Incentivizing Oral Health Care Providers to Treat Patients 

with Intellectual and Developmental Disabilities

National Council on Disability

April 5, 2023
National Council on Disability (NCD)

1331 F Street NW, Suite 850

Washington, DC 20004

Incentivizing Oral Health Care Providers to Treat Patients with Intellectual 

and Developmental Disabilities

National Council on Disability, April 5, 2023

Celebrating 39 years as an independent federal agency

This report is also available in alternative formats. Please visit the National Council on Disability 

(NCD) website (www.ncd.gov) or contact NCD to request an alternative format using the following 

information:

ncd@ncd.gov Email

202-272-2004 Voice

202-272-2022 Fax

The views contained in this report do not necessarily represent those of the Administration, as this and 

all NCD documents are not subject to the A-19 Executive Branch review process.
Letter of Transmittal

April 5, 2023

President Joseph R. Biden Jr.

The White House

Washington, DC 20500

Dear Mr. President:

Our country is failing to adequately care for the oral health needs of the over 9.4 million people with 

intellectual and developmental disabilities (IDD) in the United States who rely upon Medicaid and its 

limited network of oral healthcare providers for their oral health needs. Poor oral health contributes to 

the decay of physical health as it has been linked to respiratory, cardiovascular and endocrine disease.1

The significant health disparities existing between those with IDD and their nondisabled counterparts 

can be greatly attributed to poor oral health. On behalf of the National Council on Disability (NCD), 

I submit this report for your consideration entitled Incentivizing Oral Healthcare Providers to Treat 

Patients with Intellectual and Developmental Disabilities Through Medicaid. 

This report supplements our January 2022 report, Medicaid Oral Health Coverage for Adults 

with Intellectual and Developmental Disabilities – A Fiscal Analysis, which contained NCD’s 

recommendations for the expansion of Medicaid to provide comprehensive oral healthcare for 

persons with IDD, setting forth an evidentiary base of its cost effectiveness and how the provision of 

those services can address the chronic health disparities existing between people with IDD and their 

nondisabled counterparts. This report documents our findings that existing Medicaid policies hinder oral 

healthcare providers’ ability to safely render cost effective oral healthcare in the dental office. Absent 

their ability to obtain oral healthcare in dental offices, hospital emergency rooms serve as defacto

dental clinics for people with IDD or they do without that care to the detriment of their overall health 

and well-being. 

Addressing the oral healthcare needs of people with IDD is complex, requiring foremost dental 

healthcare professionals who have been educated and trained in caring for this vulnerable population; 

and often requiring specially trained staff, such as dental hygienists and certified registered nurse 

anesthesiologists to better prepare these patients for receipt of dental care. It also requires the 

development of compensation strategies under the Medicaid program to incentivize oral heathcare 

professionals to treat this population and that support an integrated delivery of oral healthcare.

1 Rautemaa, R., et al., (2007). Oral Infetions and systemic disease – An emerging problem in medicine. Clinical 

Microbiology and Infection: The Official Publication of the European Society of Clinical Microbiology and 

Infectious Diseases, 13 (11) (2007), pp. 1041–1047

National Council on Disability

An independent federal agency making recommendations to the President and Congress 

to enhance the quality of life for all Americans with disabilities and their families.

1331 F Street, NW ■ Suite 850 ■ Washington, DC 20004

202-272-2004 Voice ■ 202-272-2074 TTY ■ 202-272-2022 Fax ■ www.ncd.gov
Among the recommendations included in this report, the following three should be prioritized: foremost, 

Congress should be encouraged to update the definition of Medically Underserved Populations to include 

people with IDD; second, coverage for medically necessary oral healthcare services in Medicaid programs 

should be mandated for eligible adults with IDD; and finally, the U.S. Department of Health and Human 

Services must explore a new integrated, preventive, value-based healthcare program for adults with IDD 

under Medicare that covers medically necessary medical and dental services for adults with IDD.

NCD looks forward to briefing your Administration on the specific findings and recommendations 

in this report and stands ready to work with federal agencies, state governments, the disability 

community, and other stakeholders to facilitate better access to oral healthcare for people with IDD 

through Medicaid.

Respectfully Submitted,

Andrés. J. Gallegos, J.D.

Chairman

(The same letter of transmittal was sent to the President Pro Tempore of the U.S. Senate and the Speaker of the 

U.S. House of Representatives.)

2 National Council on Disability
National Council on Disability Members and Staff

Members

Andrés J. Gallegos, Chairman

Claudia Gordon, Vice Chair

Hoskie Benally, Jr.

Sascha Bittner

Theo Braddy

Shawn Kennemer

Risa Rifkin

Neil Romano

Emily Voorde

Staff

Anne C. Sommers McIntosh, Executive Director 

Joan M. Durocher, General Counsel & Director of Policy

Lisa Grubb, Director of Administration, Finance, and Operations

Stacey S. Brown, Staff Assistant

Kimie Eacobacci, Legislative Affairs Specialist

Netterie Lewis, Administrative Support Specialist

Amy Nicholas, Senior Attorney Advisor

Nick Sabula, Public Affairs Specialist

Amged Soliman, Senior Attorney Advisor

Ana Torres-Davis, Senior Attorney Advisor

Keith Woods, Financial Management Analyst

Incentivizing Oral Health Care Providers to Treat Patients 3
4 National Council on Disability
Contents

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  

Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1

Chapter 1: Research Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  2

Chapter 2: Input from the Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  2

Chapter 3: Input from the Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  2

Chapter 4: Demonstrating a Return on Investment . . . . . . . . . . . . . . . . . . . . . . . . . . .  4

Chapter 5: Promising Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  6

Chapter 6: Findings and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  6

Chapter 7: Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  7

Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  7

Appendix A: Participating Organizations . . . . . . . . . . . . . . . . . . . . . . . . . . .  7

Appendix B: Project Organizational Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

Appendix C: Focus Group 1: Self-Advocates Script . . . . . . . . . . . . . . . . . .  7

Appendix D: Oral Health Care Provider Questionnaires . . . . . . . . . . . . . .  8

Appendix E: Provider Demographics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  9

Appendix F: CDT Codes and Labels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  9

Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  9

Incentivizing Oral Health Care Providers to Treat Patients 5
6 National Council on Disability
Acknowledgments

The National Council on Disability (NCD) wishes to acknowledge the Medicaid|Medicare|CHIP 

Services Dental Association, the Special Care Dentistry Association, and the American Academy of 

Developmental Medicine and Dentistry, which conducted the research and writing of this report. NCD 

wishes to thank Mary E. Foley, M.P.H.; Martha M. Dellapenna, M.E.d.; Roxanne Parkins, M.A.; David 

Fray, D.D.S.; Steven Perlman, D.M.D., M.P.H.; and Allen Wong, D.D.S. NCD also wishes to acknowledge 

the support of the states and managed care plans that partnered with the Medicaid/Medicare/CHIP 

Services Dental Association to develop and implement this project. See Appendix A.

Incentivizing Oral Health Care Providers to Treat Patients 7
8 National Council on Disability
Executive Summary

People with intellectual and developmental 

disabilities (I/DD) experience significant issues 

accessing quality, appropriate, and timely oral 

health care (OHC) services. Despite efforts by 

federal, state, and local agencies, legislatures, 

and key advocates, adults with I/DD remain 

the largest minority population with unmet 

OHC needs. There are several systemic and 

environmental reasons for this; however, 

three major factors exist. These include (1) the 

insufficient number of 

OHC providers rendering 

care to people with 

I/DD, (2) the lack of 

government policies that 

support dental benefits 

for people with I/DD, 

and (3) the insufficient 

funding to support 

essential OHC services for people with I/DD.

In early 2022, on behalf of the National Council 

on Disability (NCD), the Medicaid|Medicare|CHIP 

Services Dental Association, in collaboration 

with the American Academy of Developmental 

Medicine and Dentistry (AADMD) and the Special 

Care Dentistry Association, undertook a study 

of OHC providers across the United States to 

explore the factors and policy incentives that 

influence their decisions to treat individuals 

with I/DD and to participate in government 

programs that provide coverage for dental care 

for individuals with I/DD. In this report, the 

legislative, environmental, and system factors 

that provide the backdrop for this project are 

described. The key to expanding access to OHC 

services for adults with I/DD is understanding 

these points, as they dictate how policy, 

programs, and services under Medicaid are 

currently operationalized and the system within 

which innovative solutions may be realized.

This effort included 

three focus groups 

targeting self-advocates 

with I/DD, their families, 

and stakeholders; 

a Project Advisory 

Committee; several 

Medicaid managed care 

plans (MCPs) contracting 

with state Medicaid dental programs; and a 

large group practice (provider organization). NCD 

developed a modified Delphi questionnaire to 

assess OHC providers’ interest and behaviors 

in participating in Medicaid programs that 

support dental care for individuals with I/DD; 

and to identify factors that drive participation in 

Medicaid oral health programs for adults with 

I/DD. The first round of questions was open 

ended and asked OHC providers to share their 

knowledge, experience, ideas, concerns, and 

Despite efforts by federal, state and 

local agencies, legislatures, and key 

advocates, adults with I/DD remain 

the largest minority population with 

unmet oral healthcare needs.

Incentivizing Oral Health Care Providers to Treat Patients 9
challenges related to participating in Medicaid 

and in treating adult patients with I/DD. It also 

asked OHC providers for suggestions for program 

improvements and ideas for policy and/or 

program reform that might incentivize more 

providers to participate in Medicaid programs that 

cover dental services for adults with I/DD.

Among the 900 OHC providers who 

responded to the first-round questionnaire, nearly 

all reported to have participated in and were 

familiar with Medicaid dental program policy and 

administration. Analysis of Round 1 responses 

revealed a broad consensus of recommendations 

for improvement and 

bias among some, in the 

perception of the patient 

base served by Medicaid.

A second round of 

closed-ended questions 

was implemented to 

learn which factors had 

the greatest influence 

over providers’ behavior 

to participate in Medicaid 

programs covering dental 

care for adults with 

I/DD. Of the 14 factors identified in Round 1, two 

factors rose to the top as having the greatest 

influence: (1) Medicaid dental reimbursement 

rates and (2) helping people in need.

Providers were also asked to share 

experiences in treating adults with 

I/DD. Regarding the types of support and 

accommodations most often needed to treat 

patients with I/DD, dental providers indicated that 

financial support to cover costs associated with 

increased time and staffing needs would be most 

helpful. For those who responded that they no 

longer treat patients with I/DD, most indicated 

that time and reimbursement rates were the two 

major factors that influenced their decisions.

Round 3 provided the opportunity to prioritize 

responses and establish consensus. In Round 3, 

OHC providers were asked to rank items in the 

order of importance to them. Six key questions 

were asked. In this round, 109 OHC providers 

responded. Providers reported that the top three 

supports or accommodations needed to treat 

adult patients with I/DD easily and effectively are 

(1) availability of financial support to cover costs 

associated with increased time and staffing needs, 

(2) increased reimbursement to support longer 

dental visits, and (3) 

specialized training.

In addition to the 

OHC provider study, 

NCD explored existing 

Medicaid dental 

reimbursement rates, 

current state budget 

expenditures, and the 

potential return on 

investment toward 

sufficiently funding 

a Medicaid dental 

benefit for adults with I/DD. This report details 

the process undertaken by NCD researchers, 

including a three-state analysis demonstrating a 

value-based1 preventive OHC model with shared 

savings based on performance by providers who 

prioritize value over volume.

In a third study, researchers investigated 

dental reimbursement rates implemented 

by several MCPs. This report demonstrates 

how variability in Medicaid managed care 

reimbursement rates may adversely affect the 

dental workforce and ultimately impact access 

to care.

These recommendations provide 

the framework for systems change 

and redesign, namely–a new 

government program in Medicare 

that supports better care at a lower 

cost for an aging population of 

individuals with I/DD living in noninstitutionalized settings across all

states.

10 National Council on Disability
The consensus statements from the OHC 

provider questionnaire along with the outcome 

analysis of the return-on-investment study form 

the basis for recommendations in this report. 

These recommendations provide the framework 

for systems change and redesign, namely, a 

new government program in Medicare that 

supports better care at a lower cost for an 

aging population of adults with I/DD living in 

noninstitutionalized settings across all states. 

The proposed integrated health care program 

will demonstrate significant savings by linking 

adults with I/DD living in the community to 

existing social support systems, integrating 

their dental and medical health care services 

and coverage, and incentivizing providers to 

deliver value-based preventive health care 

services.

Incentivizing Oral Health Care Providers to Treat Patients 11
12 National Council on Disability
Acronyms

AADMD American Academy of Developmental Medicine and Dentistry

ADA American Dental Association

BCH Boston Children’s Hospital

CDT Code Code on Dental Procedures and Nomenclature

CHIP Children’s Health Insurance Program

CMS Centers for Medicare and Medicaid Services

DD Developmental Disability/Disabilities

ECC Early Childhood Caries

EPSDT Early and Periodic Screening, Diagnostic, and Treatment

FFS Fee for Service

FMAP Federal Medical Assistance Percentage

FQHC Federally Qualified Health Center

HCBS Home- and Community-Based Services

HHS US Department of Health and Human Services

ICD International Classification of Diseases

IDD or I/DD Intellectual and Developmental Disabilities

IHI Institute for Healthcare Improvement

MCP Managed Care Plans

MSDA Medicaid|Medicare|CHIP Services Dental Association

NCD National Council on Disability

OHC Oral Health Care

OR Operating Room

PAC Project Advisory Committee

ROI Return on Investment

SCDA Special Care Dentistry Association

Incentivizing Oral Health Care Providers to Treat Patients 13
14 National Council on Disability
Oral healthcare equity for persons with 

disability is an elusive ideal that requires 

the dental profession to understand the 

nexus of health policy, redesign of health 

delivery, reimbursement for healthy 

outcomes and incentives for the health 

provider

Incentivizing Oral Health Care Providers to Treat Patients 15
16 National Council on Disability
Introduction

Over the last two decades, legislative 

changes in Medicare and Medicaid have 

taken place resulting in improvements 

in government policy, program administration, 

and services. These changes allow for more 

flexibility of services for beneficiaries, alternative 

payment schedules for providers, and various 

administrative models for state Medicaid 

programs.2 Despite this flexibility, gaps in 

federal and state policies continue to exist 

as people with I/DD are not recognized as 

medically underserved. In addition, dentists’ 

participation in Medicare and Medicaid remains 

far too low to effectively provide access to 

care for most Americans who depend on these 

government programs. Further, many persons 

with disabilities report significant barriers from 

dental providers in both physical environment 

and capacity to understand their disability and 

accommodate care.3 Oral health care (OHC) 

equity for persons with disabilities is an elusive 

ideal that requires the dental profession to 

understand the nexus of health policy, redesign 

of health delivery, reimbursement for healthy 

outcomes, and incentives for the health 

provider.

In this project, the National Council on 

Disability (NCD) explored three issues impacting 

access and use of dental care services by adults 

with intellectual and developmental disabilities 

(I/DD): (1) OHC provider participation in Medicaid 

programs that cover dental services for adults 

with I/DD; (2) return on investment (ROI) to 

states for sufficiently funding a comprehensive 

Medicaid dental benefit for adults with I/DD; and 

(3) comparison of Medicaid managed care dental 

provider reimbursement rates to Medicaid fee-forservice (FFS) dental provider reimbursement rates. 

This project addressed the following three goals:

Goal A: Gain knowledge and understanding 

of issues affecting the ability of individuals 

with I/DD to access and use dental care 

services from self-advocates with I/DD, 

parents/caregivers, and advocates and other 

key stakeholders to inform on process, the 

questionnaire, and the ROI, and provide 

evaluation in a report.

Goal B: Establish a consensus among OHC 

providers regarding approaches that 

programs may take toward policy changes 

that incentivize OHC providers to treat 

patients with I/DD.

Goal C: Establish a methodology/tool for 

use by states to calculate an ROI to state 

departments and programs for funding/

enhancing a Medicaid dental benefit for 

individuals with I/DD.

Incentivizing Oral Health Care Providers to Treat Patients 17
To achieve these goals, NCD established 

a research team to design and implement 

three studies. A Project Advisory Committee 

(PAC) was formed, made up of a group of 

20 individuals with representation from 

the target population as well as partnering 

dental organizations. 

PAC members were 

primarily responsible 

for providing technical 

assistance and support 

in the development 

and dissemination 

of the OHC provider 

questionnaire to OHC 

providers within their 

respective networks. See Appendix A and 

Appendix B.

To address Goal A, the research team 

conducted three focus groups. The first focus 

group convened people with I/DD or selfadvocates. The second group was made up of 

parents and caregivers of people with I/DD. 

The third focus group consisted of other key 

stakeholders. The purpose of the focus groups 

was to gain insight from the population to 

inform the work of the project, including the 

development of questions for the OHC Provider 

Questionnaire. Chapter 2 provides an overview 

of the focus groups and the takeaway messages 

from key informants.

To accomplish Goal B, the research team 

solicited support from state Medicaid dental 

program administrators as well as health plan 

partners to disseminate an OHC Provider 

Questionnaire to enrolled dentists across 

Medicaid and commercial networks. Chapter 3 

presents a description and purpose of the OHC 

Provider Questionnaire, targets, methods, 

and results.

To address Goal C and demonstrate an ROI 

to funding an adult dental benefit for individuals 

with I/DD, researchers created a tool for use 

by states. The tool illustrates how a state may 

strategically develop or 

enhance a benefit and 

overlay the costs to 

demonstrate an ROI or 

cost-shifting from other 

state department and 

program expenditures. 

Researchers modified a 

previous methodology 

developed by the 

Medicaid|Medicare|CHIP Services Dental 

Association in collaboration with researchers 

at Brandeis University, Massachusetts. 

Variables were adjusted to account for unique 

considerations of the population with I/DD. A full 

description of the ROI tool and its methodology 

are featured in Chapter 4.

Medicaid dental programs are required under 

federal law to produce and publish provider 

reimbursement fee schedules. The FFS provider 

reimbursement schedule is the actual amount 

to be paid to providers under an FFS program. 

Medicaid managed care plans (MCPs) that 

contract with Medicaid agencies to administer 

the dental benefits often reimburse dental 

providers at rates below the FFS reimbursement 

schedule.

In Medicaid managed care, states may 

delegate the delivery of dental care to Medicaid 

beneficiaries to MCPs. States pay MCPs riskbased capitation payments, and the plans 

typically negotiate with its network providers 

Medicaid managed care plans 

(MCPs) that contract with Medicaid 

agencies to administer the dental 

benefits often reimburse dental 

providers at rates below the FFS 

reimbursement schedule.

18 National Council on Disability
the reimbursement rates it pays for dental care 

services. Given this negotiation process, there 

may be different fee schedules or payment 

methodologies utilized by different plans. States 

have the option to direct how MCPs pay their 

network providers, but that is not a Medicaid 

requirement.

OHC providers 

participating in more 

than one Medicaid 

managed care dental

plan may be faced 

with several different 

fee schedules, any of 

which may fall below 

the state’s Medicaid FFS 

reimbursement schedule.

This practice has 

generated much 

confusion among 

OHC providers and, as 

such, has resulted in a 

decrease in the number 

of dental providers 

in some Medicaid managed care dental plan 

networks. As discussed in Chapter 4, researchers 

have applied MCP fee schedules from three 

states to the ROI model. The results of this study 

contribute to the recommendations included in 

this report.

Presented in Chapter 5 are three categories of 

promising practices that demonstrate innovative 

models to advance dental care for people with I/DD.

Chapter 6 lists recommendations for key 

stakeholders including and not limited to the 

Centers for Medicare and Medicaid Services, 

Health Resources and 

Services Administration, 

Medicaid|Medicare|CHIP 

Services Dental 

Association, 

American Academy 

of Developmental 

Medicine and Dentistry, 

Special Care Dentistry 

Association, state 

policymakers, state 

Medicaid administrators, 

Medicaid MCPs, dental 

provider organizations, 

people with I/DD, their 

parents and caregivers, 

and advocacy groups for 

people with I/DD.

Chapter 7 provides a road map for the 

development and implementation of an 

innovative, integrated, value-based, preventivefocused, government-sponsored health care 

program that supports inclusion and equity for all 

people with I/DD.

OHC providers participating in 

more than one Medicaid managed 

care dental plan may be faced with 

several different fee schedules, 

any of which may fall below the 

state’s Medicaid FFS reimbursement 

schedule. This practice has 

generated much confusion among 

OHC providers and, as such, 

has resulted in a decrease in the 

number of dental providers in some 

Medicaid managed care dental plan 

networks.

Incentivizing Oral Health Care Providers to Treat Patients 19
20 National Council on Disability
Chapter 1: Research Questions

Incentivizing Oral Health Care Providers to Treat Patients 21

T

he National Council on Disability (NCD) 

gathered information from oral health care 

(OHC) providers regarding their current 

participation in any type of Medicaid program that 

allows for the treatment of people with intellectual 

and developmental disabilities (I/DD); current 

treatment of people with I/DD; reasons why they 

participate in Medicaid programs that allow for the 

treatment of people with I/DD; reasons why they 

do not participate in Medicaid programs that allow 

for the treatment of people with I/DD; reasons 

why they treat people with I/DD; reasons why 

they do not treat people with I/DD; ideas for policy 

incentives that would increase their participation in 

Medicaid programs that allow for the treatment of 

people with I/DD; and ideas for policy incentives to 

treat people with I/DD.

To complete this task and achieve Goal B 

(Establish a consensus among OHC providers 

regarding approaches that programs may take 

toward policy changes that incentivize OHC 

providers to treat people with I/DD), NCD 

conducted a review of the literature to identify 

and validate existing perceptions noted by focus 

group participants.

Based on the evidence and input from the 

focus groups, a questionnaire framework was 

developed, and a series of open-ended questions 

for inclusion in Round 1 of the modified Delphi 

questionnaire was drafted. The Delphi method 

was selected as it uses a systematic approach 

to deploy a series of anonymous questionnaires 

with controlled feedback to obtain opinions and 

consensus from respondents.

NCD implemented the study of OHC providers 

from 49 states across the United States using 

an electronic platform and email communication. 

Following is a list of the research questions 

included in Round 1:

■ Please list and describe any factors that 

have influenced your decision (either to 

participate or not to participate) in your 

state’s Medicaid dental program or homeand community-based services (HCBS) 

program. (Please include a description of 

any individuals, institutions, organizations, 

employers, staff, programs, and/or policies 

and how they influenced your decision.)

■ If you currently do not participate in your 

state Medicaid dental program and/or HCBS 

dental program, did you ever? If yes, why 

did you leave?

■ Please share any ideas you may have that 

would change your decision to participate in 

Medicaid dental programs. In other words, 

what would it take to get you to participate?

■ Please list and describe any factors that 

have influenced your decision to treat adults 
with I/DD. Please include a description of 

any individuals, institutions, organizations, 

employers, staff, programs, and/or policies 

and how they have influenced your decision.

■ Tell us about your experiences in treating 

adult patients with I/DD. Please share your 

experiences in the various dental settings: 

(1) dental office, (2) hospital/operating room, 

and/or (3) community-based settings.

■ Please explain the types of supports or 

accommodations (physical, behavioral, 

pharmacological) you need to render dental 

care more easily and effectively to adult 

patients with I/DD.

■ Please list and describe any factors that 

have influenced your decision to not treat, 

stop treating, or limit your practice of 

treating adults with I/DD. Please include 

any individuals, institutions, organizations, 

employers, staff, programs, and/or policies 

and how they influenced your decision.

■ If you used to treat adults with I/DD and 

currently do not, why did you stop?

■ What changes would be necessary for 

you to (1) begin to treat adults with I/DD 

again and/or (2) stop limiting your practice 

to only adults with I/DD who require no 

accommodations?

22 National Council on Disability
Chapter 2: Input from the Population

Understanding the issues affecting access 

and use of dental care services for people 

with intellectual and developmental 

disabilities (I/DD) is essential to determining 

the best strategies for resolution. While the 

literature details many of the issues that have 

historically affected this population, the National 

Council on Disability (NCD) sought to update and 

validate findings. To effectively achieve this and 

meet the goals and expectations of the project, 

NCD convened three focus groups. The first 

focus group was composed of people with I/DD 

who serve as self-advocates and champions 

for other people with I/DD. The second focus 

group was made up of parents and caregivers 

of people with I/DD. The third focus group 

consisted of advocates, payers, providers, and 

policymakers who have knowledge of federal 

and state policies and practices affecting people 

with I/DD.

Goal A details project goals regarding 

the focus groups: To gain knowledge and 

understanding of issues affecting the ability of 

individuals with I/DD to access and use dental 

care services from (1) self-advocates with I/DD, 

(2) parents/caregivers, and (3) advocates and 

other key stakeholders to inform on process, the 

survey questions, and the ROI, and provide the 

final findings.

Purpose of Each Focus Group

The purpose of the Self-Advocates and Parent/

Caregiver focus groups was to gain knowledge 

and understanding of the attitudes, beliefs, 

experiences, and reactions of people with I/DD 

and caregivers of people with I/DD who have 

sought and received or have been unable to 

receive dental care for themselves or a family 

member through the existing oral health care 

delivery system. The purpose of the Stakeholder 

focus group was to gain insight into how 

government programs currently address dental 

access and care for people with I/DD, and what 

federal and state authorities or policy pathways 

currently exist to potentially advance dental policy.

Size of the Focus Groups

Based on the nature of research and information 

to be gathered, NCD estimated that five to eight 

participants should be selected for each focus 

group. NCD worked with project partners to create 

selection criteria or screens to ensure proposed 

participants had the level of knowledge, experience, 

and passion needed to effectively contribute during 

the sessions. Once a pool of names was identified, 

NCD randomly selected the final sample to reduce 

potential bias. When invited individuals declined 

participation, others were invited.

Incentivizing Oral Health Care Providers to Treat Patients 23
Question Development

To ensure the effectiveness of the focus 

groups, the research team convened a planning 

committee. The planning committee consisted of 

representatives from Medicaid|Medicare|CHIP 

Services Dental Association (MSDA), American 

Academy of Developmental Medicine and 

Dentistry (AADMD), and Special Care Dentistry 

Association (SCDA) who held subject matter 

expertise necessary to develop questions that 

would solicit meaningful responses. The planning 

committee was charged with creating between 

five and eight questions for each particular focus 

group. Questions were uniquely developed to gain 

input and knowledge from self-advocates, parents 

and caregivers, and key stakeholders of people 

with I/DD, which would inform and guide methods 

for the other aspects of the project. Separate 

scripts were developed to guide each focus 

group discussion, making sure all participants 

understood the purpose of the focus group and 

how their comments would be used by NCD.

Focus Group 1: Self-Advocates

A diverse group of five multiply marginalized 

men and women with I/DD, ranging in age from 

approximately 25 to 40 years, engaged in a 

thoughtful discussion about their experiences 

in attempting to access and use dental 

care services. Five themes regarding their 

dental experiences were discussed: Dental 

Appointments, The Dentist, The Dental Office, 

Receiving Dental Care, and Paying for Dental 

Care. These specific themes were selected 

because participants’ insights regarding 

accessing dental care and their dental experience 

(from making their appointment to the visit itself 

and then payment for services) were needed to 

inform other key aspects of the project. The script 

used for Focus Group 1 (Self-Advocates with 

I/DD) may be viewed in Appendix C.

Self-advocates with I/DD were asked a series 

of questions to gain perspective of their feelings 

and perceptions regarding dental appointment 

experiences. All agreed that some level of 

support was needed from a family member 

or another person to schedule and keep their 

dental appointments. Most reported to have had 

experiences either in accessing and/or receiving 

dental care that were not positive. This included 

issues they experienced in finding a dentist 

that would accept Medicaid or another dental 

insurance; finding a dental practice that had 

experience treating people with I/DD; and dental 

staff who seemed too busy to take the extra time 

to address their unique accessibility and/or dental 

care needs. One reported that she felt ignored.

Regarding dentists and dental office staff, 

focus group participants reported that by and 

large they liked their dentist. One participant 

said that she felt her dentist only cared about 

money and not about her as a person. She said 

Challenges self-advocates faced 

in accessing and/or receiving 

dental care

■ Finding a dentist who would accept 

Medicaid or another dental insurance

■ Finding a dental practice with experience 

treating people with I/DD

■ Dental staff seemed too busy to take extra 

time to address unique accessibility and/or 

dental care needs

24 National Council on Disability
she received a bill for services that were not 

performed. Another reported having had some 

dental work done, but it was not completed, 

leaving her still suffering in pain. Regarding 

receipt of dental care, participants said they 

found dental care generally to be anywhere from 

satisfactory to excellent. All agreed that having 

referrals from other health care professionals or 

social service agencies 

improved their dental 

office experience. For 

those who indicated that 

their dental, accessibility, 

and other special 

needs were being met, 

they reported that those dental offices offered 

accommodations such as headphones, flexible 

appointment times, and a relaxed, desensitized 

environment. When asked what recommendation 

they would offer to dental providers to improve 

dental care experiences and outcomes, they 

suggested that dentists should collaborate and 

coordinate more with medical professionals to 

better understand their 

patients’ disabilities and 

whole person needs.

When asked about 

paying for dental care, 

the consensus of the 

group was that the 

cost of dental care is 

too high, and that cost 

creates barriers to care. Despite having Medicaid 

coverage, limitations in benefits and in the 

availability of dentists exist, making it difficult 

to regularly access dental care. Each participant 

indicated that they are covered by Medicaid and 

are grateful to have it. When asked about what 

changes should be made to improve care, one 

participant commented that policymakers and 

government officials need to listen to people 

with I/DD and advocates, to ensure that policies 

and financing adequately support the clinical, 

behavioral, and structural modifications necessary 

to deliver and receive care.

Focus Group 2: Parents and 

Caregivers

Focus Group 2 was 

made up of six adult 

men and women from 

six different states. 

Participants in Focus 

Group 2 discussed their 

roles and responsibilities as caregivers for their 

adolescent or young adult. NCD used the same 

themes developed for the first focus group—

Dental Appointments, The Dentist, The Dental 

Office, Receiving Dental Care, and Paying for 

Dental Care—in the second focus group session. 

These specific themes were selected because 

participants’ insights regarding accessing dental 

care and their dental 

experience (from making 

their appointment to the 

visit and then payment 

for services) were 

considered essential 

to inform other key 

aspects of the project. 

Researchers used this 

opportunity to compare and contrast issues 

raised by the first focus group participants.

When asked about dental office challenges 

and the need for support in making and keeping 

dental appointments for the people with I/DD 

whom they cared for, all participants said that 

they had to provide some level of support when 

All agreed that having referrals from 

other health care professionals or 

social service agencies improved 

their dental office experience.

[Self-advocates] suggested that 

dentists should collaborate and 

coordinate more with medical 

professionals to better understand 

their patients’ disabilities and whole 

person needs.

Incentivizing Oral Health Care Providers to Treat Patients 25
scheduling and keeping dental appointments. 

Two indicated that they had difficulty finding a 

dentist that accepts Medicaid. Another shared that 

having flexible appointment times, a desensitized 

atmosphere, and a calm, relaxing environment 

help make the experience 

much more positive.

Regarding patient 

care, one participant 

indicated that in her 

experience, many 

dentists did not appear 

to have understanding 

or compassion when 

treating people with I/DD—two essential 

elements of appropriate health care. Another 

said that some of the dental procedures 

performed were often confusing for their loved 

one who did not fully understand the purpose 

of the dental visit or what was happening. 

Two participants, who happened to be dental 

professionals, reported that they treat their 

own children and shared how difficult it can 

sometimes be to render care to people with 

I/DD, even though they 

may be a family member. 

Another discussed 

that he observed a lack 

of continuity and/or 

coordination of dental 

care with community 

agencies and medical 

providers—two important 

aspects of whole person health care for 

people with I/DD.

Paying for dental care was a key area of 

discussion with this focus group. Several in 

the group acknowledged that Medicaid is 

. . .[H]e observed a lack of continuity 

and/or coordination of dental care 

with community agencies and 

medical providers—two important 

aspects of whole person healthcare 

for people with I/DD.

26 National Council on Disability
helpful to their family member, but because 

reimbursement to providers is so low, it 

generally does not fully cover the cost of 

care to providers. Further, payments must be 

made out-of-pocket to pay for services that are 

not covered. Despite 

these challenges and 

limitations in coverage, 

parents and caregivers 

felt strongly that if all 

dentists accepted and 

treated a small number of Medicaid-enrolled 

patients with I/DD, the access problem could be 

relieved. Participants further acknowledged that 

the dental health care delivery system for adults 

with I/DD is fractured; to realize oral health and 

oral health care equity for this population, a new 

government program, one that considers the 

social, behavioral, and 

physical needs of the 

population, is needed.

Focus Group 3: Key 

Stakeholders

This group included 

eight professional 

adult men and women 

aged 30 years and 

older representing a 

nonprofit organization, 

a social service agency, 

a community advocacy 

group, organized dentistry, a health insurance 

organization, and a state agency. This diverse 

group provided rich and varied responses that 

helped researchers gain insight into their unique 

perspectives about dental care for people 

with I/DD. Because the focus group was held 

virtually, participants from across the United 

States, as far as Hawaii, were able to join the 

session.

While the themes discussed in the third 

focus group were similar to those in the first two 

focus groups (Dental Appointments, The Dentist, 

The Dental Office, 

“Receiving” Dental Care, 

and Paying for Dental 

Care), the questions for 

this focus group were 

slightly different and 

were geared more toward policy, systems change, 

equity, and advocacy. Participants offered potential 

solutions to some of the issues and provided 

suggestions for policy change. When asked what 

questions should be included in the oral health 

care (OHC) provider questionnaire regarding dental 

care for people with I/DD, participants offered 

suggestions specifically 

related to patient physical 

and behavioral supports. 

These themes were 

subsequently included 

in the OHC provider 

questionnaire.

Focus Group 3 

was designed to gain 

information from key 

stakeholders regarding 

ideas they may have 

about policies and 

programs that promote 

and support dental care for people with I/DD, and 

to learn what issues currently exist at the systems 

level that could be improved upon by federal and/

or state legislation, regulation, policy development, 

and/or program redesign. The following 

statements highlight suggestions and comments 

from participants of Focus Group 3.

[P]ayments must be made out-ofpocket to pay for services that are 

not covered [by Medicaid].

Participants further acknowledged 

that the dental healthcare delivery 

system for adults with I/DD is 

fractured; and that to realize . . . oral 

healthcare equity for this 

population, a new government 

program, one that considers the 

social, behavioral, and physical 

needs of the population, is 

needed.

Incentivizing Oral Health Care Providers to Treat Patients 27
When asked about dental providers and the 

capacity of the dental workforce to provide 

dental care services to people with I/DD, focus 

group participants agreed that the current 

dental workforce does not sufficiently meet the 

OHC needs of the population. One participant 

commented that lack of dental school training

has created a void in the dental workforce and 

continues to contribute to gaps in the number of 

dental providers available and willing to accept 

and treat patients with I/DD. Another suggested 

that low Medicaid dental program reimbursement 

rates, credentialing issues, and a cumbersome 

prior approval process discourage dentists from 

participating in state Medicaid dental programs. 

Others suggested that staffing limitations make 

it difficult for small dental practices to treat 

people with I/DD as desensitization and behavior 

modification techniques require more provider 

time and assistance.

When asked about other challenges and/

or barriers to dental care, one participant said 

that transportation is a significant problem for 

many adults with I/DD. Another suggested 

that dental providers could potentially benefit 

by learning strategies from peers to enhance 

their physical environment and behavioral and 

clinical approaches to treating people with I/DD. 

Examples include giving providers a place to talk 

about making physical changes to the office, 

how to improve appointment scheduling, and 

rendering care. One participant suggested the 

expansion of tele-dental coverage to include oral 

health education to patients with I/DD as well 

as their parents and caregivers, and coverage 

for tele-dental preventive services. Two additional 

topics suggested for policy advancement 

included expansion of policies that support 

semiconscious sedation in dental offices settings 

and advanced policy and support for complex 

dental care rendered either in the dental office 

or hospital setting. A final suggestion included 

an idea to create a new government health care 

program for people with I/DD. All of these topics 

were noted for inclusion in the OHC provider 

questionnaire. 

Stakeholder identified challenges 

of dental workforce in meeting 

OHC needs of people with I/DD

■ Lack of dental school training

■ Low Medicaid dental program 

reimbursement rates

■ Credentialing issues

■ Cumbersome prior approval process

■ Staffing limitations

28 National Council on Disability
Chapter 3: Input from the Providers

Participation by oral health care (OHC) 

providers in Medicaid programs that serve 

people with intellectual and developmental 

disabilities (I/DD) is essential, yet historically 

these participation rates have been low when 

compared to commercial insurance rates.4

There are two intrinsic issues related to 

this problem: (1) Medicaid program policies 

restrict benefits and have reduced provider 

reimbursements compared to commercial plans 

and (2) treatment of people with I/DD often 

requires greater provider competency, more 

time, and additional staffing to support the care 

needs of the patient.

In an effort to fully understand the reasons 

why OHC providers choose not to participate 

in Medicaid programs that serve people with 

I/DD, and to identify what changes would 

need to take place to reverse their decision, 

researchers queried a sample of OHC providers 

from across the United States to quantify and 

gain consensus of their current participation 

in Medicaid programs and waivers that allow 

for the treatment of patients with I/DD; current 

treatment of patients with I/DD; reasons why 

they participate in Medicaid programs and 

waivers that allow for the treatment of patients 

with I/DD; reasons why they do not participate 

in Medicaid programs and waivers that allow 

for the treatment of patients with I/DD; reasons 

why they treat patients with I/DD; reasons 

why they do not treat patients with I/DD; ideas 

for policy incentives that would increase their 

participation in Medicaid programs that allow 

for the treatment of patients with I/DD; and 

ideas for policy incentives to treat patients 

with I/DD.

The purpose of this chapter is to detail 

how NCD engaged OHC providers across the 

United States to establish consensus regarding 

the complex factors affecting OHC providers’ 

willingness to treat individuals with I/DD and 

participate in Medicaid programs that provide 

payment of dental care services for individuals 

with I/DD, and to provide results that may be 

used to form and advance Medicaid dental policy 

Issues related to low Medicaid 

participation rates for programs 

that service people with I/DD 

compared to commercial plans

1. Restricted benefits and lower 

reimbursement rates in Medicaid 

programs

2. Greater provider competency, additional 

time and staffing required for treating 

people with I/DD

Incentivizing Oral Health Care Providers to Treat Patients 29
and other government programs serving this 

population.

Literature Review and Draft 

Questions

NCD conducted a review of the literature to 

identify barriers and challenges that people with 

I/DD face when attempting to access and use 

dental care services. In addition, the research 

team explored the science base looking for 

any notable challenges OHC providers face 

when rendering care to people with I/DD. The 

information gained from these two reviews 

was used to validate existing perceptions and 

focus group comments made by I/DD selfadvocates, parents and caregivers, and other 

key stakeholders. Collectively, this information 

was used to inform the development of the OHC 

questionnaires.

Modified Delphi Questionnaire 

Methodology

NCD employed a modified Delphi questionnaire 

methodology to assist in establishing consensus 

among existing OHC providers regarding the 

reasons for their willingness to treat or not 

treat patients with I/DD, and participate or not 

participate in Medicaid programs and waivers 

that allow for the treatment of patients with 

I/DD. OHC providers were also asked about any 

ideas they may have that would motivate them 

to participate in such programs and treat people 

with I/DD.

The Delphi method uses a systematic 

approach to deploy a series of anonymous 

questionnaires with controlled feedback to obtain 

opinions and consensus from respondents.5

NCD developed the Round 1 open-ended 

questions based on information gained from the 

literature and focus groups. The questionnaire 

was disseminated to existing OHC providers 

from across the states who, in turn, provided 

responses that allowed the researchers to 

frame items for the subsequent closed-ended 

rounds of the questionnaire. Each questionnaire 

incorporated summaries of item responses from 

the previous version so that respondents were 

able to consider them when responding in the 

next round. Round 2 and Round 3 questions 

were closed-ended. Responses most frequently 

selected in Round 2 were used in Round 3 to 

gain consensus. This process was used so that a 

convergence of opinion toward consensus would 

take place systematically. NCD set a response 

rate for each item in Round 1 (30%), Round 2 

(40%), and Round 3 (50%), meaning that only 

those items that garnered a 30 to 50 percent or 

more selection rate by providers were included in 

the next round.

Sampling

NCD implemented a combination of 

convenience and cluster sampling to gather 

information from the OHC provider community. 

Researchers solicited support from state 

Medicaid dental programs as well as members 

of the Medicaid|Medicare|CHIP Services Dental 

Association (MSDA) Corporate Round Table to 

disseminate the three rounds of the electronic 

questionnaire to their respective network 

providers. MSDA’s Corporate Round Table is 

made up of dental managed care plans (MCPs) 

(and other corporations) operating in both 

commercial and Medicaid markets. Collectively, 

these dental organizations administer dental 

benefits across 49 states and reach over 86,000 

OHC providers. Each dental plan served as 

a cluster to disseminate the questionnaire 

30 National Council on Disability
link to all dental providers in their respective 

commercial and Medicaid dental plan networks. 

Organizations that had both commercial 

and Medicaid dental plans were directed to 

disseminate the survey in the larger of their 

two networks to avoid duplication in provider 

responses.

Sample Size

The research team, with the support of project 

partners, disseminated the questionnaire to 

dental provider networks in 49 states. It is 

estimated that over 86,000 OHC providers 

received the Round 1 questionnaire. This sample 

represents approximately 40 percent of the 

dentists practicing in the United States.

Limitations of Sample

NCD attempted to query faculty and dental 

students from several US dental schools. Despite 

enthusiasm from all dental schools that were 

contacted, none were able to participate. This 

was due to the lengthy Institutional Review Board 

approval process, which did not fit within the 

timeline of the project.

Timeline

All three rounds were disseminated, and 

data were collected between March 30 and 

May 30, 2022.

Summary of the Provider 

Questionnaire: Round 1

A series of Round 1 open-ended questions 

was developed. (See Appendix D.) To quantify 

like responses and stratify them by provider 

characteristics to ultimately establish provider 

consensus, respondents were asked 21 

questions in Round 1. These questions fell into 

four overarching categories: Section 1, General 

Provider Information; Section 2, Medicaid 

Participation; Section 3, Treatment of Adults 

with I/DD; and Section 4, Other Demographic 

Information.

Under the General Provider Information 

section, providers were asked to self-designate 

by provider type, primary practice model, 

number of dentists in practice setting, number 

of hours worked per week, and age category. 

To quantify OHC providers’ participation in 

Medicaid programs and/or in Medicaid homeand community-based services (HCBS) waiver 

programs, and to glean insight into factors that 

influence their decision to participate in such 

programs, providers were asked to report the 

number of Medicaid adults with I/DD they treat 

and bill for; factors that influence their decision 

to treat adults with I/DD; reasons for leaving and/

or not participating in the Medicaid program; and 

finally, ideas that would change their decision to 

participate.

Researchers further asked providers about 

the supports and accommodations they 

need to treat adult patients with I/DD, and how 

treatment supports differed based on practice 

settings: (1) dental office, (2) hospital/operating 

room, and (3) community-based settings. 

These questions were complex and required 

greater clarity, so NCD framed the questions 

within the context of activities of daily living.6

To increase consistency among responses, 

providers were given specific definitions 

of Intellectual Disability, Developmental 

Disability, and Activities of Daily Living and 

were then asked to answer the questions 

regarding their experience based on these 

definitions.

Incentivizing Oral Health Care Providers to Treat Patients 31
Section 3 of the Round 1 survey explored 

OHC providers’ treatment of adults with 

I/DD. In this section, NCD attempted to gain 

understanding of the factors that influence 

OHC providers’ decision to treat people with 

I/DD or refer them to other providers. Additional 

questions were directed at OHC providers who 

indicated that they do not treat adults with I/DD. 

NCD wanted to learn the reasons why providers 

choose not to treat, stop treating, or limit their 

practices of people with I/DD.

In the final section, Other Demographic 

Information, providers were asked to provide 

gender, race, and ethnicity information. This 

information was also used to assess potential 

differences in OHC provider perspectives and 

practices.

RESULTS

Round 1

The Round 1 questionnaire used an open-ended 

format to elicit varied responses and attitudes 

from OHC providers. Round 1 questions may be 

viewed in Appendix D. Responses were received 

from OHC providers across nearly all specialty 

groups. Of the 900 who responded, 649 (72.11%) 

were General Dentists, 76 (8.45%) Pediatric 

Dentists, 63 (7.00%) Oral and Maxillofacial 

Surgeons, 38 (4.22%) Dental Hygienists, and 

the remaining 74 (8.22%) were in other dental 

specialties. Appendix E lists the responders by 

dental specialty. Regarding age of respondents, 

452 (50.22%) were between the ages of 25 

and 49 years, 325 (36.11%) were between 

50 and 64 years of age, and 123 (13.67%) were 

over age 65 years.

Figure 1 demonstrates the number of OHC 

providers who responded by age category. These 

data on age and specialty of dental provider 

compare closely to averages reported by the 

Figure 1. Oral Health Care Providers Who Responded to Round 1 by Age Categor

Profile of 900 questionnaire 

respondents

■ 72.1% general dentists

■ 8.5% pediatric dentists

■ 7% oral and maxillofacial surgeons

■ 4.2% dental hygienists

■ 8.2% other dental specialties

32 National Council on Disability
American Dental Association (ADA) Health Policy 

Institute. The Health Policy Institute reports that 

the average dentist’s age in 2020 was 49.3 years, 

and the average age of retirement was 68.6 

years. Additionally, the ADA reports that in 2020, 

there were 201,117 practicing dentists in the 

United States, translating 

to 61 dentists per 

100,000 population.7,8

There are 10 types 

of dentists in the United 

States recognized 

by the ADA: general 

dentist, pediatric 

dentist, orthodontist, 

periodontist, 

endodontist, oral and 

maxillofacial surgeon, prosthodontist, dental 

anesthesiologist, dental radiologist, and oral 

pathologist. The response rate to the Round 

1 questionnaire reflects the ratio of general 

dentists to the recognized specialties of 

pediatric dentists and 

orthodontists. The low 

response rate by dental 

hygienists compared to 

general dentists can be 

attributed to the fact that 

dental hygienists, while 

found in more than 90 

percent of general dental 

practices, are almost 

always employees 

who do not bill directly to insurers. The lower 

percentage of specialists responding other than 

pediatric dentists is consistent with the ratio of 

specialists. The prototypical respondents to the 

questionnaire were general dentists (72.11%) 

under age 50 years in solo private practice 

(76.00%/50.22%) working more than 30 hours 

per week (78%). Of those who responded, 

38.93 percent reported that they do not treat 

any Medicaid-enrolled adults.

Several themes were identified for each 

question. Regarding Question 7, factors that 

have influenced OHC 

providers’ decisions 

to participate in their 

state Medicaid dental 

program or HCBS 

program, 713 OHC 

providers responded 

to the question. The 

themes most often 

mentioned were 

Medicaid policies 

(81%), adverse patient experiences (60%), low 

reimbursement (53%), and positive patient 

experiences (32%).

Regarding Question 8, for OHC who currently 

do not participate in their state Medicaid dental 

program and/or HCBS 

dental program, the 

researchers asked, “Why 

did you leave?” In this 

question, respondents 

were allowed to provide 

more than one reason for 

leaving Medicaid. Among 

the total respondents 

who answered this 

question (21%), 86 

percent indicated they stopped participating 

in Medicaid because of reimbursement rates. 

Medicaid policies were also a factor for dropping 

out of the Medicaid network (35%), and 

21 percent indicated that Medicaid patients 

were problematic.

The prototypical respondents to 

the questionnaire were general 

dentists . . .under age 50 years in 

solo private practice . . . working 

more than 30 hours per week . . . 

38.93 percent reported that they 

do not treat any Medicaid-enrolled 

adults.

Among the total respondents who 

answered [why they currently 

do not participate in their state 

Medicaid dental program and/

or HCBS dental program], 86 

percent indicated they stopped 

participating in Medicaid because of 

reimbursement rates.

Incentivizing Oral Health Care Providers to Treat Patients 33
When asked in Question 9 to share any ideas 

that would change their decision to participate 

in Medicaid dental programs, 91 percent of 

OHC providers responded by saying, “raise 

reimbursement”; 55 percent suggested improving 

Medicaid policies and program administration; and 

22 percent suggested using incentives for either 

providers or patients.

Questions 10 through 

12 looked at the number 

of OHC providers 

who treat people with 

I/DD and the number of 

patients with I/DD they 

treat in their practice, 

based on patient need, 

using established criteria 

set forth in activities of 

daily living. OHC providers were asked to quantify 

the number of patients with I/DD they treat in their 

practices by patient need: No Assistance, Some 

Assistance, or Are Dependent upon Assistance.

Figure 2 illustrates the overall extent to 

which OHC providers treat patients with I/DD. 

According to provider responses, 78 percent of 

OHC providers treat patients with I/DD; however, 

there is a significant difference in the number 

of patients they treat, with the vast majority 

(61%) treating between 1 and 49 patients in 

their practice. Only 7 percent of providers treat 

between 50 and 99 patients, and 10 percent treat 

100 or more patients.

Table 1 details the 

percentage of providers 

who treat patients with 

I/DD based on the level 

of assistance their 

patients need.

Of the providers who 

treat between 1 and 

49 patients with I/DD 

per year, there was no 

significant difference in 

treatment practices based on the level of need 

for assistance among their patients. Of the OHC 

providers who treat 100 or more patients with 

I/DD in their practices, fewer (8%) reported to 

treat patients who need full assistance compared 

to those who need no assistance (13%). 

Significance was not established.

When asked . . .to share any ideas 

that would change their decision 

to participate in Medicaid dental 

programs, 91 percent of OHC 

providers responded by saying, 

“raise reimbursement”; 55 percent 

suggested improving Medicaid 

policies and program administration.

Figure 2. Overall Percentage of Oral Health Care Providers Treating Patients with

Intellectual and Developmental Disabilities (by Number in Practice)

34 National Council on Disability
In Question 13, providers were asked to list 

and describe any factors that have influenced 

their decision to treat adults with I/DD and 

to include a description of any individuals, 

institutions, organizations, employers, staff, 

programs, and/or policies and how they may 

have influenced their decision. To this question, 

567 providers responded. Among the many 

comments, the following are examples of 

reasons why providers treat patients with I/DD: 

“I have hospital privileges.” “OR [operating 

room] is less stressful.” “Moral and ethical 

obligation.” and “The right thing to do.” The 

most common reason could be summed by this 

statement, “Trying to meet the patients’ needs.” 

Examples of comments some OHC providers 

gave as to why they do not treat patients 

with I/DD included the following: “Lack of 

equipment.” “Lack of expertise.” “Transportation 

issues.” “Time factors.” “Operatory limitations 

and room logistics.” “Lack of available sedation.” 

“Insufficient staffing.” and “Poor Medicaid 

reimbursement.”

In Question 14, OHC providers were asked to 

share their experience(s) in treating adult patients 

with I/DD. Among the 580 who responded to 

this question, most comments were favorable. 

The following comments were captured: “It’s the 

right thing to do.” “It’s my responsibility.” “It’s 

an opportunity to give back.” “My faith calls for 

it.” “Inclusiveness.” “I enjoy working with the 

population.” “It’s challenging but very rewarding.” 

“I am happy to treat anyone.” and “Everyone 

deserves dental care.”

Among those responses less favorable 

toward treating adults with I/DD, the 

Table 1. Percentage of Providers Treating Patients with 

Intellectual and Developmental Disabilities by Need for 

Assistance

Number of Unduplicated 

Patients with Intellectual 

and Developmental 

Disabilities

No 

Assistance

Some 

Assistance Dependent

None 20.80% 19.41% 26.

1–49 57.47% 66.72% 59.

50–99 8.32% 6.01% 5.

100+ 13.14% 7.86% 8.

Reasons providers gave for why 

they do not treat people with I/DD

■ Lack of equipment

■ Lack of expertise

■ Transportation issues

■ Time factors

■ Operatory limitations and room logistics

■ Lack of available sedation

■ Insufficient staffing

■ Poor Medicaid reimbursement

Incentivizing Oral Health Care Providers to Treat Patients 35
following comments were noted: “It’s 

challenging.” “It takes more time.” “Inadequate 

compensation.” “Very challenging.” “Beyond our 

patient management systems.” “As long as they 

are calm, cooperative, 

and non-combative, I 

can treat them.” “Time 

and money.” “Collecting 

consent forms are 

challenging when 

patients come in on 

their own.” “You will be 

exposed to odors and 

oral conditions in much worse condition than 

normal. You risk being bitten or hit.” and “Treating 

adults with disabilities takes a lot more patience, 

more time to accomplish less, being willing to 

put yourself in physically uncomfortable positions 

to see and treat them.”

When asked in Question 15 to explain the 

types of supports or accommodations (physical, 

behavioral, other) OHC 

providers need to render 

dental care more easily 

and effectively to adult 

patients with I/DD, 

responders commented 

that they needed several 

kinds of supports. 

See Table 2 for some 

physical, behavioral, and treatment supports 

needed to render dental care.

Question 16 asked OHC providers to list and 

describe any factors that have influenced their 

Of the providers who treat between 

1 and 49 patients with I/DD per year, 

there was no significant difference 

in treatment practices based on the 

level of need for assistance among 

their patients.

Table 2. Supports Needed to Render Dental Care

Physical Infrastructure Behavioral Treatment/Other

Wheelchairs with a head rest Use of IV sedation Additional education and training

Bariatric dental chairs Access to 

anesthesiologist

Policy that supports general 

practitioner use of IV sedation

Larger operatories with open 

floor plans

Sedation via Certified 

Registered Nurse 

Anesthetist (CRNA)

Sedation support staff

Quiet spaces without lots of 

noise and distraction

Oral conscious 

sedation

Compensation for increased 

treatment time

Wheelchair-accessible treatment 

rooms

Sedation Ability to use oral sedatives

Panorex and three-dimensional 

scanning machines with 

wheelchair capability

Outreach facilitator More staff to support patient care 

and safety

Portable x-rays Better reimbursement

Regular access to the operating 

room

Initial consultation with parent/

caregiver

Papoose boards Medical consultation prior to 

treatment

Policy approval for the use of 

papoose board

36 National Council on Disability
decision not to treat, to stop treating, or to limit 

their practice of adults with I/DD. Among those 

who answered, reasons for treating or limiting 

practice included “No wheelchair accessibility.” 

“Sedation not permitted.” “Too much time to 

treat.” “Insufficient staffing to support safe 

delivery of care.” “Facility not equipped to deliver 

specialized care.” “Patients unable to transfer to 

dental chair.” and “Patients unable to complete a 

medical history.”

When asked in Question 17 why OHC 

providers who used to treat adults with I/DD 

stopped, responses provided were like ones 

already mentioned: “Staffing.” “Behavioral 

issues with patients.” “Lengthy appointments 

with poor reimbursement impact the bottom 

line.” “Patient behavior was disrespectful to 

staff.” “Patients cause problems.” “Treatment of 

patients in wheelchair or on gurneys difficult.” 

“Caretakers unable to provide sufficient 

assistance.” and “Minimal medical histories 

provided.”

Last, Question 18 asked providers to 

provide suggestions for changes that would be 

necessary for them to (1) begin to treat adults 

with I/DD again and/or (2) stop limiting their 

practice to only adults with I/DD who require 

no accommodations. Table 3 includes the 

Table 3. Provider Recommendations

■ Mandate states to assess, adjust, and reset reimbursement rates annually

■ Mandate states set dental reimbursement rates to 90 to 95 percent of the federal/state’s 

employee dental benefit

■ Mandate MCPs to mirror state fee-for-service dental provider reimbursement rates

■ Establish tele-dental coverage for oral health education and preventive services

■ Consider stand-alone state Medicaid managed care dental plan for adults with I/DD)

■ Consider an integrated, medical-dental, preventive-focused, value-based program under 

Medicare for adults (ages 21+ years) with I/DD

■ Establish state-based shared savings in Medicaid dental programs to incentivize providers 

to reduce operating room (OR) visits and increase preventive service utilization

■ Implement shared savings with MCPs to incentivize providers to reduce OR visits and 

increase preventive service utilization

■ Implement tax-credit program for dental providers who treat a “significant” number of 

adults with I/DD

■ Implement tax credit for dental providers who meet specified goals for delivering adult 

preventive dental services, treating a specified number of adults with I/DD, or treating 

adults with I/DD outside of the OR

■ Design and implement a provider practice protection program with wraparound financial 

support and/or funding to support additional staffing for oral health care providers who 

treat 100 or more adult patients with I/DD per year

■ Design and implement an oral health care provider loan forgiveness program for 

providers who treat 100 or more adult Medicaid patients per year

■ Expand provider eligibility to include a case/care manager in dental offices

Incentivizing Oral Health Care Providers to Treat Patients 37
recommendations offered by providers. Note:

The authors included direct quotes received 

from dental providers in the questionnaire. 

Language and terms used by providers in Table 3 

may not be technically 

correct.

Discussion

The modified Delphi 

Round 1 questionnaire 

provided the opportunity 

to gain insight regarding 

OHC providers’ 

motivation, concerns, 

and challenges in 

participating in Medicaid and waiver programs 

serving adults with I/DD, and in treating patients 

with I/DD. Close to 25 percent of OHC providers 

do not treat patients with I/DD. For those 

who do, the majority treat between 1 and 

49 per year. Despite challenges in rendering 

care to adults with I/DD, most OHC providers 

who responded said they feel a sense of 

responsibility, want to give back, and find it 

rewarding.

Low Medicaid reimbursement rates, 

the need for extended appointment times 

with no additional compensation, policies 

prohibiting sedation and restraints, and 

limited access to the operating room were 

the most common reasons why OHC 

providers stopped treating adults with I/DD 

and/or limited their practice.

One dentist commented, “I participate 

as an adult Medicaid provider because 

there is a huge need in the community! 

What limits us from doing treatment is they 

only allow $275 worth of treatment when 

these patients are the ones that tend to 

have poor OH [oral hygiene] and need extensive 

treatment.”

Another dentist shared, “I have not left, 

but let’s speak very honestly here. Medicaid 

pays overwhelmingly 

poorly, particularly in 

Kentucky where the 

managed care plans 

cut fees by an average 

of 10 percent from the 

existing KY Medicaid 

rates, approximately 

eight years ago. . . . 

There exists minimal 

incentive to take 

Medicaid when you break down the overall cost 

per patient, the administrative issues/difficulties/

burdens imparted by filing for state and federal 

“I participate as an adult Medicaid 

provider because there is a huge 

need in the community! What limits 

us from doing treatment is they only 

allow $275 worth of treatment when 

these patients are the ones that tend 

to have poor OH [oral hygiene] and 

need extensive treatment.”

Provider perspective on 

disincentives to treat people with 

I/DD within Medicaid programs

“I have not left, but let’s speak very honestly 

here. Medicaid pays overwhelmingly 

poorly . . . There exists minimal incentive to 

take Medicaid when you break down the 

overall cost per patient, the administrative 

issues/difficulties/burdens imparted by filing 

for state and federal dollars, and the high 

occurrence of sociocultural issues with 

patients that further complicate the process. 

People who take Medicaid don’t really do it 

for the money, but when you stop and look 

at how little you make relative to the overall 

cost, it quickly looks like a place to exit the 

Medicaid game.”

38 National Council on Disability
dollars, and the high occurrence of sociocultural 

issues with patients that further complicate the 

process. People who take Medicaid don’t really 

do it for the money, but when you stop and look 

at how little you make relative to the overall 

cost, it quickly looks like a place to exit the 

Medicaid game.”

Second Provider Questionnaire: 

Round 2

Comments gathered from just under nine 

hundred OHC providers across the United 

States in Round 1 were analyzed and grouped 

by like-themes for the development of the 

Round 2 questionnaire. The purpose of 

the Round 2 questionnaire was to narrow 

the field of responses from OHC providers 

moving toward consensus. One hundred and 

sixty-six OHC providers responded to the 

Round 2 questionnaire. One hundred and 

fifty-three providers answered the question 

regarding whether they participated in Round 

1. Thirteen skipped this question. Of these 

respondents, 92 (60.13%) participated in 

Round 1 and the remaining 61 OHC providers 

(39.87%) indicated they had not. Among the 

166 respondents to Round 2, 128 responded 

to the question regarding age. 51.56 percent 

indicated they were between ages 25 and 49 

years, compared with 31.25 percent between 

ages 50 and 64 years, and 17.19 percent ages 

65 years and older. Regarding the question 

of primary practice model, of the 128 OHC 

providers who answered this question, 74.22 

percent indicated they were from private 

traditional practice settings, 11.72 percent 

were from federally qualified health centers, 

5.47 percent were from corporate (dental 

service organizations); 3.9 percent were from 

community or mobile clinics; 3.13 percent were 

from hospital clinics; and 1.56 percent were 

from academia.

In Round 2, the researchers limited the 

questions to only those in which 30 percent or 

more of the providers agreed on the importance 

of a theme in Round 1. Researchers drafted 

statements based on information gathered 

in Round 1 and then asked OHC providers to 

specify their level of agreement using a fivepoint Likert scale: “I disagree very strongly.” 

“I disagree.” “Neither disagree nor agree.” 

“I agree.” “I agree very strongly.” Round 2 

questions may be viewed in Appendix D.

Based on the Round 2 provider responses, 

the number one item selected to influence 

an OHC provider’s decision to participate in 

Medicaid programs that serve adults with 

I/DD was supportive of patients with I/DD—

“helping people in need.” Following this were 

several items that dissuade providers from 

participating in Medicaid. These included 

“missed appointments;” “low reimbursement 

rates;” “cost;” “inadequate dental benefits 

and coverage;” and “Medicaid prior approval 

policies.”

Regarding suggestions to increase 

participation in Medicaid dental programs, the 

items that ranked highest were “adjusting 

reimbursement rates annually;” “implementing 

provider incentives;” “delivering patient 

incentives;” and “permitting billing for missed 

appointments.”

Finally, the factor that most influenced the 

OHC providers’ decisions to treat adults with 

I/DD were “filling a critical unmet need;” After 

this, “time;” “feeling competent;” “staffing;” 

and “having the appropriate equipment” were 

selected.

Incentivizing Oral Health Care Providers to Treat Patients 39
Discussion

Round 2 provided an opportunity for researchers 

to narrow the field of items that OHC providers 

perceive to be important factors when 

considering Medicaid 

participation and 

treatment of adults 

with I/DD. In Round 2, 

the researchers were 

successful at collecting 

data that strengthened 

the level of importance 

of such items. The 

outcome of Round 2 questions portrays a 

spectrum of dentistry that seeks to serve 

patients with I/DD and even challenging behavior 

but is concerned about the reimbursement. For 

those 80 of 166 providers who were concerned 

about behavior, further analysis is needed to 

determine the correlation with reimbursement. 

It is obvious that behavior lengthens and 

prevents appointments that in turn increases the 

cost factor of treatment.

Eight factors to 

increase participation 

in Medicaid were 

proposed in this 

questionnaire. More 

than 72 percent of 

dentists responded that 

they agreed or agreed strongly that annual 

reimbursement rate adjustments would cause 

them to participate.

Other incentives such as the number of 

patients and preventive services were less 

influential. This response indicates that dental 

providers are focused on the completion of a 

treatment plan as the indicator of success. The 

emphasis on prevention is perceived as less 

profitable.

Of the eight factors, only the reimbursement 

annual adjustment had broad consensus support. 

Sixty percent of responding providers stated 

they agreed or strongly

agreed that specialized 

training would help 

render care to adults with 

I/DD. Other supports to 

patients did not garner 

broad consensus. These 

included case/care 

management, incentives, or billing for missed 

appointments and reimbursement for behavioral 

support (only 30% agreed). Consensus was 

evident on some issues: “Treating adult patients 

with IDD requires more time.” (88%) and “Dental 

providers should have real time access to medical 

histories of patients with I/DD.” (74%). Sixty-eight 

percent of questionnaire respondents stated that 

“Treating patients with I/DD is rewarding.”

Third Provider 

Questionnaire: 

Round 3

Responses from the 

first two questionnaires 

helped to shape the 

third questionnaire. In 

Rounds 1 and 2, the research team attempted to 

understand factors and strategies that influence 

an OHC provider’s decision to participate in 

their state’s Medicaid dental program. In Round 

3, OHC providers were asked to rank order by 

importance a list of factors and strategies that 

had been identified in the previous rounds. In 

response to Round 3, 109 providers ranked 

More than 72 percent of dentists 

responded that they agreed or 

agreed strongly that annual 

reimbursement rate adjustments 

would cause them to participate.

Sixty percent of responding 

providers stated they agreed or 

strongly agreed that specialized 

training would help render care to 

adults with I/DD.

40 National Council on Disability
the items based on their perceived level of 

importance.

Round Three: Section One—Medicaid 

Participation

In Round 3, Question 2, providers ranked (1–10) 

factors from Rounds 1 and 2 that influenced their 

decision to participate 

in the state Medicaid 

dental program. These 

included: cost, provider 

reimbursement rates, 

participation in Medicaid 

managed care, helping 

people in need, behavior 

of Medicaid patients with 

I/DD, existing Medicaid 

dental benefit/covered services, Medicaid 

administrative policies, missed appointments, 

prior approval policies, and Medicaid audits.

More than half of responding providers 

ranked helping people in need (58.71%) and 

reimbursement rates (79.82%) as the factors 

that most influence their 

decision to participate 

in a Medicaid dental 

program. The factor of 

cost ranked behind as the 

most critical rated by 54 

percent of providers. Next 

reported was missed 

appointments; 33 percent of providers ranked 

this item in the top three levels of importance. No 

other factor exceeded 3 percent of providers to 

rank as their most primary concern.

This reflects a common desire to help patients 

with I/DD, compounded by a consensus on 

problematic reimbursement rates. In fact, nearly 

80 percent of providers ranked the issue of

reimbursement rates as either first, second, or 

third in their priority of factor importance, while 

59 percent ranked helping people in need as first, 

second, or third in priority.

In Question 3, providers were asked to rank 

strategies that they think Medicaid administrators

should implement to 

increase OHC provider 

participation in Medicaid 

dental programs. The 

following eight strategies 

were captured from 

Round 2 for inclusion 

in this round: annual 

adjustments of dental 

reimbursement rates, 

provider participation incentives, provider 

performance incentives, provider incentives 

based on number of patients seen per year, 

provider incentives based on preventive service 

delivery, coverage for case/care management 

services, policy permitting billing for missed 

appointments, and 

patient incentives to keep 

appointments.

Of the eight 

strategies listed, 

61 percent of 

respondents ranked 

annual adjustments 

of dental reimbursement rates as their first 

choice. The second closest strategy was 

provider participation incentives at 12 percent, 

followed by policy permitting billing for missed 

appointments.

Question 4 asked OHC providers to rank on a 

scale of 1 to 10 the factors in order of importance 

More than half of responding 

providers ranked helping people in 

need (58.71%) and reimbursement 

rates (79.82%) as the factors that 

most influence their decision to 

participate in a Medicaid dental 

program.

[N]early 80 percent of providers 

ranked the issue of reimbursement 

rates as either first, second, or 

third in their priority of factor 

importance . . .

Incentivizing Oral Health Care Providers to Treat Patients 41
that would influence them to treat individuals 

with I/DD. The following factors were identified by 

providers in Rounds 1 and 2 and were included in 

Round 3: having hospital privileges, professional 

organization(s), professional peers, treating 

adults with I/DD fulfills a critical unmet need, 

time, feeling competent, 

staff, specialized office 

equipment, and treating 

adults with I/DD fulfills 

a moral and ethical 

obligation.

Providers rated time

as the greatest factor 

(scoring 6.22 of 10) in 

their decision to treat 

persons with I/DD. 

Forty-seven percent 

of OHC providers 

ranked time as one of their top three priorities. 

This indicates that dental providers expressed 

difficulty in providing a procedure within the 

time considered profitable. Staff was stated 

by more than half of providers as a limiting 

factor to serving adults with I/DD. During the 

COVID-19 pandemic, staff shortages emerged 

as a significant issue for 

dental practices. It is 

unclear if this response 

is related to generalized 

staffing issues or if it 

reflects a lack of staff 

training or willingness 

to serve adults with I/DD. OHC providers also 

ranked treating adults with I/DD fulfills a critical 

unmet need (5.96 of 10) and treating adults with 

I/DD fulfills a moral and ethical obligation (5.16 

of 10) as their second and third highest priorities, 

respectively.

In Question 5, OHC providers ranked (1–10) 

in the order of importance their experiences 

reported in the Round 2 questionnaire. The 

following rank order scores were captured: 

(1) more time required—average 6.47; (2) very 

challenging—5.80; (3) patients need to be 

desensitized and this 

takes knowledge, skill, 

and competency—5.09; 

(4) patients’ behavior 

requires support—4.57; 

(5) very rewarding—4.36; 

(6) need for four-handed 

dentistry—3.76; (7) 

limited training and 

experience—3.39; and 

(8) lack of real-time 

access to medical 

records—2.56.

The top four ranked experiences reveal a 

consensus that all relate to the challenge of 

behavior in treating adults with I/DD. It appears 

that most OHC providers desire to treat patients 

and complete a procedure; however, they view 

patient needs, such as desensitization, as 

challenges that require more time, knowledge, 

skill, and support. The 

experience factor of 

being very rewarding 

was listed as fifth out 

of the eight factors in 

order of importance. This 

would imply that while 

dentists were found in the previous question to 

recognize the moral and ethical need, they feel a 

dissonance in the ability to reconcile the delivery 

of that care for completion of procedures. The 

emphasis on collaborative care, wellness, health 

promotion, and prevention found in medical plans 

[P]roviders were asked to rank 

strategies that they think Medicaid 

administrators should implement to 

increase OHC provider participation 

in Medicaid dental programs . . . 

61 percent of respondents ranked 

annual adjustments of dental 

reimbursement rates as their first 

choice.

[D]ental providers expressed 

difficulty in providing a procedure 

within the time considered 

profitable.

42 National Council on Disability
has not been integrated and incorporated into 

an effective reimbursement model that includes 

and incentivizes dental teams to treat patients 

with I/DD.

In Rounds 1 and 

2, dental providers 

were asked to explain 

the types of supports 

or accommodations 

needed to render dental 

care more easily and 

effectively to adult 

patients with I/DD. 

Among the responses 

provided, eight themes were identified by 

providers as “needed support” for use in dental 

office, hospital, and community settings. The 

following eight supports or accommodations 

needed were included in Round 3, Question 

6: specialized training, availability of financial 

support to cover costs associated with 

increased time and staffing needs, use of care 

management facilitators to support dental 

care, use of outreach facilitators to link patients 

to specialized social services, increased 

reimbursement to support longer dental visits, 

increased frequencies for preventive dental 

benefits, coverage for oral health education and 

preventive tele-dentistry services, and financial 

support to cover specialized equipment.

Of the 109 responding providers, 75 

replied to this question with a consensus of 

these top three reasons: (1) availability of 

financial support to cover costs associated 

with increased time and staffing needs (80% 

of responders [60] ranked this reason as first, 

second, or third); (2) increased reimbursement 

to support longer dental visits (59% [44] 

ranked this as first, second, or third); and (3) 

specialized training (52% [39] ranked as first, 

second, or third).

It is revealing that most dentists responded 

that those solutions 

related to the challenges 

of reimbursement 

and training were 

important, yet they 

rated very low their 

belief in the proposed 

accommodations 

or support of care 

management (2), 

outreach facilitators 

to social services (2), coverage for oral health 

education and preventive tele-dentistry services 

(1), and financial support for specialized 

The emphasis on collaborative 

care, wellness, health promotion, 

and prevention found in medical 

plans has not been integrated 

and incorporated into an effective 

reimbursement model that includes 

and incentivizes dental teams to 

treat patients with I/DD.

Incentivizing Oral Health Care Providers to Treat Patients 43
equipment (1). Further, it is significant that 

11 respondents (15%) supported increased 

frequency of preventive dental visits.

In the final question, researchers attempted 

to understand why dental providers do not 

treat adults with I/DD, and the types of 

changes needed to begin treating them in their 

practices. Providers were asked to rank, in 

order of importance, the following actions that 

would impact them to participate in Medicaid 

dental programs. To achieve consensus on 

these actions, providers ranked the following 

in first, second, or third level of importance for 

the impetus to begin service for adults with 

I/DD: (1) mandate states to assess, adjust, and 

reset reimbursement 

rates annually (55 of 

75, 73%); (2) mandate 

states to set dental 

reimbursement rates to 

90 to 95 percent of the 

federal/state’s employee 

dental benefit (50 of 

75, 67%); (3) mandate 

MCPs to implement provider reimbursement 

rates to 90 to 95 percent of commercial dental 

benefit plans offered to federal and state 

employees (37 of 75, 49%); (4) implement 

tax-credit program for OHC providers who treat 

a “significant” number of Medicaid patients 

(16 of 75, 21%); (5) establish a specialized 

Medicaid MCP unique for I/DD adult patients 

(13 of 75, 17%); (6) increase reimbursement 

for extended appointment times and behavior 

management of adults with I/DD (13 of 75, 

17%); (7) implement reimbursement for teledental preventive services (10 of 75, 13%); 

(8) design and implement a Medicaid dental 

provider loan forgiveness program for treating 

Medicaid beneficiaries with I/DD (6 of 75, 

8%); (8) implement value-based incentives for 

providers (5 out of 75, 7%); (9) implement tax 

credit for OHC providers who meet a specified 

goal for delivering adult preventive dental 

services, treating x number of adults with 

I/DD, or treating adults with I/DD outside of 

the operating room (5 of 75, 6%); (10) design 

and implement a provider practice protection 

program (wraparound money) for providers 

who treat 100 or more adult Medicaid patients 

with I/DD per year (4 of 75, 5%); (11) expand 

provider eligibility to include a case/care 

manager in dental offices (4 of 75, 5%); (12) 

provide training to support the treatment of 

individuals with I/DD (4 

of 75, 5%); (13) develop 

policy to mandate care 

management services 

at the health plan level 

for Medicaid patients 

with I/DD (2 of 75, 3%); 

and (14) implement 

advanced policies that 

permit dental providers to render IV sedation 

and/or oral sedation in the dental office setting 

(1 of 75, 1%).

Discussion

Consensus was reached on reimbursement rates

as the top three strategies toward advancing 

OHC provider participation in Medicaid programs 

that support dental care services for adults with 

I/DD. It can be surmised that dentists propose 

solutions of which they have the most familiarity 

of a predictable impact. Thus, a consensus on 

those familiar solutions is apparent. Very few 

dental teams include the connections to social 

supports that drive the determinants of health, 

OHC providers focus on the 

immediate financial challenges to 

provide care and are less inclined to 

endorse supports to families until 

that existential fiscal challenge is 

addressed.

44 National Council on Disability
and less are convinced of the impact of these 

accommodations. These results give rise to the 

belief that dental attitudes may change when 

educated to the possibility of improving oral 

health outcomes rather than viewing completion 

of treatment plan. OHC providers focus on the 

immediate financial challenges to provide care

and are less inclined to endorse supports to 

families until that existential fiscal challenge is 

addressed. Similarly, creative uses of Medicaid 

options to change the health outcomes through 

care managers or even loan forgiveness did 

not appeal to the majority of respondents. 

This reinforces the understanding that financial 

pressures drive the decision to provide care to 

adults with I/DD.

Incentivizing Oral Health Care Providers to Treat Patients 45
46 National Council on Disability
Chapter 4: Demonstrating a Return on Investment

Adults with intellectual and developmental 

disabilities (I/DD) form an aging 

population living and contributing to 

communities across the United States. Accessing 

community-based social 

and health care services 

is essential for people 

with I/DD to maintain 

their independence, 

overall health, and wellbeing. This includes the 

ability to receive dental 

care close to home 

where transportation and other access barriers 

are minimized.

As mentioned in Chapter 3, many dental 

providers do not participate in Medicaid programs 

or waivers serving people with I/DD. In addition, 

many who do participate in the Medicaid programs 

do not treat people with I/DD. The reasons for this 

have been well documented in this report.

People with I/DD often experience complex 

medical conditions placing them at higher risk 

for disease and disability. When the number of 

available dental practices are reduced either 

because of existing Medicaid policies or lack 

of willingness by dental providers to treat 

people with I/DD, the prevalence of dental 

disease among the population living within the 

community increases along with significant 

pain and suffering for the individuals. Need for 

care is heightened, and people are forced to 

visit the emergency department for temporary 

relief of pain and suffering, only to return soon 

thereafter. This cycle 

of emergent care does 

not prevent, manage, or 

eliminate disease; and 

its cost to the person, 

the community, and 

government programs 

paying for such services 

is high.

Better care and improved health outcomes at 

lower costs may be realized through value-based, 

Framework for achieving ROI 

for a traditional Medicaid dental 

program

1. Identifying applicable Medicaid authority

2. Determining eligibility

3. Defining the population

4. Designing the dental benefit

5. Determining the reimbursement rates

6. Demonstrating an ROI

This cycle of emergent care does 

not prevent, manage, or eliminate 

disease; and its cost to the person, 

the community, and government 

programs paying for such services 

is high.

Incentivizing Oral Health Care Providers to Treat Patients 47
integrated, preventive health care programs. 

Such programs have been well designed and 

demonstrated in Medicare. These models have 

not been fully understood and recognized by the 

dental industry, or by Medicaid-funded dental 

programs.

For this report, NCD explored the potential 

return on investment (ROI) to funding a Medicaid 

dental benefit for adults with I/DD. Researchers 

proposed that the health 

care model must be 

integrated, preventive 

focused, and value 

based. The research team 

designed a framework 

with steps toward 

achieving an ROI for 

a traditional Medicaid dental program. Steps 

of the model include identifying the applicable 

Medicaid authority (legislation, regulation, federal 

or state program) under which the benefit will 

fall, determining eligibility (setting parameters), 

defining the population, designing the dental 

benefit (eligible services, frequencies, and 

limitations), determining the reimbursement 

rates, overlaying the financial model, and 

demonstrating an ROI. A brief description of these 

steps is listed next. These steps do not provide a 

technical description, as specifications may vary 

by Medicaid authority and program type. Such 

steps may also be adapted for Medicare, should 

an integrated program for people with I/DD be 

included under this government program.

Step 1. Explore existing state Medicaid 

authority to determine which policy pathway 

would best support an integrated health care 

model for adults with I/DD. Review the state 

plan to see if a dental benefit for adults exists. 

If an adult dental benefit exists, consider if it 

can be modified for adults with I/DD through a 

state plan amendment. If one does not exist, 

consider whether one may be added via a 

state plan amendment, or explore the potential 

development of integrating a dental benefit into a 

Medicaid waiver. Several different kinds of state 

Medicaid waivers exist where dental benefits 

could potentially be integrated.

Step 2. Determine who would be eligible 

under the new program. Medicaid eligibility

is established under 

federal law, and states 

have the authority to 

expand that eligibility 

(individuals who qualify 

under § 435.217).9 States 

may differ in eligibility, so 

understanding the unique 

legislative or regulatory language under any given 

state Medicaid program is essential. Investigate 

state Medicaid rules and other legislative language 

to determine Medicaid eligibility.

Step 3. Define the I/DD population to 

establish fiscal program parameters. This step 

is challenging as definitions of I/DD vary by federal 

and state agencies and even by state programs. 

Some states cluster groups by their disability, 

and others separate them. Understanding who is 

eligible for a new program is dependent upon how 

the population is defined and/or how a population 

may already be defined under an existing waiver. 

For example, the Supplemental Security Income 

program, an important Medicaid eligibility pathway 

for people with I/DD, generally uses conditionspecific definitions and does not recognize 

developmental disabilities.10 Other examples 

include alignment with the Developmental 

Disabilities Assistance and Bill of Rights Act of 

200011—reliant upon three or more substantial 

functional limitations; intellectual disability—using 

an explicit IQ score combined with an assessment 

Better care and improved health 

outcomes at lower costs may be 

realized through value-based, 

integrated, preventive health care 

programs.

48 National Council on Disability
of adaptive deficits in the conceptual, social, and 

practical skills learned by people that help them 

function in their everyday lives; alignment with 

the broader construct described by the American 

Association on Intellectual and Developmental 

Disabilities; and inclusion of specific conditions 

such as autism, cerebral palsy, Down syndrome, 

epilepsy, and/or neurological impairment.12

Step 4. Design an evidence-based dental 

benefit. As part of this 

process, care should 

be taken to explore the 

professional literature to 

identify standards of care, 

professional guidelines, 

and evidence-based 

services that meet the specific needs of people 

with I/DD. Technical assistance from subject 

matter experts will help to provide clarity. Frame 

a basic dental fee-for-service benefit.13 Once the 

actual service codes are determined (based on 

the Code on Dental Procedures and Nomenclature 

[CDT Code]),14 set frequencies and limitations for 

each dental service.

Step 5. Set reimbursement rates. This 

step can be very challenging, as it requires the 

strategic weighing of the impact of rates on 

provider satisfaction against the state Medicaid 

budget. Rates that are too low discourage 

provider participation in the Medicaid dental

program network. Rates that are too high 

tax the state budget. States must balance 

their budgets annually—this means a finite 

budget with rules for 

cost accounting and 

containment.

Figure 3 is an example 

of a tool used to design a 

dental benefit for adults 

with I/DD and estimate 

its costs. Columns three and four quantify the 

frequencies and limitations. Reimbursement fees 

from an existing state Early and Periodic Screening, 

Diagnostic, and Treatment (EPSDT) benefit program 

were used as a starting point to set the new 

program rates. The last two columns allow for rate 

adjustments. These are considered independently 

for each dental service to address the added time 

Rates that are too low discourage 

provider participation in the Medicaid 

dental program network. Rates that 

are too high tax the state budget.

Figure 3. Example of Preventive Dental Benefit Modelin

Incentivizing Oral Health Care Providers to Treat Patients 49
it may take a provider to perform a procedure, and 

any advanced treatment needs of the patient.

Step 6. Overlay the financial model to 

quantify the costs of the program by inputting 

an estimated number of eligible enrollees, 

services, unit costs, and expected use 

of services. Figure 4 is an example of preventive 

services proposed for inclusion in a Medicaid 

dental benefit. On the left, the services are 

listed along with the proposed unit cost. On 

the right, the number of Medicaid-enrolled 

adults with I/DD is indicated in the first column. 

The number of enrollees to use the services is 

proposed and listed in the second column. The 

anticipated frequency for each service is listed 

in the third column. The total number of services 

for the year is calculated and listed in the fourth 

column with a total annual cost of all anticipated 

services ($54,168,214) computed in the last 

column.

The second half of this step is to assess 

the total costs listed in the last column and 

determine if any cost adjustments need to take 

place. Administrators may use any of the financial 

levers listed in the model below to adjust the 

annual costs of services. In this case, Figure 5. 

Figure 4. Example of the Financial Model for a Preventive Dental Benefit for

People with Intellectual and Developmental Disabilities

Figure 5. Example of Potential Cost Adjustments Using Financial Lever

50 National Council on Disability
demonstrates the elimination of fluoride treatment 

from the list of services. All costs associated with 

that service were deleted from the model. As 

a result, the total annual costs were reduced to 

$46,781,639.

A final piece to this step is applying the 

Federal Medical Assistance Percentage (FMAP), 

also referred to as the federal match. This 

percentage differs by state and by programs. 

In this example, the FMAP was 64 percent. 

Applying the FMAP 

to the model reduced 

the state cost of the 

proposed dental benefit 

to $16,841,390. Figure 6 

shows the state costs 

after applying the FMAP 

to the model.

Step 7. The final step in building the model 

is demonstrating a cost-neutral dental benefit 

and ROI. Cost-neutrality means that aggregate 

costs do not increase. To achieve this, costs may 

be shifted from one state program to another. 

ROI is a financial calculation that demonstrates 

costs invested in one area result in savings in 

another. It is used to identify past and future 

financial returns. If a state is going to invest in a 

dental benefit for adults with I/DD, the questions 

state accounting officials consider are as follows: 

Where in the state budget could dollars be 

shifted to support a dental benefit? Where in the 

state budget might savings be realized?

To determine this, the research team 

adopted a process previously developed 

by the Medicaid|Medicare|CHIP Services 

Dental Association (MSDA) in collaboration 

with researchers from Brandeis University, 

Massachusetts.15 Researchers investigated 

state general fund 

expenditures by function 

to identify those state 

departments and 

programs that support 

and help to maintain 

health, social, and 

other services for 

people with I/DD. These included Medicaid, the 

largest state budget expenditure, education, 

transportation, unemployment, public assistance, 

and other related social service programs as 

described in the 2021 State Expenditure Report

by the National Association of State Budget 

Officers.16 From this information, the researchers 

considered other state programs where dollars 

could potentially be shifted to realize costneutrality and/or ROI.

ROI is a financial calculation that 

demonstrates costs invested in one 

area result in savings in another. It 

is used to identify past and future 

financial returns.

Figure 6. State Costs After Applying the Federal Medical Assistance Percentag

Incentivizing Oral Health Care Providers to Treat Patients 51
In 2016, MSDA in collaboration with 

researchers at Brandeis University developed a 

tool to demonstrate the potential ROI to funding a 

Medicaid adult dental benefit. The tool illustrates 

how a state may strategically develop or enhance 

an existing benefit and overlay the costs to 

demonstrate an ROI or cost-shifting from other 

state departments and programs. In the previous 

study, the researchers explored the literature 

to identify direct and indirect linkages between 

poor oral health and state-funded programs. 

Three economic pathways were identified. These 

included underemployment/unemployment, opioid 

misuse, and the medical costs associated with 

end-stage renal disease and liver transplants. 

The result of the original research demonstrated 

an ROI to the state for funding a Medicaid adult 

dental benefit. Since that time, several states have 

used the tool to calculate cost offsets in the overall 

state budget. The full methodology and results 

have been previously published.17 Further study 

will be needed to determine whether these costoffset pathways apply to adults with I/DD and/or 

if additional direct or indirect linkages between 

poor oral health among people with I/DD and other 

government program costs can be identified and 

applied to the model.

For the purposes of this report, the research 

team explored the potential use of this tool and 

how it may be adapted to demonstrate an ROI 

on a dental benefit uniquely designed for adults 

with I/DD.18 Following is a description of the tool, 

its chapters or sections, and potential inputs for 

calculating an ROI for a dental benefit for adults 

with I/DD. This tool has been validated for use in 

estimating the ROI for an adult Medicaid dental 

benefit. Further study is needed to test inputs 

specifically designed to realize an ROI for a dental 

benefit for adults with I/DD.

Chapter 1: Context

■ Table of Contents (TOC): The TOC includes 

an interactive link to the contents of the 

chapter and the pages (tabs) included in the 

ROI tool.

■ Background and Objectives: This section 

identifies a series of variables and data sets 

that have been incorporated into the tool 

to demonstrate state-specific impact in the 

final calculations and results.

■ Getting Started—The Basics: This section 

includes a description of the step-by step 

process the user takes in each of the 

input’s tabs, including the use of drop-down 

choices, and how choices impact various 

formulas in the tool.

Chapter 2: Inputs

■ State and Other Financial Characteristics:

This tab is used to input specific state-based 

programmatic information and data. Various 

financial drivers (expenditures and state tax 

revenue) that may impact the calculation of 

the ROI are included.

■ State Medicaid Characteristic: This 

section focuses on key Medicaid program 

characteristics such as overall population, 

Medicaid program expenditures, and 

the proposed Medicaid dental program 

information.

Chapter 3: Policy Change

■ Expansion of Dental Benefits: This tab helps 

the user describe the proposed expansion in 

dental coverage. It includes estimates of the 

proposed new benefit or expanded dental 

benefit.

52 National Council on Disability
■ Explore Potential Costs of Dental Benefit:

The Cost tab is designed to help explore 

possible costs related to adult dental 

coverage. It allows the user to explore 

multiple possibilities in sequence and can 

be saved for multiple scenarios. This tab 

helps demonstrate a range of both costs 

and offsets for a given change in dental 

coverage.

■ Reduction in Dental Benefits: The Reduce

tab is designed to help states explore and 

estimate the impact of either a reduction or 

a total elimination of an adult dental benefit 

on the input variables.

■ Note: This chapter includes two tabs that 

require state data be input.

Chapter 4: Calculations

■ Oral Health Aesthetics Index Related 

Offsets: This section quantifies the 

aesthetic-related cost offsets based on the 

Dental Problem Index that was developed 

as part of the research study. Both Medicaid 

and state general revenue savings and 

state and federal tax revenue totals are all 

calculated.

■ Cost Offsets Secondary to Chronic Dental 

Pain: This tab calculates the aestheticrelated cost offsets based on the painrelated offsets that were identified as part of 

the research study.

■ Results Summary Table: This summary tab 

shows the total overall state budget impact 

for both pathways used in the study. The 

analysis table includes a Costs Section, an 

Offsets Section, and a Benefit-Cost Ratio 

Section. The overall state budget impact also 

includes budgeted federal revenue.

■ Offsets Summary Table: This final summary 

table includes a state total of the offsets 

for the specific areas of the study: 

employability, pain-related and direct 

Medicaid-related. This includes a value of 

the costs, percentage of coverage costs that 

are offset, and a net savings or loss from a 

reduction in coverage.

Chapter 5: Appendices

■ This series of tabs includes current data 

and information from various public sources 

that serve to pre-populate many of the 

worksheets within the ROI tool chapters. 

These pre-populated tabs include data in the 

following areas:

❍ State socioeconomic statistics

❍ Coverage statistics by state

❍ Medicaid/CHIP income eligibility 

requirements by state

❍ List of dental codes and rates

Chapter 6: Supplements

■ References

■ Glossary of terms

■ Examples

■ Acknowledgments

Value-Based Care and Shared 

Savings

Over the last two decades, several legislative 

changes in Medicaid and Medicare have 

taken place resulting in improvements in 

policy, program administration, and services.19

These changes have led to the development 

of innovative models that allow for more 

flexibility of services for beneficiaries, 

Incentivizing Oral Health Care Providers to Treat Patients 53
alternative payment schedules for providers, 

various administrative models for states, and 

lowered health care costs. These models, most 

of which have been 

implemented under the 

Medicare program, have 

demonstrated significant 

improvements in health 

and health care, while 

lowering costs.

Medicaid dental 

programs have been 

slow to follow suit. 

This is due to the lack 

of knowledge and 

understanding of how 

these models work and may be adapted to 

dentistry. Since its inception, the dental industry 

has operated under the traditional fee-for-service 

(FFS) model. Under this model, dental providers 

are paid for each service performed. All dental 

services or procedures 

are coded by CDT 

Code. The CDT Code 

Maintenance Committee 

of the ADA manages the 

set of codes.

Missing from dental 

practice are diagnostic

codes, such as the 

International Classification 

of Diseases (ICD) codes, 

which medical providers 

and payers use to monitor 

health status, monitor disease prevalence, and 

assess for medical necessity—conditions that 

Missing from dental practice are 

diagnostic codes, such as the 

International Classification of 

Diseases (ICD) codes, which medical 

providers and payers use to monitor 

health status, monitor disease 

prevalence, and assess for medical 

necessity—conditions that require 

health care services.

54 National Council on Disability
require health care services. Like dentistry, 

medicine uses a procedure coding system entitled 

the Current Procedural Terminology (CPT®). 

This set of codes provide the uniform language 

for coding medical services and procedures 

used to pay for services that are medically 

necessary.

20,21 By using both coding systems, 

Medicaid, Medicare, and other payers can more 

effectively assess medical necessity against the 

appropriateness of the procedure(s) being billed. 

In other words, if diagnostic coding were used 

in dentistry, payers could better understand the 

health outcomes of dental care and more easily 

design value-based payment incentives.

In addition, quality in program and provider 

performance can be measured against the health 

outcomes of the individual and populations 

served.

In 1991, the 

Institute for Healthcare 

Improvement (IHI) 

founded the science of 

improvement aimed at 

helping health systems, 

countries, and other 

organizations advance 

quality, safety, and value in health care.22 IHI has 

three goals for health care delivery systems:

■ Optimally use their resources to deliver 

better outcomes for patients and achieve 

financial sustainability.

■ Catalyze faster progress in the 

transformation of health care delivery to 

advance patient and population outcomes, 

leveraging improvement science methods 

that achieve better results per unit of cost.

■ Reduce the burden of health care and allow 

reallocation to other societal needs.23

The concept of value-based care is an 

evolution of this process that builds on these 

goals to transition systems of care from volume 

to value.

Value Equation: Value = Quality/Cost

The traditional dental model encourages 

volume over value, discourages preventive over 

surgical, and costs more. 

This means dental care 

is primarily focused on 

treatment after disease 

occurs. The cost of 

treating disease far 

exceeds the cost of 

preventing it.

Moving dental care to a value-based model 

will promote quality and prevention, improve 

health outcomes, and lower costs. Shared 

savings is a value-based payment model that 

rewards dental providers for delivering higher 

quality oral health care services to beneficiaries. 

The model that follows shows a shared savings 

model that was developed by Boston Children’s 

Hospital (BCH) in collaboration with MSDA 

in 2012. The model aims to reduce operating 

room treatment of early childhood caries (ECC) 

and reduce treatment costs to the MassHealth 

Dental Program.

This means dental care is primarily 

focused on treatment after disease 

occurs. The cost of treating disease

far exceeds the cost of preventing it.

Incentivizing Oral Health Care Providers to Treat Patients 55
In the BCH model, providers were incentivized 

to shift treatment approaches of ECC from the 

surgical treatment model to a preventive, disease 

management approach. Providers used topical 

fluoride varnish and/or silver diamine fluoride to 

arrest dental disease rather than treat caries with 

surgical restoration.

BCH demonstrated 

that by shifting the 

treatment modality to 

a preventive, caries 

disease management 

model, dental disease 

was arrested, young 

children were spared the risks associated with 

the operating room, significant savings were 

observed by the MassHealth Dental Program, 

and participating providers were remunerated 

through a shared savings model.

Table 6 demonstrates the reduced operating 

room costs, savings to the state, and how 

those savings may be shared with providers to 

incentivize preventive, risk-based oral health care 

in the BCH program.

Table 6 shows the results of a record 

review at BCH that revealed that for the 129 

patient records reviewed, 20.9 percent of the 

patients were referred to the operating room 

for treatment of ECC. 

A subsequent study 

of the 401 patients 

enrolled in the ECC 

disease management 

project who received 

disease management 

services demonstrated reduced referrals 

to the operating room of only 10.9 percent. 

Had the 401 patients been treated under the 

traditional surgical approach provided to the 

historical control patients, there would have 

been 84 (20.9%) referrals to the operating 

room. Assuming the Medicaid payment 

Moving dental care to a valuebased model will promote quality 

and prevention, improve health 

outcomes, and lower costs.

Table 6. Boston Children’s Hospital Results of Early Childhood Caries Historical 

and Disease Management Protocols with Shared Savings

Patient Count: 129 401 401

Hx Control ECC DM 

Protocol

Reduction

Referral to OR 20.90% 10.90% 20.90% 48%

Patients 44 84 40 Fewer patients referred 

to OR

OR MassHealth 

Payment

$5,000 $5,000

$219,635 $419,045 $200,500 Reduction in 

MassHealth Payment

Incentive: 10% $20,050 $500 Per Patient kept 

out of OR

Net savings $180,450 $50 Per ECC patient

Note: DM, disease management; ECC, early childhood caries; Hx, history; OR, operating room.

56 National Council on Disability
for the operating room facility charge plus 

the anesthesiology charge, plus the dental 

treatment charge equaled approximately 

$5,000, a figure consistent with the 

MassHealth fee schedule at the time,24 the 

traditional approach would have cost Medicaid 

$419,045 or $87.00 per member/per month 

(PM/PM). Of the 401 

patients treated with the 

disease management 

service delivery model, 

only 44 patients (10.9%) 

were referred to the 

operating room. This 

48 percent reduction in 

the number of patients 

to the operating room 

reduced Medicaid 

payments to $219,635, 

a savings to Medicaid of approximately 

$200,500.

With the shared savings model, providers 

were then paid a percentage of the savings. In 

the previous example, the total amount available 

to pay out provider incentives was 10 percent 

($20,050) of the 

reduction in MassHealth 

payments. Shared 

savings payments to 

dental providers totaled 

$500/patient kept out of 

the operating room.

A similar shared 

savings model may be applied by Medicaid 

dental programs and other dental payers to 

incentivize dentists to deliver preventive, 

disease management dental care to patients 

with I/DD in their dental offices and not in the 

operating room.

Reimbursement Rates

Medicaid dental provider reimbursement rates 

are an important consideration when attempting 

to estimate the ROI to funding a dental 

benefit. Except for payment of dental services 

rendered in Federally Qualified Health Centers 

(FQHCs), most Medicaid dental programs 

continue to use a FFS 

payment methodology 

to reimburse dental 

providers.

Medicaid dental 

programs are required 

under federal law to 

produce and publish 

provider reimbursement 

fee schedules. The FFS 

provider reimbursement 

schedule is the actual 

amount to be paid to providers under a FFS 

program. Medicaid managed care plans 

(MCPs) that contract with Medicaid agencies 

to administer the dental benefits typically 

negotiate dental reimbursement rates with 

their network providers. Given this negotiation 

process, there may 

be different fee 

schedules or payment 

methodologies utilized 

by different plans. In 

some cases, the MCP 

rates are lower than 

the FFS reimbursement 

rates. States have the option to direct how 

MCPs pay their network providers, but that is 

not a Medicaid requirement. This practice has 

generated much confusion among oral health 

care (OHC) providers and, as such, has resulted 

A similar shared savings model 

may be applied by Medicaid dental 

programs and other dental payers 

to incentivize dentists to deliver 

preventive, disease management 

dental care to patients with I/DD in 

their dental offices and not in the 

operating room.

Medicaid FFS reimbursement 

rates, on average, are only 61.8 

percent of private dental insurance 

reimbursement for children and 

46.1 percent for adults.

Incentivizing Oral Health Care Providers to Treat Patients 57
in a decrease in the number of dental providers 

in some Medicaid managed care dental plan 

networks.

Regarding differences between Medicaid 

and commercial dental reimbursement rates, 

Medicaid FFS reimbursement rates, on average, 

are only 61.8 percent of private dental insurance 

reimbursement for children and 46.1 percent for 

adults.25

Shown in Figures 7, 8, 9, 10, and 11 are five 

charts illustrating a comparison between state 

Medicaid FFS and MCP reimbursement rate 

schedules. State and MCP names have been 

removed as plan information is considered 

proprietary. Each table compares specific dental 

service codes. The list of CDT service codes and 

labels depicted in each chart may be identified in 

Appendix F.

Figure 7. Comparison of “State A” Medicaid Fee-for-Service Rates with Managed

Care Plan Rates

Figure 8. Comparison of “State A” Medicaid Fee-for-Service Rates with Managed

Care Plan Rates

58 National Council on Disability
Figure 9. Comparison of “State B” Medicaid Fee-for-Service Rates with Managed

Care Plan Rates

Figure 10. Comparison of “State C” Medicaid Fee-for-Service Rates with

Managed Care Plan Rates

Figure 11. Comparison of “State C” Medicaid Fee-for-Service Rates with

Managed Care Plan Rates

Incentivizing Oral Health Care Providers to Treat Patients 59
60 National Council on Disability
Chapter 5: Promising Practices

State Medicaid dental program 

administrators, managed care plans 

(MCPs), providers, and people with 

intellectual and developmental disabilities (I/DD) 

continue to search for solutions to the dental 

care access issues people with I/DD face. 

Three overarching issues exist: (1) limited policy, 

coverage, and benefits to support oral health care 

services for people with I/DD; (2) limited oral 

health care provider availability and (3) limited 

financing to support essential oral health care 

services.

This report has 

discussed these 

issues in detail and 

has attempted to glean 

ideas from stakeholders 

for new and improved 

strategies to address 

these problems. Over the last several years, 

particularly due to the COVID-19 pandemic, these 

problems have intensified. Communities have 

come together to address the policy and program 

issues that create barriers and challenges for all 

stakeholders. Based on the recent collaborative 

efforts taking place across several states, it has 

become clear that a multipronged approach

toward a solution is essential. Strategies that only 

address state policy or provider needs and fail to 

understand beneficiary needs will fall short of the 

goal to improve oral health for people with I/DD.

Policy Advancement

Maryland

In 2018, Senate Bill 284—Maryland Medicaid 

Assistance Program—Dental Coverage for 

Adults—Pilot Program (Chapter 621 of the Acts of 

2018) was signed into law.26 The bill called for the 

development of an adult dental benefit for people 

ages 21 to 64 years who 

are dually eligible for both 

Medicare and Medicaid. 

Neither Medicaid nor 

Medicare cover general 

dental services for adults 

in Maryland. The bill 

required the Maryland 

Department of Public Health to amend its 1115 

Medicaid waiver so that dental services could be 

covered for the estimated 38,510 dual eligibles. 

Maryland’s 1115 waiver program is a statewide 

mandatory managed care program for Medicaid 

enrollees. In 2019, the Adult Dental Pilot was 

implemented. This “carve-out” program covers 

diagnostic, preventive, and restorative services, 

as well as dental extractions. The annual benefit is 

capped at $800 per person.

Strategies that only address state 

policy or provider needs and fail to 

understand beneficiary needs will 

fall short of the goal to improve oral 

health for people with I/DD.

Incentivizing Oral Health Care Providers to Treat Patients 61
In June 2022, the state of Maryland officially 

notified the Centers for Medicare and Medicaid 

Services (CMS) that the Adult Dental Pilot 

program will be phased out after January 1, 

2023. Legislation passed in the State General 

Assembly requires the expansion of the benefits 

to all enrolled Medicaid adults. Dental coverage 

will also be expanded to include enhanced 

restorative services such as crowns, oral surgery, 

endodontics, and periodontal services. The 

benefit will not require cost sharing, and the $800 

cap will be eliminated.

Louisiana

Louisiana Medicaid is expanding its 

comprehensive dental care to adults ages 21 

years and older with 

I/DD who are enrolled in 

the New Opportunities 

Waiver, Residential 

Options Waiver, or 

Supports Waiver. More 

than 12,000 people have 

access to the new dental 

coverage that began July 1, 2022. The coverage 

includes diagnostic services, preventive services, 

restorative services, endodontics, periodontics, 

prosthodontics, oral and maxillofacial surgery, 

orthodontics, and emergency care. The expansion 

was part of the Louisiana Department of Health’s 

Fiscal Year 2022 Business Plan, Together: Building 

a Stronger LDH and a Healthier Louisiana.27

New Hampshire

New Hampshire Medicaid will launch an adult 

dental benefit for people ages 21 years and over 

beginning April 1, 2023 after Governor Christopher 

Sununu signed into law HB103 and SB 422 on 

July 1, 2022. This signing culminates years of work 

by stakeholders across the state to close the gap 

in oral health care services for many disadvantaged 

adults living in New Hampshire. The benefit will 

cover medically necessary services including 

care coordination and transportation to dental 

appointments. A $1,500 annual per member 

cap will be implemented excluding the costs of 

preventive services. Cost sharing will be applied 

for non-preventive services for those members 

whose incomes fall above 100 percent of the 

federal poverty level. This amount is limited to 5 

percent of household income. A settlement with a 

vendor created the funding source for this benefit.

Medicaid|Medicare|CHIP Services 

Dental Association Oral Health Policy 

Academy

In September 2021, the 

Medicaid|Medicare|CHIP 

Services Dental 

Association (MSDA) 

launched a multistate 

Oral Health Policy 

Academy to advance 

Medicaid dental policy 

for adults with I/DD. Through funding provided by 

the Delta Dental Foundation, MSDA convened 

six state teams with representatives from 

state Medicaid agencies, organized dentistry, 

academia, philanthropy, and advocacy. The 

purpose of the learning academy was to assist 

states in finding policy solutions that would 

advance oral health and oral health care equity 

for adults with I/DD. Because Medicaid policy 

varies so much by state, the policy academy was 

structured to have full group learning sessions 

and then individual state breakouts. Discussions 

included content related to the three main 

problems (listed earlier) affecting access to dental 

The purpose of the learning 

academy was to assist states in 

finding policy solutions that would 

advance oral health and oral health 

care equity for adults with I/DD.

62 National Council on Disability
care for people with I/DD and the following 

strategies to address them:

■ Explore existing state Medicaid policy 

to identify traditional and nontraditional 

pathways for delivering and administering 

dental services to adults with I/DD.

■ Explore Medicaid managed care authorities 

states may utilize to deliver dental care to 

people with I/DD through MCPs, such as 

managed care organizations and prepaid 

ambulatory health plans.

■ Explore federal funding to support state 

efforts to fund an adult Medicaid dental 

benefit for people with I/DD.

In Chapter 4, the seven steps states are 

taking to develop a dental benefit for adults 

with I/DD are described. Through the policy 

academy, all states have learned how to design, 

develop, and implement a carve-out dental 

benefit for adults with I/DD. As part of this 

process, participants learned about Medicaid 

authorities such as state plans and Medicaid 

waivers as policy pathways for pursuing a 

new dental benefit. Michigan, Ohio, Indiana, 

North Carolina, New Hampshire, and Arkansas 

participated in the learning collaborative. All but 

one state has signed on for Year 2, which will 

focus on evolving a traditional dental benefit 

into a value-based program.

Dental Provider Training

Centers for Inclusive Dentistry 

Immersion Program at New York 

University

The Delta Dental Foundation Centers for 

Inclusive Dentistry Immersion Program is an 

intensive three-day continuing education course 

that offers hands-on experience for practicing 

dentists, dental hygienists, and dental assistants 

who are interested in expanding their skills and 

knowledge in providing dental care for patients 

with disabilities. Chair-side training and observed 

delivery of care are emphasized with the goals 

of advancing dental providers’ comfort and 

treatment of people with I/DD in their dental 

office. The program launched its first training at 

the New York University (NYU) Dentistry Oral 

Health Center for People with Disabilities in 

June 2022. Course topics include (1) Learning 

to Become a Competent and Willing Provider 

for Patients with Differing Needs; (2) Observing 

the Patient Workflow; (3) Learning to Utilize Best 

Accommodations in Health Risk Assessment 

and Treatment Planning for Patients with Special 

Health Care Needs (SHCN); (4) Learning to 

Communicate Strategies for Patients and 

Families with SHCN; (5) Learning How to Work 

with Caregivers to Maintain Oral Health for 

Persons with Disabilities; (6) Learning Physical 

Ergonomics for Treating Patients with Disabilities; 

and (7) Learning Best Accommodations of the 

Physical Space Characteristics and Needs for 

Treating Persons with Disabilities.

A prerequisite of the program is the 

completion of didactic curricula. These 

webinars may be accessed online via the NYU 

Dentistry series, New Treatment Paradigms for 

Managing the Oral Health Needs of Patients 

with Disabilities: Ethical Considerations in the 

COVID-19 Era.

University of Pennsylvania, School 

of Dental Medicine

In 2018, the University of Pennsylvania, School 

of Dental Medicine recognized the inability 

to find oral health care as a growing problem 

Incentivizing Oral Health Care Providers to Treat Patients 63
among adults with I/DD. In response, the 

administration called on faculty to develop a 

curriculum in which every graduating student 

would achieve competence in treating 

patients with complex physical, medical, and 

behavioral needs. Not only would the students 

learn didactically, but they would also learn 

experientially in a new Personalized Care Suite 

designed to provide state-of-the-art care without 

general anesthesia.

The UPENN Personalized Care Suite opened 

in January 2021 as the clinical site for treating 

persons with disabilities. The clinic also serves 

as a site for the development of new products 

aimed at enhancing oral health care for people 

with I/DD.

Every Penn Dental Medicine student 

rotates through this new center, learning from 

interprofessional faculty serving patients with 

conditions that range from autism, Alzheimer’s, 

and paralysis to movement disorders, complex 

medical conditions, and much more. The UPENN 

Personalized Care Suite includes (1) a Quiet 

Room for patients who are sensitive to light and 

sound; (2) a six-chair open bay with capacity to 

supply nitrous oxide; (3) six closed operatories; 

(4) a Wheelchair Lift Room, allowing patients 

to remain in their wheelchair, where the dental 

provider can provide safer, more comfortable, and 

less stressful care; (5) Hover Chair Rooms, which 

provide glides for patients on a stretcher; and 

(6) a Radiology Room equipped with a cone-beam 

computed tomography that delivers improved 

precision in diagnosis and treatment planning.

The center also houses the Colgate-Palmolive 

Innovation Laboratory that allows for the 

development and refinement of new products 

that facilitate optimal dental care for patients with 

disabilities.

Penn Dental Medicine also houses a collection 

of resources and offers numerous online 

continuing education unit courses and training at 

no cost. A three- to five-day immersion program 

for dental teams was established in 2022. 

This program is designed to expand the dental 

professional’s capability to treat patients with 

disabilities and to foster equitable oral health care 

worldwide.

Financing

The third consideration of the multipronged 

approach toward improving the oral health care 

and oral health of people with I/DD is financing. 

For dental programs designed under Medicaid, 

new state funding is often very limited. State 

budget officers look for budget neutrality or ways 

to shift dollars from another program to support a 

new dental program. This concept was explained 

in detail in Chapter 4.

Another approach is to demonstrate how new 

funding may demonstrate an ROI. This was also 

explained in Chapter 4. With either of these two 

approaches, program proposals should consider 

value-based models with provider incentives such 

as the shared savings model also demonstrated 

in Chapter 4.

A final approach offered here is the creation 

of a totally new integrated, preventive, valuebased government program under Medicare. 

Because under federal law Medicare has 

traditionally covered health care services for 

many people with I/DD, this concept proposes to 

expand that coverage by establishing a broader 

definition of eligible people with I/DD and adding 

64 National Council on Disability
medically necessary dental services so that an 

integrated, preventive, value-based model may 

be implemented.

This approach demonstrates cost-shifting of 

dental expenditures for CMS (from Medicaid 

to Medicare) and reduces state expenditures 

for dental care under the Medicaid program. 

Because the model for the program would be 

integrated (medical and dental) for both services 

and coverage, it would promote better care at 

lower costs. 

Incentivizing Oral Health Care Providers to Treat Patients 65
66 National Council on Disability
Chapter 6: Findings and Recommendations

Access to quality, appropriate, and timely 

oral health care services is a significant 

issue faced by people with intellectual 

and developmental disabilities (I/DD). Despite 

efforts by federal, state, and local agencies, 

legislatures, and key advocates, adults with I/DD 

remain the largest minority population with unmet 

oral health care needs. There are several systemic 

and environmental reasons for this; however, 

three major factors include the insufficient number 

of oral health care (OHC) professionals rendering 

care to these individuals, lack of government 

policies that support dental benefits for individuals 

with I/DD, and inadequate financing.

As the health care system in the United 

States continues to evolve, care must be 

taken to ensure that government policies and 

programs serving people with I/DD advance 

within the system to deliver quality-driven, 

patient-centered, integrated health care

services. Legislators, federal and state agencies, 

Medicaid managed care plans (MCPs), and 

providers must work together to ensure that 

a sufficient and competent integrated health 

care workforce is in place, and that policies 

support coverage of benefits that meet the 

special needs of people with I/DD. Financing 

to support the administration of programs 

and services must be sufficient and readily 

available. The following is a list of findings 

and recommendations for consideration by 

Congress, the Department of Health and Human 

Services (HHS), state Medicaid agencies, 

Medicaid MCPs, professional organizations, 

and dental providers. Collectively, these 

recommendations provide a framework to 

address the issues identified by people with 

I/DD, their parents and caregivers, as well as 

oral health care providers across the United 

States.

FINDING #1: Adults with I/DD are an aging population with complex conditions that warrant 

integrated coordinated health care services between medical and dental providers. Conflicting 

definitions of the population exist, creating confusion and inconsistency across government 

programs. Medicare and Medicaid programs do not support dental care for adults with I/DD.

Incentivizing Oral Health Care Providers to Treat Patients 67
Recommendations to Congress

1. I/DD Definition – Congress should create one I/DD definition and require all HHS 

agencies to use it to determine eligibility or qualifying criteria for a unique program 

designed for adults with I/DD.

2. Medicaid – Congress should mandate medically necessary oral health care services in 

Medicaid programs for eligible adults with I/DD that include an “essential” dental benefit 

package and provider reimbursement rates set and maintained at 90 to 95 percent federal 

and state employee benefit.

3. Medicare – Congress should require that HHS explore a new integrated, preventive, 

value-based health care program for adults with I/DD under Medicare that covers 

medically necessary medical and dental services, and assess the potential costeffectiveness of this program against Medicaid expenditures. (Costs associated with 

coverage for adults with I/DD currently covered by Medicare or Medicaid would be shifted 

to this new program. Dental services would be included.)

68 National Council on Disability

FINDING #2: Unlike the Medicaid medical program, Medicaid dental program claims data 

capture services delivered but do not capture or link dental services to medical necessity. 

The absence of codes that document medical necessity inhibit the ability of Medicaid dental 

programs to establish medical necessity, assess beneficiary oral health outcomes, assess oral 

health care outcomes, and validate charges associated with service delivery. Such antiquated 

programs are unable to demonstrate better care, better health, and lower costs.

Recommendations to HHS

1. HHS/Centers for Medicare and Medicaid Services (CMS) should mandate dental 

providers use the same diagnostic coding system as medical providers, in addition 

to using CDT Code, so that Medicaid programs may establish medical necessity and 

ensure appropriate payment of dental services for people with I/DD.

2. HHS/CMS should incentivize Medicaid dental programs to implement value-based 

payment models that link reimbursement to provider incentives, provider performance, 

and patient outcomes for people with I/DD.
Recommendations to HHS: continued

3. CMS should consider an opportunity for developing new and innovative value-based 

payment models for Medicare and/or Medicaid dental programs.

4. CMS should consider an opportunity for updating and validating the 

Medicaid|Medicare|CHIP Services Dental Association return-on-investment tool with 

customized data from state government programs that serve I/DD populations, for use 

by Medicaid dental programs serving people with I/DD.

5. HHS/Health Resources and Services Administration should create grant programs that 

demonstrate value-based workforce models that integrate and coordinate medical 

and dental services and payment models for children and adults with I/DD, outside of 

Federally Qualified Health Centers.

6. HHS/Administration for Community Living or the National Institutes of Health should 

create a research opportunity to assess the extent to which dental providers use the 

operating room to treat people with I/DD to determine comparative costs between 

dental care in operating rooms versus dental offices.

Recommendations to Congress

1. Congress should update the definition of Medically Underserved Populations to include 

people with I/DD and include the new definition in all applicable programs and services.

FINDING #3. State Medicaid programs are not required under federal law to cover dental 

services for adults with I/DD. Existing Medicaid programs serving people with I/DD generally 

exclude dental services. Programs that exist struggle to find dentists to treat adults with I/DD. 

Because dental provider availability is limited, many adults with I/DD resort to accessing costly 

dental services in the emergency department.

Incentivizing Oral Health Care Providers to Treat Patients 69
Recommendations to State Medicaid Agencies and Programs

1. State Medicaid agencies should create unique dental programs through new or existing 

1115 Demonstration, 1915 (c), and 1915 (k) authorities, specifically designed to meet 

the needs of adults with I/DD. Such programs should include coverage for oral health 

education services for I/DD members, parents, and caregivers; tele-dental oral health 

education; and preventive services. In addition, support care coordination between 

medical and dental providers as well as enable services to address the special needs of 

people with I/DD, and the social determinants of health.

2. Medicaid dental programs should implement value-based payment models that link 

reimbursement to provider incentives, provider performance, and patient outcomes for 

people with I/DD, and incentivize providers to reduce use of the operating room and shift 

to more cost-effective treatment settings.

3. Medicaid dental programs and Medicaid MCPs should collect and use risk factor data 

including and not limited to physical, oral, social, race/ethnicity, and gender identity to 

assess and improve oral health and oral health care equity for all Medicaid beneficiaries.

4. State Medicaid agencies should enhance Medicaid reimbursement to providers who 

participate in certified continuing education unit clinical dental training programs for people 

with I/DD.

70 National Council on Disability

Recommendations to CMS

1. CMS should enhance Medicaid reimbursement to providers who participate in certified 

continuing education unit clinical dental training programs for people with I/DD.

2. CMS should implement use of a coding system to identify people with I/DD so that 

provider reimbursement may be enhanced to support increased time and staffing needed 

to adequately meet the needs of the patient.

FINDING #4: Adults with I/DD form an aging population with complex conditions that warrant 

integrated coordinated health care services between medical and dental providers. Standards of 

care and professional guidelines to support integrated health care models for adults with I/DD 

are few and far between. Dental and medical systems of health care do not support integrated 
health care models for people with I/DD. Few professional dental education and continuing 

education programs incorporate integrated health care models.

Recommendations to Professional Associations and Dental Schools

1. The American Dental Association, American Academy of Developmental Medicine and 

Dentistry, Special Care Dentistry Association, American Academy of Pediatric Dentistry, 

and American Medical Association should collaborate to create and publish evidencebased standards of care and clinical guidelines to support the integration of oral and 

medical health care services for adults with I/DD.

2. The Commission on Dental Accreditation should expand dental and dental hygiene school 

competency requirements and curricula (didactic and clinical) to ensure competency in the 

delivery of comprehensive and integrated dental health care services to people with I/DD.

3. Dental schools and dental professional organizations should create and implement 

didactic and clinical continuing education courses to increase competency in the delivery 

of comprehensive and integrated dental health care services to people with I/DD.

Recommendation to Dental Providers

1. Dental providers should collaborate, communicate, coordinate, and cooperate with 

medical providers, care management facilitators, and social support services in the 

provision of dental health care services for people with I/DD.

Incentivizing Oral Health Care Providers to Treat Patients 71
72 National Council on Disability
Chapter 7: Conclusion

Despite the well-recognized health 

disparities that adults with I/DD 

experience, gaps in federal and state 

policies continue to exist as people with 

I/DD are not formally recognized as medically 

underserved. Existing federal mandates fail to 

ensure that people with I/DD ages 21 years and 

older have equitable access to oral health care 

services.

Adults with I/DD form an aging population 

with complex health conditions. Essential is their 

need for available, accessible, and reliable health 

care with community-based support services 

to achieve and maintain independence in their 

communities. When such services, including 

dental care, are not fully available, complications 

surface, disrupt, and give rise to emergent, 

preventable, and costly care.

Many believe that adults with I/DD must 

be treated in the operating room where costs 

of care have been growing exponentially. It is 

further argued that dental care for people with 

I/DD requires dental specialty services. Neither 

are essential to meeting the needs of a growing 

population. According to several experts, many 

people with I/DD may receive oral health care 

services by general dentists safely and effectively 

in the dental office. Preventive oral health 

care models that embrace new technologies, 

products, and services such as silver diamine 

fluoride to prevent and manage oral disease 

deliver better health at lower costs. By promoting 

a community-based model of care, access to oral 

health care services for people with I/DD will 

become more equitably available.

Over the last several years, there has 

been a growing issue with the availability of 

operating room time for dental providers. 

Hospital administrators have limited access to 

the operating room for many dental providers 

resulting in exceptionally long wait times for 

those people with I/DD who need the additional 

services that only an operating room can provide. 

Pain and suffering are not acceptable for anyone, 

much less an individual with I/DD who may not 

understand the reasons or be responsible for 

their circumstance. Policies, programs, services, 

and coverage must align to prevent these 

conditions.

Medicare and Medicaid are two government 

programs currently serving people with I/DD. 

Medicare covers medical services (expenses) 

and excludes dental care, while Medicaid covers 

dental care but only to age 20 years. (Dental 

coverage for adults ages 21 years and older is 

optional under federal law.) These two systems 

fail adults with I/DD, leaving a huge gap in oral 

health care for this population. Strong evidence 

clearly demonstrates the impact of oral diseases 

on health.28 The need for risk-based prevention 

Incentivizing Oral Health Care Providers to Treat Patients 73
for people with I/DD cannot be overemphasized. 

If chronic oral diseases are not prevented and/

or mediated through preventive oral health 

care, other complex conditions will worsen. 

The outcome has been and will continue to be 

realized in exorbitant costs to the American 

taxpayer.

In this study, oral health care providers made 

a strong statement about their willingness 

to treat people with I/DD. They also reached 

consensus and affirmed the need for sufficient 

reimbursement to cover costs associated with 

the needs of the population. Adults with I/DD 

need longer appointment times so that care may 

be rendered slowly, gently, and compassionately. 

Often, they need to be sedated. Many people 

with I/DD get confused or do not have the 

capacity to understand what is happening to 

them during their dental care visit. Extended time 

is essential for explanation and settling. To render 

this type of care often takes additional time and 

specially trained staff such as certified registered 

nurse anesthesiologists. Covering the costs of 

these positions is essential to operationalizing the 

care delivery model people with I/DD need.

When oral health care providers do not 

have the support needed to render this type 

of care to people with I/DD, patients become 

distressed, providers become frustrated, 

safety consequences occur, and ultimately 

providers drop out of the system. This leaves the 

emergency department as the only viable option 

for oral health care for the population.

When sufficient means are well understood 

and embedded into an integrated, preventivefocused, value-based model of health care, 

both medical and dental providers may more 

optimally deliver collaborative, cooperative, and 

coordinated health care for people with I/DD. 

The Medicare program offers the best potential 

for success for such a program. Housed under 

one roof, with one budget, Medicare could 

develop a unique program for all adults with 

I/DD covering both medical and dental care 

validated and paid for with one coding system 

that documents medical necessity and covers 

both medical and dental provider payments via 

Current Procedural Terminology and Code on 

Dental Procedures and Nomenclature codes. 

To transition the adult I/DD population at age 21 

years to a separate program would allow CMS 

to shift costs from one government program to 

another, where medical cost savings from oral 

health care coverage could be assessed and a 

return on investment realized.

During the last two decades, the health care 

delivery system has undergone major changes 

as a direct result of legislative policies beginning 

with the Reauthorization of the Children’s Health 

Insurance Program followed by the Patient 

Protection and Affordable Care Act. Both provide 

provisions for this proposed model, delivering 

quality in health care and advancing equitable

access. Value-based care builds on the initial 

concepts associated with these two laws, where 

improvements in health care, health outcomes, 

and costs continue to be important and are 

associated with quality, measurement, and 

performance, but now are more closely aligned 

with payment. The operational framework moves 

away from traditional fee-for-service models 

to one that incentivizes and rewards quality 

over quantity. For people with I/DD, the model 

proposed here will ensure better health care, 

better health outcomes, and lower costs for all 

involved.

74 National Council on Disability
Appendices

Appendix A: Participating Organizations

American Academy of Developmental Medicine and Dentistry

Delta Dental of Arkansas

Delta Dental of Indiana

Delta Dental of Michigan

Delta Dental of Ohio

Developmental Disabilities Nurses Association

Envolve Dental

Guardian Avesis

MCNA Dental

Medicaid|Medicare|CHIP Services Dental Association

New Hampshire Department of Health and Human Services, Division of Medicaid Services

New Jersey FamilyCare

North Carolina Department of Health and Human Services/Division of Health Benefits

Project Accessible Oral Health

Oral Health Center for People with Disabilities at NYU College of Dentistry

Special Care Dentistry Association

Incentivizing Oral Health Care Providers to Treat Patients 75
Appendix B: Project Organizational Chart

76 National Council on Disability
Appendix C: Focus Group 1: Self-Advocates Script

Welcome

■ Good evening and thank you all for being here tonight.

■ My name is Barbie Vartanian, and I am going to be the leader of our Focus Group.

■ Tonight’s Focus Group is the first of three that will be held this week.

■ Focus Group #1 is for Self-Advocates of People with intellectual and developmental disabilities 

(I/DD)—that’s why all of you have been invited.

■ Focus Group #2 is for Parents and Caregivers of people with I/DD.

■ Focus Group #3 is for Stakeholders or other advocates, health care providers, or experts 

specialized in caring for persons with I/DD.

Purpose

■ These three Focus Groups are part of a bigger project aimed at improving dental care for 

individuals with I/DD. I am working with a couple of national organizations on this project for the 

National Council on Disability.

■ The purpose of the Focus Groups is to have participants share ideas and experiences and provide 

important information for us to think about.

■ The information that you provide will be used to

❍ Develop questions for a questionnaire that will then be sent to dental providers such as 

dentists and dental hygienists

❍ Develop recommendations for improving Medicaid and dental care

Thank You

■ We’re thrilled to have you and want you to know how much we appreciate your time and 

willingness to help us with this important project.

Introductions

■ Before we begin, I’d like to have each of you introduce yourself.

■ Because this is a virtual Zoom call, I will call your name.

■ When I do, I would like for you to please provide your name and tell us a little bit about yourself.

Incentivizing Oral Health Care Providers to Treat Patients 77
Focus Group Rules

■ One more important thing before we begin.

■ We have a couple of important rules to go over with you:

❍ We want YOU to do the talking.

❍ We would like EVERYONE to participate.

❍ I may call on you if I haven’t heard from you in a while.

■ There are no right or wrong answers.

■ Every person’s experience and opinion are important.

■ Speak up whether you agree or disagree.

■ We want to hear a wide range of opinions.

■ We want folks to feel comfortable sharing when sensitive issues come up.

■ We will be recording the group call:

❍ We want to capture everything you have to say.

❍ We don’t identify anyone by name in our report. You will remain anonymous.

■ Please do not take notes.

■ Keep your computer on mute when you are not talking.

■ Raise your hand to speak.

■ Because this is a Zoom call, I am going to ask you all to raise your hand before you speak. When 

I call your name, please be sure to unmute yourself.

Icebreaker

■ What is your favorite ice cream flavor?

■ What is your favorite outside activity?

Begin the Session

■ I am going to say a word, or phrase, and I’d like you to respond by saying the “first word—single 

word—that comes to your mind.”

■ Teeth—Can you tell me a little bit more about that?

■ Smile—Can you tell me a little bit more about that?

■ Chewing

■ Toothbrushing

78 National Council on Disability
■ Flossing

■ Dentist

So now I am going to ask you some questions about going to the dentist:

Dental Appointments

■ Do you make your own dental appointments?

■ Do you make them by phone or online?

■ What’s it like making your dental appointment?

■ Tell me more about the conversation with the person on the phone.

■ Is there anything else about making a dental appointment that you want to share with us?

■ What would you recommend that would make it easier for you to make an appointment for yourself?

■ Note: If they don’t offer any issues—then keep moving, don’t prompt.

Dentist

■ Do you have a dentist?

If Yes:

■ How long have you been going to your current dentist?

■ What do you like about your dentist?

■ Is there anything you don’t like about your dentist?

■ Can you explain further?

■ Did you feel that your dentist meets your needs?

■ Do you think that your dentist has experience in treating patients with I/DD?

If No:

■ For those who mentioned that you do not have a dentist. Can you tell me a little more about 

why you don’t have a dentist?

■ Have you ever been to the dentist? If yes, what did you like about that dentist?

❍ Why did you leave that dentist?

❍ Was there anything that you didn’t like about your dentist?

❍ If you could tell that dentist something, what would it be?

Dental Offices—Dental Office Experiences

■ What do you like about your DENTAL OFFICE?

■ Does the DENTAL OFFICE have ACCOMMODATIONS that meet your needs?

Incentivizing Oral Health Care Providers to Treat Patients 79
■ What can you tell us about the people other than the dentist, like the dental assistants and the 

front desk receptionist?

■ What do you like about them?

■ What do you not like about your DENTAL OFFICE or the staff in the DENTAL OFFICE?

■ What would you CHANGE if you could about your DENTAL OFFICE?

■ What SUGGESTIONS would you offer to make the DENTAL OFFICE better for you?

Dental Care—Now we are going to talk a little bit about your experiences when getting 

dental care either from your dentist or your dental hygienist.

■ Overall, can you tell us how comfortable you are when you are getting dental care?

Examples of responses may include:

❍ I was scared.

❍ I felt disrespected.

❍ It was easy. I was totally comfortable.

❍ Dentist was nice/mean.

■ Can you tell us about what it is like getting your teeth cleaned?

❍ If they describe superficially or with one word—ask them to explain further.

■ For those of you who have ever got a dental filling—What was that like?

■ What about getting numb? How was that?

■ Was your dentist able to complete your dental work in the office, or did you have to go to the 

operating room?

■ For those who had to go to the operating room—What was that like?

■ Have you ever had to go to the emergency room for a dental problem? If yes—can you tell us a 

little more about this experience for you.

Paying for Dental Care—Let’s talk now about paying for dental care.

■ What do you think about the cost of dental care?

■ How do you pay your dentist for dental care?

❍ Do you pay with cash or a check, or do you have dental insurance?

❍ If you have dental insurance, do you know what kind of dental insurance you have?

❍ Does the dental insurance help with the costs? Is it enough?

80 National Council on Disability
❍ For those who use Medicaid to pay for dental care/visits, how do you like it?

❍ Does Medicaid help pay for the cost of your dental care?

❍ Why or what do you like about it?

❍ Why or what don’t you like about it?

Incentivizing Oral Health Care Providers to Treat Patients 81
Appendix D: Oral Health Care Provider Questionnaires

Round 1

1. Please enter your primary dental specialty. Please select one.

❍ Dental Hygiene

❍ Dental Therapy

❍ General Dentistry

❍ Dental Anesthesiology

❍ Dental Public Health

❍ Endodontics

❍ Oral and Maxillofacial Pathology

❍ Oral and Maxillofacial Radiology

❍ Oral and Maxillofacial Surgery

❍ Oral Facial Pain

❍ Oral Medicine

❍ Orthodontics and Dentofacial Orthopedics

❍ Pediatric Dentistry

❍ Periodontics

❍ Prosthodontics

2. Please enter your PRIMARY practice model. Please select one.

❍ Private [Traditional]

❍ Corporate or DSO

❍ FQHC | Health Center

❍ Hospital-based

❍ Community-based

❍ University-Faculty Practice

❍ Mobile (Nonaffiliated)

3. Please enter the number of dentists in your primary practice setting.

❍ Solo (1)

❍ Small Group (2–4)

❍ Large Group (5+)

82 National Council on Disability
4. Please select the response that best describes the number of hours you work per week.

❍ <10 hours/week

❍ –

❍ >30 hours/week

5. Please select the category that best describes your age:

❍ 25–49 Years

❍ 50–64 Years

❍ 65+ Years

6. Please indicate the number of Medicaid-enrolled adults (ages 21+) in your practice that you 

regularly treat and for whom you bill. (Select 1).

❍ None

❍ 1 to 49 Unduplicated Medicaid-enrolled adult patients

❍ 50 to 99 Unduplicated Medicaid-enrolled adult patients

❍ 100 + More Unduplicated Medicaid-enrolled adult patients

7. Please list and describe any factors that have influenced your decision (either to participate or not 

to participate) in your State’s Medicaid Dental Program or HCBS program.

Please include a description of any individuals, institutions, organizations, employers, staff, 

programs, and/or policies and how they influenced your decision.

8. If you currently do not participate in your State Medicaid Dental Program and/or HCBS Dental 

Program, did you ever? If yes, why did you leave? If this question does not apply to you, please 

type in “NA” and move to Question 12.

9. Please share any ideas you may have that would change your decision to participate in Medicaid 

Dental Programs. In other words, what would it take to get you to participate? If this question 

does not apply to you, please type in “NA”.

Incentivizing Oral Health Care Providers to Treat Patients 83
In this section, we are attempting to understand (1) the extent to which dental providers 

treat adult patients with I/DD, and (2) the supports and accommodations needed to treat 

adult patients with I/DD, based on each patient’s required level of assistance as described in 

the Activities of Daily Living (ADL).

Please share your experiences in the various dental settings: (1) dental office, (2) hospital/

operating room, and/or (3) community-based settings.

For the purposes of this questionnaire, the following definitions apply:

Intellectual disability is a condition characterized by significant limitations in both 

intellectual functioning and adaptive behavior that originates before the age of 22 years.

Developmental disabilities are a group of conditions due to an impairment in physical, 

learning, language, or behavior areas. These conditions begin during the developmental 

period, may impact day-to-day functioning, and usually last throughout a person’s lifetime.

ADLs are basic self-care activities that must be performed on a day-to-day basis for one to 

live independently. ADLs are typically limited to the five below:

1. Mobility (also called ambulating or transferring)—The ability to move about both inside and 

outside of one’s home. This includes walking, going up and down stairs, getting out of bed 

and into a wheelchair, and standing from a seated position to use a walker.

2. Dressing—Choosing appropriate clothing and putting it on. This includes fastening buttons 

and zipping zippers.

3. Eating—Utilizing a fork and other utensils to get food to the mouth and the physical act of 

eating.

4. Personal Hygiene—Safely getting in and out of the bathtub or shower and cleaning oneself. 

Also includes other grooming activities, such as shaving, nail care, and brushing teeth.

5. Toileting (also called continence)—Making it to the toilet in time by controlling one’s 

bladder.

84 National Council on Disability

10. Please indicate below the number of adult patients (ages 21+) with I/DD in your practice that you 

regularly treat that require NO ASSISTANCE based on the Activities of Daily Living (ADL).

❍ None

❍ 1 to 49 Unduplicated adult patients with I/DD

❍ 50 to 99 Unduplicated adult patients with I/DD

❍ 100 + More Unduplicated adult patients with I/DD
11. Please indicate below the number of adult patients (ages 21+) with I/DD in your practice that you 

regularly treat, that require SOME ASSISTANCE based on the Activities of Daily Living (ADL).

❍ None

❍ 1 to 49 Unduplicated adult patients with I/DD

❍ 50 to 99 Unduplicated adult patients with I/DD

❍ 100 + More Unduplicated adult patients with I/DD

12. Please indicate below the number of adult patients (ages 21+) with I/DD in your practice that you 

regularly treat that ARE DEPENDENT ON ASSISTANCE based on the Activities of Daily Living (ADL).

❍ None

❍ 1 to 49 Unduplicated adult patients with I/DD

❍ 50 to 99 Unduplicated adult patients with I/DD

❍ 100 + More Unduplicated adult patients with I/DD

13. Please list and describe any FACTORS that have influenced your decision to treat adult individuals 

with I/DD. Please include a description of any individuals, institutions, organizations, employers, 

staff, programs, and/or policies and how they have influenced your decision.

14. Tell us about your experience(s) in treating adult patients with I/DD?

15. Please explain the types of supports or accommodations (physical, behavioral, pharmacological) 

you need to render dental care more easily and effectively to adult patients with I/DD.

❍ In Office

❍ In Hospital

❍ In Community-based

We are attempting to understand FACTORS that influence oral health care providers’ decision 

NOT TO TREAT adult individuals with I/DD or limit their practice. Please only complete 

Questions 16, 17, and 18 if you do not treat adults with I/DD, and/or limit your practice to only 

those adults with I/DD that require no special accommodations.

Incentivizing Oral Health Care Providers to Treat Patients 85
16. Please list and describe any FACTORS that have influenced your decision to not treat, stop 

treating, or limit your practice of adults with I/DD. Please include any individuals, institutions, 

organizations, employers, staff, programs, and/or policies and how they influenced your decision. 

If this question does not apply to you, please enter NA.

17. If you used to treat adults with I/DD and currently do not, why did you stop? If this question does 

not apply to you, please enter NA.

18. What changes would be necessary for you to begin to treat adults with I/DD again, and/or stop 

limiting your practice to only adults with I/DD that require no accommodations?

19. Gender (Please select one)

❍ Woman

❍ Man

❍ Transgender

❍ Nonbinary/nonconforming

❍ Prefer not to respond

20. Race (Please select one)

❍ Native American Indian

❍ Asian

❍ Black or African American

❍ Native Hawaiian or Other Pacific Islander

❍ White

❍ Two or more races

21. Ethnicity (Please select one)

❍ Yes, Hispanic/Latino

❍ No, not Hispanic/Latino

86 National Council on Disability
Example of Round 2 Questions

1. I participated in Round I of the NCD/MSDA Oral Health Care Provider Questionnaire.

❍ Yes

❍ No

2. In Round 1, we attempted to understand FACTORS that influence an oral health care provider’s 

decision to participate in their state’s Medicaid Dental Program. We asked respondents to list and 

describe any factors that have influenced their decision to participate in their state’s Medicaid Dental 

Program. We further asked respondents to include a description of any individuals, institutions, 

organizations, employers, staff, programs, and/or policies and how they influenced their decision.

Results: Among the 695 providers who responded to this question, 14 items were identified 

as FACTORS that influence an oral health care provider’s decision to participate in their state’s 

Medicaid Dental Program.

Building Consensus: Please provide your level of agreement with the statements below.

I disagree very strongly; I disagree; I neither disagree nor agree; I agree; I agree very strongly.

❍ “Cost” influences my decision to participate in my state’s Medicaid dental program.

❍ My “professional organization” influences my decision to participate in my state’s Medicaid 

dental program.

❍ My “employer” influences my decision to participate in my state’s Medicaid dental program.

❍ My “staff” influence my decision to participate in my state’s Medicaid dental program.

❍ Medicaid dental “reimbursement rates” influence my decision to participate in my state’s 

Medicaid dental program.

❍ “Participation in Medicaid Managed Care” negatively influences my decision to participate in 

my state’s Medicaid dental program.

❍ “Helping people in need” influences my decision to participate in my state’s Medicaid dental 

program.

❍ The “behavior of Medicaid patients” influences my decision to participate in my state’s 

Medicaid dental program.

❍ Existing “Medicaid dental benefit/covered services” influences my decision to participate in my 

state’s Medicaid dental program.

❍ Medicaid “administrative policies” influence my decision to participate in my state’s Medicaid 

dental program.

❍ “Missed appointments” influence my decision to participate in my state’s Medicaid dental 

program.

Incentivizing Oral Health Care Providers to Treat Patients 87
❍ “Prior approval policies” influence my decision to participate in my state’s Medicaid dental 

program.

❍ “Medicaid audits” influence my decision to participate in my state’s Medicaid dental 

program.

❍ “Policies prohibiting a dental provider’s ability to charge for no-shows” influence my 

decision.

3. In Round 1, we were interested in hearing what ideas oral health care providers may have about 

changes that could be made to Medicaid that might influence their decision to participate. We 

asked providers to share any ideas they may have that would change their decision to participate 

in Medicaid Dental Programs. In other words, [we asked] what would it take to get them to 

participate?

Results: Among the 682 providers who responded to this question, four themes were mentioned 

most often: (1) assessing and adjusting reimbursement rates annually, (2) implementing provider 

incentives, (3) incorporating support for care management, and (4) applying administrative policies 

to address no-shows.

Building Consensus: Please provide your level of agreement with the statements below.

I disagree very strongly; I disagree; I neither disagree nor agree; I agree; I agree very strongly.

❍ I would participate in the Medicaid dental program in my state if the program assessed and 

adjusted dental reimbursement rates annually.

❍ I would participate in the Medicaid dental program in my state if the program implemented 

provider participation incentives.

❍ I would participate in the Medicaid dental program in my state if the program implemented 

provider performance incentives.

❍ I would participate in the Medicaid dental program in my state if the program implemented 

provider incentives based on the number of patients treated per year.

❍ I would participate in the Medicaid dental program in my state if the program implemented 

provider incentives based on preventive service delivery.

❍ I would participate in the Medicaid dental program in my state if the program covered case or 

care management for dental services.

❍ I would participate in the Medicaid dental program in my state if the program allowed me to bill 

patients for missing appointments.

❍ I would participate in the Medicaid dental program in my state if the program incentivized 

patients and /or assisted patients to keep their appointments.

88 National Council on Disability
Example of Round 3 Questions

1. I participated in Round I and/or Round II of the NCD/MSDA Oral Health Care Provider 

Questionnaire.

❍ Yes

❍ No

2. In Rounds 1 and 2, we attempted to understand FACTORS that influence an oral health care 

provider’s decision to participate in their state’s Medicaid Dental Program. Among the providers 

who responded to this question, the following FACTORS were identified most often.

Building Consensus: Please rank the FACTORS listed below in the order of importance to you.

❍ Cost

❍ Reimbursement rates

❍ Participation in Medicaid managed care

❍ Helping people in need

❍ Behavior of Medicaid patients

❍ Existing Medicaid dental benefit/covered services

❍ Medicaid administrative policies

❍ Missed appointments

❍ Prior approval policies

❍ Medicaid audits

3. In Rounds 1 and 2, we asked providers to list what strategies they think Medicaid programs 

should implement to increase dental provider participation. Results: Among the providers who 

responded to this question, the following strategies were mentioned most often.

Building Consensus: Please rank the strategies listed below in the order of importance to you.

❍ Annual adjustments of dental reimbursement rates

❍ Provider participation incentives

❍ Provider performance incentives

❍ Provider incentives based on number of patients seen per year

❍ Provider incentives based on preventive service delivery

❍ Coverage for case/care management services

❍ Policy permitting billing for missed appointments

Incentivizing Oral Health Care Providers to Treat Patients 89
4. In Rounds 1 and 2, we attempted to learn what FACTORS influence oral health care providers’ 

decisions to treat adults with I/DD. Among the providers who responded to this question, the 

following FACTORS were identified most often.

Building Consensus: Please rank the influencing FACTORS in the order of importance to you.

❍ Having hospital privileges

❍ Professional organization(s)

❍ Professional peers

❍ Treating adults with I/DD fulfills a critical unmet need

❍ Time

❍ Feeling competent

❍ Staff

❍ Specialized office equipment

❍ Treating adults with I/DD fulfills a moral and ethical obligation

❍ Patient incentives to keep appointments

90 National Council on Disability
Appendix E: Provider Demographics

Round 1 [900]

Dental Specialty

Dental Hygiene 4.22% Oral and Maxillofacial Radiology 0.0

Dental Therapy 0.11% Oral and Maxillofacial Surgery 7.

General Dentistry 72.11% Oral Facial Pain 0.0

Dental Anesthesiology 0.11% Oral Medicine 0.3

Dental Public Health 2.22% Orthodontics 2.8

Endodontics 1.44% Pediatric Dentistry 0.7

Oral and Maxillofacial Pathology Prosthodontics 0.33

Primary Practice Setting and Hours per Week

Solo Practice (1) 50.11% <10 hours per week 1.7

Small Group (2–4) 36.44% Between 11 and 30 hours per week 20.0

Large Group (5) 13.44% >30 hours per week 78.2

Round 1 [900] Round 2 [166] Round 3 [75]

Primary Practice Model

Private (Traditional) 76.22% (686) 74.22% (94) 70.67% (

Corporate (Dental Service Organization) 7.78% (70) 5.47% (7) 9.33% 

Federally Qualified Health Center 6.22% (56) 11.72% (15) 6.67% 

Hospital 2.22% (20) 3.13% (4) 0.

Community-Based 3.78% (34) 1.56% (2) 8.00% 

University Faculty Practice 2.78% (25) 1.56% (2) 1.33% 

Mobile (Nonaffiliated) 1.00% (9) 2.34% (3) 4.00% 

No Response

Age Category

25–49 Years 50.22% (452) 51.56% (66) 53.33% (

50–64 Years 36.11% (325) 31.25% (40) 30.67% (

65+ Years 13.67% (123) 17.19% (22) 16.00% (

Race/Ethnicity

Native American Indian 1.00% (5) 2.65% (3) 0

Asian 9.09% (46) 11.50% (13) 16.00% (

African American 6.91% (35) 3.54% (4) 9.33% 

Native Hawaiian/Pacific Islander 0.39% (2) 0.00 0

Two or More Races 5.37% (29) 4.42% (5) 4.00% 

White 76.87% (389) 80.53% (91) 70.67% (

Incentivizing Oral Health Care Providers to Treat Patients 91
Appendix F: CDT Codes and Labels

CDT Code Label

D1110 Prophylaxis-Ages 14+

D0120 Periodic Oral Evaluation on an Established Patient

D0140 Limited Oral Evaluation

D0150 Comprehensive Oral Evaluation

D0220 Intraoral-Periapical-First Film

D0230 Intraoral-Periapical-Each Additional Film

D0272 Bitewing-Two Films

D0274 Bitewing-Four Films

92 National Council on Disability
Endnotes

1 Value-based care is a model of care that promotes quality and prevention, measures and improves outcomes, 

and lowers costs.

2 H.R. 3590, “Patient Protection and Affordable Care Act,” Congress.gov, https://www.congress.gov/bill/

111th-congress/house-bill/3590.

3 National Council on Disability, I/DD Self-Advocate Focus Group, March 2022.

4 National Council on Disability, Medicaid Oral Health Coverage for Adults with Intellectual and Developmental 

Disabilities—A Fiscal Analysis (Washington, DC: NCD 2022), https://ncd.gov/sites/default/files/NCD_Medicaid_

Report_508.pdf.

5 C.K. Cramer, G.D. Klasser, and J.B. Epstein, “The Delphi Process in Dental Research,” Journal of EvidenceBased Dental Practice 8 (2008): 211–220.

6 Centers for Medicare and Medicaid Services, Activities of Daily Living, https://www.cms.gov/research-statisticsdata-and-systems/research/mcbs/downloads/2008_appendix_b.pdf.

7 ADA, “ADA Health Policy Institute,” https://www.ADA.org/resources/research/health-policy-institute.

8 ADA, “Supply of Dentists in the US: 2001-2021,” https://www.ada.org/resources/research/health-policy-institute

/dentist-workforce/the-changing-dentist-workforce.

9 42 C.F.R. 435.217, “Individuals Receiving Home and Community-Based Services,” Cornell Law School, https://

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10 Social Security Administration, Disability Benefits: How You Qualify, accessed August 3, 2022, https://www.ssa

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11 Administration for Community Living, “Developmental Disabilities Assistance and Bill of Rights Act of 2000,” 

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12 Social Security Administration, “Disability Benefits: How You Qualify,” accessed August 3, 2022, https://www

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13 Medicaid|Medicare|CHIP Services Dental Association,” Medicaid Oral Health Policy Academy for Adults 

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14 11 Centers for Medicare and Medicaid Services, “Code Sets Overview,” accessed August 10, 2022, https://

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15 Medicaid|Medicare|CHIP Services Dental Association, “Health Care Innovation Challenge Collaborative 

Proposal to CMS/CMMI” (unpublished 2012).

16 National Association of State Budget Officers, “Summary: 2021 State Expenditure Report (2021),” https://

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17 Y. Halasa-Rappel, C.A. Tschampl, M.E. Foley, M. Dellapenn, and D. Shepard, “Broken Smiles: The Impact of 

Untreated Dental Caries and Missing Anterior Teeth on Employment,” Journal of Public Health Dentistry 79, 

no. 3 (2019): 231–237, https://doi.org/10.1111/jphd.12317.

18 Medicaid|Medicare|CHIP Services Dental Association, “Medicaid Oral Health Policy Academy for Adults with 

Intellectual and Developmental Disabilities, I/DD Dental Policy Tool Kit,” 2022, https://www.medicaiddental.org

/presentations.

Incentivizing Oral Health Care Providers to Treat Patients 93
19 Healthcare.gov, “Patient Protection and Affordable Care Act,” accessed August 3, 2022, https://www.healthcare

.gov/glossary/patient-protection-and-affordable-care-act/.

20 American Medical Association, “CPT Overview and Code Approval,” accessed August 3, 2022, https://www

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21 B. Caldwell, “ICD, and CPT Codes: The Language of Healthcare Billing,” Pollen, last modified September 7, 

2021, https://www.simplepractice.com/blog/icd-codes-and-cpt-codes/.

22 Institute for Healthcare Improvement, “Science of Improvement,” assessed August 3, 2022, https://www.ihi.org/

about/Pages/ScienceofImprovement.aspx.

23 Institute for Healthcare Improvement, “Value Management, Waste, and Flow,” assessed August 3, 2022, 

https://www.ihi.org/Topics/QualityCostValue/Pages/default.aspx.

24 M.G.L. c. 118G Division of Healthcare Finance and Policy; 114.3 CMR 14.00: Dental Services.

25 N. Gupta, C. Yarbrough, M. Vujicic, A. Blatz, and B. Harrison, Medicaid Fee-for-Service Reimbursement Rates 

for Child and Adult Dental Care Services for All States, 2016, Health Policy Institute Research Brief, American 

Dental Association, last modified April 2017, https://www.ada.org/-/media/project/ada-organization/ada/ada-org/

files/resources/research/hpi/hpibrief_0417_1.

26 Maryland Department of Health, “Maryland HealthChoice Program Section 1115 Waiver Amendment 

Application,” last modified June 30, 2022, https://health.maryland.gov/mmcp/Documents/1115%20Waiver%20

Medicaid/MDH%201115%20Waiver%20Amendment%20and%20Attachments%20June%202022%20final.pdf.

27 Louisiana Department of Health, “FY2022 Together: Building a Stronger LDH and a Healthier Louisiana,” 

https://ldh.la.gov/businessplan.

28 Ng MW, Torresyap G, White A, Melvin P, Graham D, Kane D, Scoville R, Ohiomoba H. Disease management 

of early childhood caries: results of a pilot quality improvement project. J Health Care Poor Underserved. 2012 

Aug;23(3 Suppl):193–209. doi:10.1353/hpu.2012.0122. PMID: 22864497.

94 National Council on Disability
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Washington, DC 20004