could select more than one action to provide outreach to families and may be counted in 

more than one category. 

a

States reported other actions, such as outreach to families with children who have not received a 

dental service in the past year and free dental screening programs. 

All but one of the 51 state Medicaid programs reported they have taken 

at least one action since 2000 to recruit Medicaid dental providers (see 

table 6), and some states provided evidence that their initiatives have 

enhanced their Medicaid dental provider networks. For example, one state 

Medicaid program implemented an initiative that included simplifying 

claims processing, increasing reimbursement rates, educating and 

recruiting providers, and educating beneficiaries. According to a study of 

this program published in the Journal of Rural Health, from fiscal year 

1999 to 2002, this state Medicaid program saw a 39 percent increase in the 

number of dentists accepting Medicaid and a 57 percent increase in the 

number of Medicaid-enrolled children receiving dental services after 

implementing this initiative.27

 

27Mary Greene-McIntyre, Mary Hayes Finch, and John Searcy, “Smile Alabama! Initiative: 

Interim Results from a Program To Increase Children’s Access to Dental Care,” Journal of 

Rural Health, vol. 19 suppl. (2003): 407-15. 

Page 14 GAO-09-723 Medicaid Dental Services for Children
Table 6: Actions to Recruit Dental Providers since 2000, as Reported by State Medicaid Programs 

State actions to recruit dental providers 

States responding

(51 states)

Met with dental provider groups to encourage them to see more children in Medicaid 45

Increased dental fee-for-service reimbursement rates 44

Streamlined fee-for-service claims processing 36

Reduced or eliminated administrative burdens, such as prior authorization requirements 35

Action by other state agencies, such as providing scholarships, loan repayment, or other funding to dental 

providers for serving low-income communities 34

Encouraged non-dental providers, such as pediatricians, to provide basic oral health care 31

Sent literature to dental providers to encourage them to see more children in Medicaid 21

Increased funding to clinics serving Medicaid children for hiring more dental providers 14

Increased dental managed care capitation payments to MCOs 11

Paid for advertisements aimed at dental providers to encourage them to see more children in Medicaid 5

Invested in health information technology that allows rural dental providers to consult with dentists in other 

areas on high risk cases 2

Other actions taken by the state Medicaid agencya 22

Total number of states that have taken one or more actions to recruit dental providers 50

Source: GAO (Survey of state Medicaid directors conducted between December 2008 and January 2009). 

Note: States could select more than one action to recruit dental providers and may be counted in 

more than one category. 

a

States reported other actions by the state Medicaid agency, including investing in telemedicine, 

producing a guide of program procedure codes with descriptions of services and prior authorization 

requirements, and introducing eligibility verification systems with free online access. 

Although nearly all states reported that since 2000 they have undertaken 

initiatives to improve children’s access to dental care, CMS 416 data on 

children’s access to dental care show that access rates remain low, and 

states report facing the same barriers they faced in 2000. CMS 416 data 

show dental utilization rates have improved since 2000, from a national 

average of 27 percent to 35 percent in 2007—but in 2007 only 1 state 

reported a dental utilization rate above 50 percent and 12 states’ utilization 

rates remained below 30 percent. Less than half of the states that reported 

undertaking initiatives to improve children’s access to dental care (21 

states) reported that all their initiatives met their expectations. Nearly all 

(48 of 51 states) reported that the principal barriers that contributed to the 

low use of dental services by Medicaid beneficiaries in 2000—including 

low provider participation rates, administrative burdens, and insufficient 

funding—continue to impede their current efforts. Apart from funding 

concerns, states most often reported that a lack of provider and 

beneficiary participation hindered their efforts to improve access to 

Medicaid dental services in their state (see table 7). Twenty-six states 

Page 15 GAO-09-723 Medicaid Dental Services for Children
reported these and other barriers resulted in one or more of their 

improvement initiatives not being implemented or their expectations not 

being met. 

Table 7: Barriers That Hinder State Initiatives to Improve Access to Medicaid Dental 

Services, as Reported by State Medicaid Programs 

Barriers to state initiatives 

States responding

(51 states)

Lack of available funding 44

Lack of provider participation 40

Lack of beneficiary participation 38

Administrative burden on providers 31

Difficulty coordinating with other state agencies 13

Lack of CMS approval for state initiatives 5

Other barriersa6

Source: GAO (Survey of state Medicaid directors conducted between December 2008 and January 2009). 

Note: States could select more than one barrier and may be counted in more than one category. 

a

States reported other barriers, including staffing shortages that limit the agencies’ ability to take on 

additional projects and cultural competency barriers, such as translating oral health information into 

other languages. 

When asked to describe the extent to which state goals were being met, 

some states reported that successes in increasing the numbers of 

providers enrolled in the Medicaid program have resulted in increasing 

rates of utilization by children, but that more needs to be done to increase 

the percentage of children receiving dental services beyond current levels. 

States also described other challenges to meeting their goals and 

improving children’s access to dental care, such as fluctuations in 

eligibility for services, lack of beneficiary compliance, low oral health 

awareness among beneficiaries, and a lack of demand for routine dental 

care by beneficiaries. 

In addition to barriers that hinder state initiatives, states report that access 

rates could also be affected by two other types of barriers: those faced by 

children seeking dental services and those faced by providers serving 

Medicaid beneficiaries. For children seeking dental services, most states 

reported that finding a provider that accepts Medicaid is a moderate or 

major barrier. Comparatively fewer states reported that obtaining 

transportation to and from the provider’s office or the ability of parents to 

take time off work are moderate or major barriers for children seeking 

dental care. For providers, most states also reported that beneficiaries not 

showing up for appointments and a limited capacity to accept new 

Page 16 GAO-09-723 Medicaid Dental Services for Children
patients (reported by 45 and 30 states, respectively) are moderate to major 

barriers. One state noted that these issues are particularly significant when 

they are combined together, at which point they can become moderate to 

major barriers for dental providers. See figure 1 for barriers faced by 

children and providers. 

Figure 1: Barriers to Children Seeking Medicaid Dental Services and Barriers to Dental Providers Serving Medicaid 

Beneficiaries, as Reported by State Medicaid Programs 

Responding to congressional concern about CMS oversight of state 

Medicaid dental services, CMS has taken a number of actions since May 

2007 to strengthen its oversight of Medicaid dental services for children, 

but gaps remain in the agency’s efforts. 

CMS Has Taken 

Source: GAO (Survey of state Medicaid directors conducted between December 2008 and January 2009).

To what extent do you believe the following are barriers

to dental providers beginning to serve or serving more

Medicaid beneficiaries?

Low reimbursement rates......................................................................

Administrative requirements..................................................................

Limited capacity to accept new patients................................................

Beneficiary does not show up for appointments....................................

Beneficiary does not follow treatment plan as advised by the provider....

Other barriers.........................................................................................

28 17 6

Major/moderate barrierMinor barrierNot a barrier

30 13 8

45 6 0

30 20 1

36 9 6

14 2 8

To what extent do you believe the following are ba

To what extent do you believe the following are barriers to 

children receiving Medicaid dental services in your state?

Finding a dental provider that accepts Medicaid................................ ...

Transportation to and from the dental provider’s office..........................

Distance between the dental provider’s office and the family’s home....

Parents are unable to take time off work...............................................

Other barriers........................................................................................

43 6 2

Major/moderate barrierMinor barrierNot a barrier

25 16 10

34 14 3

27 22 2

23 1 7

Action to Improve 

Federal Oversight of 

State Medicaid Dental 

Services for Children, 

but Gaps Remain 

Page 17 GAO-09-723 Medicaid Dental Services for Children
In February 2008 and September 2008 Subcommittee hearings, CMS 

officials described several initiatives under way by CMS to improve 

monitoring of state programs and to provide guidance and facilitate 

collaboration. At the time of our review, some of these initiatives had been 

completed, while others were still under way. CMS initiatives include the 

following: 

CMS Has Taken Steps 

toward Improving 

Oversight of State 

Medicaid Dental Services 

for Children 

• Focused dental reviews in 17 states. Between October 2007 and May 

2008, CMS conducted a series of focused dental reviews in 17 states.28 The 

reviews were designed to examine state efforts to improve children’s 

dental utilization rates, assess state compliance with federal Medicaid 

statutes and regulations, and identify promising or notable state practices 

to improve the delivery of oral health services. In January 2009, CMS 

published a summary report of its findings and recommendations in 16 

states (in February 2008, CMS had published a separate report on 

Maryland).29 CMS had concerns that 11 of the 17 states were not adhering 

to federal law or regulation, including multiple findings in some states. For 

example, CMS found that 6 states had inadequate dental networks in 

MCOs that provided Medicaid dental services, 2 states had not ensured 

that all medically necessary dental services were provided, and 1 state had 

inappropriately limited reimbursement for out-of-state emergency dental 

services, leaving the remainder of the costs to the beneficiaries.30 CMS also 

 

28Fifteen of the 17 states reviewed had reported dental utilization rates below 30 percent in 

fiscal year 2006: Arkansas, California, Delaware, District of Columbia, Florida, Louisiana, 

Michigan, Missouri, Montana, Nevada, New Jersey, New York, North Dakota, Pennsylvania, 

and Wisconsin. In addition, Maryland was reviewed in October 2007 and Georgia was 

reviewed in May 2008 at the request of the Subcommittee. 

29CMS, 2008 National Dental Summary, (January 2009) and Final Report on Maryland’s 

Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Program With a 

Focus on Dental Services for Children (Feb. 5, 2008). 

30CMS regional offices noted deficiencies for some states with respect to certain Medicaid 

requirements such as: (i) states must ensure, through their contracts, that MCOs maintain 

and monitor a network of appropriate providers that is supported by written agreements 

and is sufficient to provide adequate access to covered services (see 42 C.F.R. 

438.206(b)(1)); (ii) states must ensure that all covered services are available and accessible 

to MCO enrollees (see 42 C.F.R. § 438.206(a)); and (iii) Medicaid beneficiaries cannot be 

charged cost-sharing for EPSDT or emergency services (see 42 C.F.R. 447.53(b)). 

Page 18 GAO-09-723 Medicaid Dental Services for Children
made recommendations to all 17 states it reviewed and identified several 

promising practices, which it highlighted in its summary report.31

• Improved collection of CMS 416 reports. In June 2007, CMS began an 

initiative to improve reporting by states that had not submitted timely or 

reliable dental utilization data in their annual CMS 416 reports. CMS sent 

formal requests to 22 states that had failed to submit complete CMS 416 

reports for one or more years. CMS also contacted the states and provided 

technical assistance on problems with data collection methodology. As of 

March 2009, all 51 states had submitted their 2007 CMS 416 reports to 

CMS. CMS 416 reports for 2008 were due to CMS in April 2009, however, 

as of early June 2009, only 42 states had submitted their 2008 reports. 

• Review of state periodicity schedules. In 2008, CMS examined dentalrelated periodicity schedules from all states. CMS found that all but three 

states reported having some type of periodicity schedule, but not all 

schedules were in compliance with CMS requirements. For example, some 

schedules indicated when a primary care provider should refer a child to a 

dentist, but the schedule did not specify how often dental services should 

occur. CMS also found that periodicity schedules in several states were 

not readily accessible by providers or beneficiaries. For states that had not 

submitted separate dental periodicity schedules as required by CMS, CMS 

recommended that the states adopt AAPD’s periodicity schedule for 

children. 

• Publication of a dental policy document. CMS posted a 16-page 

document on Medicaid dental policy issues on its Web site in September 

2008. This document covered a variety of questions from states on topics 

including periodicity schedules, dental referral requirements, covered 

services, and patient cost sharing.32 For example, one question asked if the 

state could allow providers to bill patients for missed appointments. CMS 

responded that Medicaid policy did not permit such billing, in part because 

 

31Provider reimbursement rates were not a specific part of CMS’s focused dental reviews, 

even though some providers and others interviewed by CMS noted that low payment rates 

contributed to low provider participation in Medicaid. A CMS official indicated that the 

issue of low reimbursement rates would likely be part of ongoing discussions involving 

Medicaid dental topics such as delivery systems and administrative issues, but would not 

be the focus of its oversight efforts. The official reported that the agency plans to continue 

working with states and the American Dental Association on reimbursement issues. 

32HHS, Centers for Medicare & Medicaid Services, Policy Issues in the Delivery of Dental 

Services to Medicaid Children and Their Families (Sept. 22, 2008); 

http://www.cms.hhs.gov/medicaiddentalcoverage/ (accessed Oct. 6, 2008). 

Page 19 GAO-09-723 Medicaid Dental Services for Children
no service was delivered. Further, missed appointments are not a distinct, 

reimbursable Medicaid service, but are instead considered part of a 

provider’s overall cost of doing business. 

• Communications with states and stakeholders. From 2007 through 

2009, CMS held several meetings and conference calls with state dental 

representatives, provider associations, and other stakeholders to discuss 

issues concerning Medicaid dental services for children. For example, 

CMS presented information on Medicaid dental issues at the April 2008 

National Oral Health Conference sponsored by the American Association 

of Public Health Dentistry and the Association of State and Territorial 

Dental Directors. Other groups involved in CMS partnership activities 

included AAPD, the American Dental Association, and the Association of 

Community Affiliated Plans. 

• Establishment of an Oral Health Technical Advisory Group. In 

conjunction with NASMD, CMS established an Oral Health Technical 

Advisory Group to address issues related to oral health services, including 

access and quality. A NASMD member chairs the advisory group and, as of 

January 2009, other members included CMS representatives, state 

representatives from different regions of the country, and other NASMD 

staff. Advisory group projects include examining the effects on oral health 

programs of recent legislation, such as the Recovery Act and the 

Children’s Health Insurance Program Reauthorization Act of 2009, 

considering improvements to the CMS 416 annual reports, and improving 

materials used to inform beneficiaries of their Medicaid dental benefits. 

• Sharing of promising state practices related to dental services. CMS 

posted “promising practices”—described by CMS as successful state 

programs that reflect innovative approaches to meeting common 

problems—on its Web site.33 As of May 2009, CMS had posted promising 

practices from 4 states related to Medicaid dental services: 

Delaware increased reimbursement, reduced administrative burden on 

providers, and increased provider outreach. 

South Carolina increased reimbursement rates, reduced administrative 

barriers, and began an outreach campaign to encourage dentists to 

participate in Medicaid. 

 

33See http://www.cms.hhs.gov/MedicaidCHIPQualPrac/MCPPDL/list.asp (accessed May 20, 

2009). 

Page 20 GAO-09-723 Medicaid Dental Services for Children
Tennessee increased reimbursement, separated (or “carved out”) the 

dental benefit from Medicaid managed care contracts, and hired a 

contractor to administer the dental benefit. 

Virginia increased reimbursement, carved out the dental benefit from 

Medicaid managed care contracts, and adopted incentives to increase 

provider participation, such as establishment of a dedicated call center, 

new billing options and quicker payment, streamlined prior authorization 

for care, and simplified provider credentialing. 

Gaps Remain in CMS 

Efforts to Monitor 

Provision of Dental 

Services to Children in 

Medicaid, Provide 

Guidance, and Facilitate 

Collaboration among 

States 

Although CMS has taken a number of important steps, gaps in CMS 

oversight point to opportunities for further action to improve access to 

dental services for children in Medicaid. Remaining gaps in CMS oversight 

include the following: 

• CMS does not have plans to conduct focused dental reviews in 

additional states. CMS’s focused dental reviews targeted 15 states with 

the lowest dental utilization rates, but 2006 CMS 416 reports showed that 

in 24 additional states (including Georgia and Maryland) in that year, 

between 31 and 40 percent of eligible children received any dental 

service—well below HHS’s Healthy People 2010 goal of having 66 percent 

of low-income children under age 19 receive a preventive dental service. 

According to CMS officials, CMS, at the time or our review, did not plan to 

conduct focused dental reviews in these states, potentially missing an 

opportunity to identify important areas for improvement.34 When asked 

what additional assistance CMS could provide, 6 states responding to our 

survey reported that they believed that an independent review of dental 

services would be helpful to their Medicaid programs. 

• CMS did not require corrective action in states found to have 

inadequate MCO networks. CMS’s focused dental reviews identified 8 

states that provided dental services through managed care that did not 

ensure that MCO provider networks were adequate to afford access to 

covered dental services. In 6 states, CMS presented its concerns as a 

“finding,” that is, a concern that the state is not adhering to federal law or 

regulation. In the remaining 2 states, CMS cited deficiencies in MCO 

provider networks, but did not report its concerns as findings. CMS made 

recommendations to strengthen MCO provider networks in all 8 states; 

 

34In commenting on a draft of this report, CMS indicated that it would consider additional 

focused dental reviews as part of a broader planning effort to review all EPSDT services. 

Page 21 GAO-09-723 Medicaid Dental Services for Children
however, CMS did not require these states to take corrective action—

rather, agency officials indicated they would follow up with states on the 

status of CMS’s recommendations. 

• CMS 416 reports provide limited information on dental service 

utilization. The CMS 416 report only gathers data on the number of 

children who received a preventive dental service, a dental treatment 

service, or any dental service. We have reported in the past that these data 

are limited in their usefulness for oversight of Medicaid dental services for 

children.35 For example, because dental services delivered to managed 

care enrollees are not reported separately from services to fee-for-service 

enrollees, the CMS 416 data does not provide information that could be 

used to flag problems with a specific service delivery method. Further, it is 

not possible to determine how many children in a state received all of the 

recommended dental services included in the state’s periodicity schedule. 

According to the CMS Deputy Administrator, the Oral Health Technical 

Advisory Group has a project under way to consider improvements to the 

CMS 416. 

• States report that additional guidance from CMS is needed. In 

response to our survey, 2 states reported that CMS’s September 2008 

policy paper on Medicaid dental issues was helpful, but nearly all states 

(49 of 51) reported that additional CMS guidance could help them improve 

delivery of Medicaid dental services. States cited a need for additional 

information in several areas: for example, guidance on standards for 

dental care, information on billing policies, better definitions for outreach 

and transportation services in Medicaid programs, establishing 

appropriate dental fee schedules, improving documentation and coding 

practices, and information on quality and preventive initiatives. 

• CMS has posted relatively few promising practices on its Web site. 

When asked what CMS assistance would be helpful to their state Medicaid 

program, the most common answer (other than increasing the federal 

medical assistance percentage), cited by 37 states, was information on 

other states’ efforts to improve dental utilization. Although CMS maintains 

a Web site to publicize promising state Medicaid dental practices, 11 states 

reported that they were unaware of the promising practices posted on 

CMS’s Web site. The 4 promising practices posted as of May 2009 are just a 

few of the practices that could be shared with other states. For example, 

during its focused dental reviews, CMS identified 17 additional promising 

 

35GAO, Medicaid: Concerns Remain about Sufficiency of Data for Oversight of Children’s 

Dental Services, GAO-07-826T (Washington, D.C.: May 2, 2007). 

Page 22 GAO-09-723 Medicaid Dental Services for Children
and notable practices, none of which were included on the CMS promising 

practice Web site. Further, 26 states responding to our survey reported 

that their states had “best practices” that could be shared with other 

states, such as providing mobile dental vans, training and reimbursing 

physicians to do oral screens and apply fluoride varnish, and establishing a 

dental home for children (see app. V for brief descriptions of these 

practices). 

CMS has begun several initiatives to strengthen its oversight of state 

Medicaid dental services for children, but information on the oral health of 

and receipt of dental services by Medicaid children show that much more 

needs to be done. Although many states have reported moderate increases 

in access to Medicaid dental services, we reported in September 2008 that 

the extent of dental disease in children had not decreased and that 

millions of children were estimated to have untreated tooth decay. States 

responding to our survey reported that a lack of available funding, low 

provider participation, and administrative burdens—many of the same 

factors that contributed to the low use of dental services in 2000—still 

present barriers to access today. Through a series of focused reviews of 

states’ efforts to provide dental services to children in Medicaid, CMS has 

identified deficiencies in several state Medicaid programs. Although CMS 

made recommendations for improvement to the states, it required no 

corrective actions. Moreover, not all states with low rates of children’s 

dental utilization have been reviewed, nor are such reviews planned. 

These reviews have not only identified problem areas, but have also 

helped identify information on promising state dental practices that could 

be useful to other states seeking to improve their own programs. Finally, 

for Medicaid-enrolled children who receive dental services through 

managed care programs, CMS has found that certain states have not 

ensured that MCOs have adequate provider networks to provide covered 

dental services to their enrollees. Although CMS and states have taken 

steps to address long-standing barriers, continued attention and action is 

needed to ensure children’s access to Medicaid dental services. 

To strengthen monitoring of state Medicaid dental services for children 

and help states improve children’s access to Medicaid dental services, we 

are recommending that the Administrator of CMS take the following four 

actions: 

Conclusions 

Recommendations for 

Executive Action 

Page 23 GAO-09-723 Medicaid Dental Services for Children
• Develop a plan to review dental services for Medicaid children in all states 

with low utilization rates, such as those not meeting HHS’s Healthy People 

2010 targets. 

• Ensure that states found to have inadequate MCO dental provider 

networks take action to strengthen these networks. 

• Work with stakeholders to develop needed guidance on topics of concern 

to states. 

• Identify ways to improve sharing of promising practices among states. 

We provided a draft of this report for comment to HHS. Responding for 

HHS, CMS provided written comments. In summary, CMS concurred with 

three of our recommendations—specifically, to ensure that states found to 

have inadequate MCO provider networks take corrective action, to 

develop additional guidance on topics of concern to states, and to improve 

sharing of promising practices among states and other stakeholders. CMS 

described several initiatives planned or under way that would strengthen 

its oversight of state Medicaid dental services for children. CMS concurred 

in part with our fourth recommendation, to develop a plan to review 

Medicaid dental services in states with low utilization rates. In following 

up with CMS, an official clarified that CMS agreed with the need to review 

Medicaid dental services in these states but wanted this plan to be part of 

the agency’s broader plan to review all EPSDT services. As part of this 

broader plan, CMS would consider additional focused dental reviews as 

well as comprehensive EPSDT service reviews.36 We believe that CMS’s 

action will meet the intent of our recommendation. CMS also noted that 

the Children’s Health Insurance Program Reauthorization Act of 2009 

included a number of provisions related to dental services that the agency 

was in the process of implementing, including requirements for states to 

post a listing of participating Medicaid and CHIP dental providers on 

HHS’s www.insurekidsnow.gov Web site, to publish new quality measures 

for Medicaid and CHIP children, and to report additional information on 

Agency Comments 

 

36In July 2009, CMS reported that it was developing a comprehensive workplan that 

included establishing a regular schedule for reviewing state EPSDT policy and 

implementation efforts. See Medicaid Preventive Services: Concerted Efforts Needed to 

Ensure Beneficiaries Receive Services, GAO-09-578 (Washington, D.C.: August 14, 2009). 

Page 24 GAO-09-723 Medicaid Dental Services for Children
children receiving dental care under Medicaid.37 Finally, CMS provided one 

technical comment, which we incorporated into the report. CMS’s letter is 

reprinted in appendix VI. 

As agreed with your offices, unless you publicly announce the contents of 

this report earlier, we plan no further distribution until 30 days from the 

report date. At that time, we will send copies of this report to the Secretary 

of HHS and other interested parties. 

In addition, the report will be available at no charge on GAO’s Web site at 

http://www.gao.gov. If you or your staffs have any questions about this 

report, please contact me at (202) 512-7114 or cackleya@gao.gov. Contact 

points for our Offices of Congressional Relations and Public Affairs may 

be found on the last page of this report. GAO staff that made major 

Alicia Puente Cackley 

contributions to this report are listed in appendix VII. 

 

Director, Health Care 

37The Children’s Health Insurance Program Reauthorization Act of 2009 also mandates that 

GAO conduct a study on certain dental workforce and other Medicaid and CHIP dental 

issues and submit a report to Congress by August 2010. See Pub. L. No. 111-3, § 501(h), 123 

Stat. 8, 88 (Feb. 4, 2009). 

Page 25 GAO-09-723 Medicaid Dental Services for Children
Appendix I: Methods Used by State Medicaid 

Programs to Monitor the Statewide Provision 

of Dental Care to Children 

State 

CMS 416 

data 

Claims and/or 

encounter data 

from MCOs 

Phone calls to 

state and/or 

MCOs on 

concerns 

Beneficiary 

satisfaction 

surveys 

Survey for 

problems 

obtaining 

services 

Survey to 

monitor oral 

health of 

children 

Other 

methodsa

Alaska ● ○ ○ ○ ○ ○ ●

Ala. ● ○ ○ ○ ○ ○ ●

Ark. ● ○ ○ ● ○ ○ ●

Ariz. ● ● ○ ● ● ○ ●

Calif. ● ● ○ ○ ○ ○ ○

Colo. ● ● ○ ○ ○ ○ ●

Conn. ● ● ○ ○ ○ ○ ○

D.C. ● ● ● ● ● ● ○

Del. ● ○ ○ ○ ○ ○ ●

Fla. ● ○ ○ ○ ○ ○ ○

Ga. ● ● ● ● ● ○ ○

Hawaii ● ○ ○ ○ ○ ○ ○

Iowa ● ○ ● ● ○ ○ ○

Idaho ● ○ ○ ○ ○ ○ ○

Ill. ● ○ ○ ● ● ○ ●

Ind. ● ○ ○ ○ ○ ○ ○

Kans. ● ○ ● ○ ○ ○ ○

Ky. ● ○ ○ ○ ○ ○ ○

La. ● ● ○ ○ ○ ○ ●

Mass. ● ● ● ● ● ○ ○

Md. ● ● ● ● ● ● ●

Maine ● ○ ○ ○ ○ ○ ○

Mich. ● ● ○ ○ ○ ○ ○

Minn. ● ○ ● ○ ○ ○ ○

Mo. ● ○ ○ ○ ○ ○ ○

Miss. ● ○ ○ ○ ○ ○ ●

Mont. ● ● ○ ○ ○ ○ ○

N.C. ● ● ○ ● ○ ○ ○

N.Dak. ● ○ ○ ○ ○ ○ ●

Nebr. ● ○ ○ ○ ○ ○ ○

N.H. ● ○ ● ○ ● ○ ●

N.J. ● ● ○ ● ○ ○ ○

N.Mex. ● ● ● ○ ○ ○ ○

Appendix I: Methods Used by State Medicaid 

Programs to Monitor the Statewide Provision 

of Dental Care to Children 

Page 26 GAO-09-723 Medicaid Dental Services for Children 
Appendix I: Methods Used by State Medicaid 

Programs to Monitor the Statewide Provision 

of Dental Care to Children 

State 

CMS 416 

data 

Claims and/or 

encounter data 

from MCOs 

Phone calls to 

state and/or 

MCOs on 

concerns 

Beneficiary 

satisfaction 

surveys 

Survey for 

problems 

obtaining 

services 

Survey to 

monitor oral 

health of 

children 

Other 

methodsa

Nev. ● ● ○ ● ○ ○ ○

N.Y. ● ● ● ○ ○ ○ ○

Ohio ● ● ● ● ● ● ○

Okla. ● ○ ○ ○ ○ ○ ○

Ore. ● ● ● ○ ○ ○ ●

Pa. ● ● ● ● ● ● ○

R.I. ● ● ● ● ● ○ ○

S.C. ● ○ ○ ○ ● ● ●

S.Dak. ○ ○ ○ ○ ○ ○ ●

Tenn. ● ● ○ ● ○ ○ ○

Tex. ● ○ ○ ○ ○ ● ○

Utah ● ● ○ ○ ○ ○ ○

Va. ● ○ ● ● ○ ○ ●

Vt. ● ○ ○ ○ ○ ○ ○

Wash. ● ○ ○ ○ ○ ○ ●

Wis. ● ● ● ○ ○ ● ●

W.Va. ● ○ ○ ○ ○ ○ ○

Wyo. ● ○ ○ ○ ○ ○ ●

Source: GAO (Survey of state Medicaid directors conducted between December 2008 and January 2009). 

● State did have this method of monitoring children’s dental care.

○ State did not have this method of monitoring children’s dental care. 

a

States reported using other methods to monitor the provision of Medicaid dental services, including 

generating ad hoc reports on various dental procedures and analyzing monthly budget reports by 

procedure code to monitor utilization trends. 

Page 27 GAO-09-723 Medicaid Dental Services for Children
Appendix II: Statewide Utilization Goals for 

the Provision of Dental Care to Children in 

State Medicaid Programs 

State 

Percentage of 

children who 

receive any dental 

care in a given 

time period is to 

exceed a certain 

threshold 

Percentage of 

children who 

received dental 

preventive 

services is to 

exceed a certain 

threshold 

Ratio of 

participating 

dental providers in 

Medicaid exceeds 

a certain threshold

Percentage of 

children who 

received 

restorative 

procedures for 

oral health 

problems exceeds 

a certain threshold

Percentage of 

children who 

report difficulty 

finding dental 

care is to fall 

below a certain 

threshold 

Other state 

goalsa

Alaskab ○ ○ ○ ○ ○ ○

Ala. ● ● ○ ○ ○ ○

Ark. ● ○ ● ● ○ ○

Ariz. ● ○ ○ ○ ○ ●

Calif. ○ ○ ○ ○ ○ ●

Colo. ● ● ○ ○ ○ ●

Conn. ● ● ● ● ○ ●

D.C. ● ● ○ ● ● ○

Del. ● ○ ● ○ ● ○

Fla. ○ ● ● ○ ● ○

Ga. ● ● ● ● ● ○

Hawaii ● ○ ● ○ ○ ○

Iowa ● ● ○ ● ○ ○

Idaho ○ ● ● ○ ● ○

Ill. ● ● ○ ○ ○ ○

Ind.b○ ○ ○ ○ ○ ○

Kans. ○ ○ ○ ○ ○ ●

Ky.b○ ○ ○ ○ ○ ○

La. ○ ○ ● ○ ○ ○

Mass. ● ● ● ○ ● ●

Md. ● ● ● ● ○ ●

Maine ● ● ○ ○ ○ ○

Mich. ● ● ○ ● ○ ○

Minn.b○ ○ ○ ○ ○ ○

Mo.b ○ ○ ○ ○ ○ ○

Miss.b○ ○ ○ ○ ○ ○

Mont. ● ○ ○ ○ ○ ○

N.C. ● ● ● ○ ○ ●

N.Dak. ● ● ● ● ● ○

Nebr.b○ ○ ○ ○ ○ ○

Appendix II: Statewide Utilization Goals for 

the Provision of Dental Care to Children in 

State Medicaid Programs 

Page 28 GAO-09-723 Medicaid Dental Services for Children 
Appendix II: Statewide Utilization Goals for 

the Provision of Dental Care to Children in 

State Medicaid Programs 

State 

Percentage of 

children who 

receive any dental 

care in a given 

time period is to 

exceed a certain 

threshold 

Percentage of 

children who 

received dental 

preventive 

services is to 

exceed a certain 

threshold 

Ratio of 

participating 

dental providers in 

Medicaid exceeds 

a certain threshold

Percentage of 

children who 

received 

restorative 

procedures for 

oral health 

problems exceeds 

a certain threshold

Percentage of 

children who 

report difficulty 

finding dental 

care is to fall 

below a certain 

threshold 

Other state 

goalsa

N.H. ● ● ○ ● ● ●

N.J. ● ● ● ● ○ ○

N.Mex. ● ● ● ● ● ○

Nev. ○ ○ ○ ○ ○ ●

N.Y. ● ○ ○ ○ ○ ○

Ohio ● ○ ○ ○ ○ ●

Okla. ● ● ● ● ○ ●

Ore. ○ ○ ○ ○ ○ ●

Pa. ● ● ○ ○ ○ ○

R.I. ○ ○ ○ ○ ○ ●

S.C. ● ○ ○ ○ ● ○

S.Dak. ● ● ○ ○ ○ ○

Tenn. ● ○ ● ○ ○ ○

Tex. ○ ● ○ ○ ○ ○

Utah ○ ● ○ ● ○ ○

Va. ● ○ ○ ○ ○ ●

Vt.b○ ○ ○ ○ ○ ○

Wash. ○ ○ ○ ○ ○ ●

Wis. ● ● ● ○ ○ ○

W.Va.b○ ○ ○ ○ ○ ○

Wyo. ● ● ○ ● ● ○

Source: GAO (Survey of state Medicaid directors conducted between December 2008 and January 2009). 

● State did have this access goal for children’s dental care. 

○ State did not have this access goal for children’s dental care. 

a

States reported other goals, including the percentage of children who are continually enrolled and 

receive appropriate follow-up or increasing levels of provider participation. 

b

These states reported they do not have goals related to the provision of dental care for children in 

state Medicaid programs. 

Page 29 GAO-09-723 Medicaid Dental Services for Children
Appendix III: Access Standards Set by the 21 

States That Provide Dental Services through Appendix III: Access Standards Set by the 21 Managed Care Organizations (MCOs) 

States That Provide Dental Services through 

Managed Care Organizations (MCOs) 

Access Standards States Set For MCOs 

State 

Percentage 

of children 

who should 

receive a 

dental visit 

Minimum 

payment 

rates for 

dental 

services 

Beneficiary 

satisfaction 

scores or 

ratings 

Minimum 

provider 

to 

patient 

ratios 

Maximum 

travel 

times 

Maximum 

travel 

distances

Maximum 

waiting times 

when 

scheduling 

dental 

appointments 

Maximum 

waiting times 

when 

scheduling 

emergency 

dental 

appointments

Other 

standardsa

Ariz. ● ○ ○ ○ ○ ○ ● ● ●

Calif. ○ ● ● ● ● ● ● ● ●

D.C. ● ● ○ ○ ● ● ● ● ○

Fla. ● ○ ○ ● ● ● ● ● ○

Ga. ● ○ ○ ○ ● ● ● ○ ●

Idaho ○ ● ○ ○ ○ ● ○ ○ ○

Ky. ○ ● ● ○ ● ● ○ ○ ○

Md. ● ● ● ● ● ● ● ● ○

Mich. ○ ○ ○ ○ ○ ○ ● ● ○

Minn. ○ ○ ○ ○ ● ● ● ● ●

Mo. ○ ○ ○ ○ ○ ● ● ● ●

N.J. ● ○ ● ● ● ● ● ● ●

N.Mex. ○ ○ ○ ○ ○ ○ ● ● ○

Nev. ● ○ ○ ● ○ ○ ● ● ○

N.Y. ● ○ ○ ● ● ● ● ● ○

Ohio ● ○ ● ○ ○ ● ○ ○ ●

Ore. ○ ○ ○ ○ ● ● ○ ○ ●

Pa. ● ○ ● ○ ● ○ ● ● ○

R.I. ● ● ○ ○ ○ ● ● ● ●

Tex. ○ ○ ○ ○ ○ ● ● ● ●

Wis. ● ○ ○ ○ ○ ○ ● ● ○

Source: GAO (Survey of state Medicaid directors conducted between December 2008 and January 2009). 

● State did have this standard for MCO networks in their state. 

○ State did not have this standard for MCO networks in their state. 

a

States reported other standards, such as identifying and managing beneficiaries who use emergency 

room facilities to obtain dental services. 

Page 30 GAO-09-723 Medicaid Dental Services for Children 
Appendix IV: Extent to Which Managed Care 

Organizations (MCO) Meet State Standards Appendix IV: Extent to Which Managed Care and State Verification of MCO Networks 

Organizations (MCO) Meet State Standards 

and State Verification of MCO Networks 

Extent to which MCOs meet established 

standards 

Method used to verify that dental providers are accepting 

children in Medicaid 

State Meet all Meet some Meet none 

Routinely contact a 

selection of 

providers to 

determine if they 

accept new Medicaid 

patients 

Examine networks in 

responses to 

complaints or other 

concerns on an ad 

hoc basis Other verificationa

Ariz. D ○ ● ●

Calif. D ● ● ●

D.C. D ● ● ○

Fla. D ● ○ ○

Ga. D ● ● ○

Idaho D ○ ● ○

Ky. D ○ ○ ○

Md. D ● ● ○

Mich. D ○ ○ ○

Minn. D ○ ● ○

Mo. D ○ ● ○

N.J. D ○ ● ●

N.Mex. D ● ● ○

Nev. D ● ● ○

N.Y. D ● ● ○

Ohio D ● ● ○

Ore. D ○ ● ○

Pa. D ● ● ○

R.I. D ● ● ○

Tex. D ● ● ○

Wis. D ○ ● ○

Source: GAO (Survey of state Medicaid directors conducted between December 2008 and January 2009). 

D Degree to which MCOs meet standards. 

● State did report using this method to verify MCO provider networks. 

○ State did not report using this method to verify MCO provider networks. 

a

States reported using other methods to verify MCO networks, including monthly spot checks, 

monitoring provider registration, and requiring annual network development plans. 

Page 31 GAO-09-723 Medicaid Dental Services for Children
Appendix V: CMS Promising Practices and Appendix V: CMS Promising Practices and State Reported Best Practices 

State Reported Best Practices 

To promote information sharing and collaboration among states, the 

Centers for Medicare & Medicaid Services (CMS) has created a Web site in 

which it publishes notable “Promising Practices” related to Medicaid and 

the State Children’s Health Insurance Program (SCHIP). Dental care is one 

of the subject areas covered on this Web site. To nominate a promising 

practice, a state must complete an application describing the underlying 

problem, the approach taken, and the results obtained. A promising 

practice is defined by CMS as an approach to meeting a challenge related 

to Medicaid/SCHIP program operations, clinical practice, or functional 

level that serves to enhance quality of care and/or life and may be of 

interest to other states. Specifically, the practice must: 

• Be related to the improvement of quality of care and/or life for Medicaid 

and/or SCHIP beneficiaries. 

• Address a significant problem in health status or functioning based on 

trends in mortality, morbidity, quality of life, utilization, and/or costs. 

• Reflect an innovative approach to meeting a common problem. 

• Have been in operation for a sufficient period of time to demonstrate 

effectiveness (e.g., minimum 12 months). 

• Have demonstrated success through tangible results (e.g., improvements 

in beneficiary physical or mental well-being, savings). 

• Comply with federal Medicaid statute and regulations and CMS policy 

direction. 

As of May 2009, there were five dental practices listed on CMS’s 

“Promising Practices” Web site, four of which pertained to Medicaid.1

Each of the 4 states cited as having promising practices also indicated on

our survey of state Medicaid programs that they consider their state to 

have a dental best practice. 

 

In addition to these 4 states, 22 states responding to our survey reported 

that they had best practices that could be shared with other states. See 

table 12 for brief descriptions of all 26 state-reported best practices. 

1

The additional promising practice was related to dental benefits under the SCHIP 

program. 

Page 32 GAO-09-723 Medicaid Dental Services for Children
Appendix V: CMS Promising Practices and 

State Reported Best Practices 

Table 8: Description of State-Reported Best Practices for Improving Dental Care for Children in Medicaid 

State State-reported best practice 

Ala. The “Smile Alabama!” initiative encompassed administrative reforms, implemented a case management system, 

increased outreach to patients and dentists, and set reimbursement rates equal to rates paid by commercial insurers. 

Ark. The state contracted with an organization to assist with outreach, scheduling, reminders, and transportation for Medicaid 

beneficiaries needing dental care. 

Ariz. The Oral Health Performance Improvement Project assists health plans identify gaps in quality-improvement strategies 

and address those areas. Examples include collaboration with programs such as Head Start and using health plan staff 

or dental providers to make presentations in schools or at community health fairs. 

Conn. The state established dental healthcare specialists who interact with the community to stress the importance of a dental 

home and regular dental care. Specialists interact with dentists to ensure families and children make their 6-month 

checkups, and act as a point of contact for the dentists. Specialists also provide oral health counseling and assistance, 

such as obtaining transportation and addressing language barriers. The state also created a member outreach 

handbook, including information on office etiquette and making appointments. 

Del.* The state reimburses providers at 85 percent of usual and customary rates, which has encouraged dentists to participate 

in the state Medicaid program. 

Fla. The state provides coverage of fluoride varnish applications by non-dentists. 

Ga. A managed care organization implemented a program that transferred a significant percentage of patients receiving 

intravenous sedation from outpatient hospital settings to dental offices. 

Iowa As part of the I Smile Dental Home Plan, Oral Health Care Coordinators, who are dental hygienists employed by the 

Department of Public Health, work with counties to strengthen the public health dental system, link with local boards of 

health, provide training and oversight of health agency staff, and coordinate services for children ages 12 and under. 

Ill. The state implemented several initiatives; (1) the Dental Champions Program, a peer-to-peer provider 

recruitment/retention effort to enroll providers, particularly in underserved areas, and to encourage increased 

participation among enrolled providers; (2) dental administrators and Early and Periodic Screening, Diagnostic, and 

Treatment (EPSDT) program outreach; (3) dental grants to build infrastructure in the public delivery system; and 

(4) fluoride varnish application in pediatric practices to promote a focus on oral health and appropriate referrals. 

Mich. In its Healthy Kids Dental Program, the state contracted with one dental insurer so that all beneficiaries have access to

the insurer’s dental network. Beneficiaries carry the insurer’s card, so they are treated the same as other employersponsored subscribers. 

N.C. The state described two initiatives: (1) The Physician Fluoride Varnish Program, known as Into the Mouth of Babes, in 

which Medicaid recipients ages 6-42 months receive oral health services from participating primary care physicians; and 

(2) Carolina Dental Home Program, which is a pilot project that seeks to identify high-risk preschool Medicaid recipients 

and facilitates care coordination and referrals to general and pediatric dentists. 

N.H. The Statewide Sealant Project is a school based program in which volunteer dentists and dental hygienists provide 

examinations and sealant applications. Other initiatives include raising dental rates, promoting access through 

partnership building, reducing administrative burdens, hiring a dental director, educating primary care physicians and 

caregivers, working to reduce broken appointments, and establishing a liaison between the state Medicaid program and 

Medicaid providers. 

N.J. The state reported three dental initiatives: (1) the Pediatric Oral Health Forum and Committee, which developed and is 

implementing the Pediatric Oral Health Action Plan; (2) a Collaborative to Improve Birth Outcomes and Health Status of 

Children, which facilitates coordination of care between medical providers and dentists; and (3) the New Jersey Smiles 

initiative, which aims to increase the percentage of children up to age 6 who have a dental home and who receive annual 

dental visits. 

N.Mex. The state created a special needs code, a reimbursement strategy that allows for dental practitioners to be eligible for an 

encounter fee of $90 (in addition to other billable services) when providing dental care to a person with developmental 

disabilities, if the practitioner has been through the program training and has become certified. 

Page 33 GAO-09-723 Medicaid Dental Services for Children
Appendix V: CMS Promising Practices and 

State Reported Best Practices 

State State-reported best practice 

Nev. The Pay for Performance Program provides bonuses to health plans based on high performance and plan improvement, 

and has been incorporated into managed care contracts. 

Ohio The state reported two initiatives; (1) reimbursement of physicians for application of fluoride varnish for children from first 

tooth eruption to age 3; and (2) use of mobile dental vans to improve access in underserved areas. 

Okla. The state has implemented a student loan repayment program for dentists who agree to practice in identified areas and 

have at least 30 percent of their practice composed of Medicaid beneficiaries. 

Ore. The Early Childhood Cavities Prevention Program trains general medical practitioners to perform oral screenings and 

apply fluoride. 

Pa. The state described two initiatives: (1) the Dental Disease Management Program, which encourages dental practices to 

provide comprehensive preventive, routine, and follow-up dental care; and (2) a requirement that providers notify the 

Department’s Intensive Care Management Unit or Access Plus contractor when a child is referred to a dentist in order to 

be reimbursed. Follow up is made to confirm that the recommended visit has occurred. For children in MCOs, the 

provider must notify the MCO that the child is due for a dental referral as part of a complete EPSDT screen. 

R.I. The Dental Benefits Manager Program is charged (among other things) with increasing reimbursement rates, ensuring 

there are sufficient dentists participating in the network, and assisting beneficiaries with finding dentists, securing 

transportation, and providing interpretation services. 

S.C.* The state increased fees to the 75th percentile of private-sector reimbursement rates and reduced administrative barriers

for providers. The South Carolina Dental Association began an outreach campaign to encourage dentists to participate in 

Medicaid. 

S.Dak. The Accessing Better Children’s Dentistry is an initiative in which certified dentists receive an enhanced reimbursement

for certain procedures. 

Tenn.* The state carved out the dental benefit in a Medicaid managed care environment and selected a benefit manager to 

administer dental benefits and establish reasonable provider reimbursement rates. Other activities include gathering 

input through a dental advisory committee, recruiting community-based dentists, and additional education and outreach. 

Tex. The First Dental Home initiative expands preventive dental services to children 6 through 35 months of age by providing 

risk assessments, anticipatory guidance, and more frequent dental checkup visits, based on the child’s risk of developing 

caries. 

Va.* The Smiles for Children Program includes an increase in dental fees, streamlined administration, and the reduction of 

prior authorization requirements. The program also includes a Broken Appointment initiative, which tracks broken 

appointments and provides assistance, such as transportation, to help families keep their appointments. 

Wash. The Access to Baby and Child Dentistry program focuses on providing dental benefits to children up to age 5 by 

conducting outreach to organizations in which Medicaid-eligible children receive services, identifying and enrolling 

children in the program, educating families and caregivers, and matching each child with a program-certified dentist. 

Source: GAO (Survey of state Medicaid directors conducted between December 2008 and January 2009). 

* Posted on CMS’s Web site as a promising practice as of May 2009. 

Page 34 GAO-09-723 Medicaid Dental Services for Children
Appendix VI: Comments from the Department Appendix VI: Comments from the of Health and Human Services 

Department of Health and Human Services 

Page 35 GAO-09-723 Medicaid Dental Services for Children 
Appendix VI: Comments from the Department 

of Health and Human Services 

Page 36 GAO-09-723 Medicaid Dental Services for Children
Appendix VI: Comments from the Department 

of Health and Human Services 

Page 37 GAO-09-723 Medicaid Dental Services for Children
Appendix VI: Comments from the Department 

of Health and Human Services 

Page 38 GAO-09-723 Medicaid Dental Services for Children
Appendix VI: Comments from the Department 

of Health and Human Services 

Page 39 GAO-09-723 Medicaid Dental Services for Children
Appendix VI: Comments from the Department 

of Health and Human Services 

Page 40 GAO-09-723 Medicaid Dental Services for Children
Appendix VII: 

A

GAO Contact and Staff 

cknowledgments 

Page 41 GAO-09-723 

Appendix VII: GAO Contact and Staff 

Acknowledgments 

Alicia Puente Cackley, (202) 512-7114 or cackleya@gao.gov 

In addition to the contact named above, Katherine Iritani, Acting Director; 

Susannah Bloch; Sarah Burton; Martha Kelly; Ba Lin; Sarah Marshall; Terry 

Saiki; Jessica Cobert Smith; Teresa Tam; and Hemi Tewarson made key 

contributions to this report. 

GAO Contact 

Staff 

Acknowledgments 

 Medicaid Dental Services for Children 
Related GAO Products Related GAO Products 

Medicaid: Extent of Dental Disease in Children Has Not Decreased, and 

Millions Are Estimated to Have Untreated Tooth Decay. GAO-08-1121. 

Washington, D.C.: September 23, 2008. 

Medicaid: Extent of Dental Disease in Children Has Not Decreased. 

GAO-08-1176T. Washington, D.C.: September 23, 2008. 

Medicaid: Concerns Remain about Sufficiency of Data for Oversight of 

Children’s Dental Services. GAO-07-826T. Washington, D.C.: May 2, 2007. 

Medicaid Managed Care: Access and Quality Requirements Specific to 

Low-Income and Other Special Needs Enrollees. GAO-05-44R. 

Washington, D.C.: December 8, 2004. 

Medicaid and SCHIP: States Use Varying Approaches to Monitor 

Children’s Access to Care. GAO-03-222. Washington, D.C.: January 14, 

2003. 

Medicaid: Stronger Efforts Needed to Ensure Children’s Access to Health 

Screening Services. GAO-01-749. Washington, D.C.: July 13, 2001. 

Oral Health: Factors Contributing to Low Use of Dental Services by LowIncome Populations. GAO/HEHS-00-149. Washington, D.C.: September 11, 

2000. 

Oral Health: Dental Disease Is a Chronic Problem Among Low-Income 

Populations. GAO/HEHS-00-72. Washington, D.C.: April 12, 2000. 

Medicaid Managed Care: Challenge of Holding Plans Accountable 

Requires Greater State Effort. GAO/HEHS-97-86. Washington, D.C.: 

May 16, 1997. 

(290705) Page 42 GAO-09-723 Medicaid Dental Services for Children
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U.S. Government Accountability Office, 441 G Street NW, Room 7149 

Washington, DC 20548 

Public Affairs 

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