Medicaid: State and Federal Actions Have Been Taken to Improve Children's Access to Dental Services, but Gaps Remain
Published: 2009-09-30T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Children's access to Medicaid dental services is a long-standing concern. The tragic case of a 12-year-old boy who died from an untreated infected tooth that led to a fatal brain infection renewed attention to this issue. He was enrolled in Medicaid--a joint federal and state program that provides health care coverage, including dental care, for 30 million low-income children--but, like many children in Medicaid, he experienced difficulty finding a dentist who would treat him. At the federal level, the Centers for Medicare & Medicaid Services (CMS), an agency within the Department of Health and Human Services (HHS), oversees Medicaid. In this report, GAO examined (1) state strategies to monitor and improve access to dental care for children in Medicaid and (2) CMS actions since 2007 to improve oversight of Medicaid dental services for children. GAO surveyed all state Medicaid programs and interviewed state and federal officials, and dental researchers and associations
section_title: What GAO Found
paragraphs: State Medicaid programs reported that they use multiple strategies to monitor and improve access to dental services for children, but problems persist. Most states responding to our survey use a variety of tools, such as examining claims and utilization data, to monitor the provision of dental services to children in Medicaid. Although all 21 states that provide Medicaid dental services through managed care organizations (MCO) reported that they set measurable access standards for MCOs, 14 states reported that MCOs do not meet all of the state's dental access standards. Almost all states described initiatives to improve access to dental services, including simplifying claims processing, increasing reimbursement rates, recruiting providers, and educating beneficiaries. Nonetheless, access rates remain low and states reported that long-standing barriers hinder further improvement. Since May 2007, CMS has taken steps to strengthen its oversight of Medicaid dental services for children, but gaps remain. For example, CMS reviews of Medicaid dental services in 17 states identified a number of concerns and made recommendations for improvement. Nonetheless, at the time of our review CMS did not plan to perform more reviews, even though other states had utilization rates well below HHS's 2010 target for low-income children receiving a preventive dental service. CMS also provided guidance to states and facilitated collaboration among stakeholders, but states reported needing more CMS support, including guidance on setting dental payment rates, on quality initiatives, and on promoting outreach. States also reported wanting more information on other states' efforts to improve dental utilization.

section_title: Letter
paragraphs: Dental disease is a significant problem for children in Medicaid, a joint  federal and state program that provides health care coverage, including  dental care, for low-income children. Although dental services are a  mandatory benefit for the 30 million children served by Medicaid, these  children often experience elevated levels of dental problems and have  difficulty finding dentists to treat them. Attention to this subject became  more acute after the widely publicized case of a 12-year-old boy who died  in 2007 as a result of an untreated infected tooth, even though he was  entitled to dental coverage under Medicaid. In testimony before the  Subcommittee on Domestic Policy of the Committee on Oversight and  Government Reform last year, we reported that children in Medicaid were  almost twice as likely to have untreated cavities as children with private  insurance. We also reported that the percentage of children in Medicaid  ages 2 through 18 who received any dental care—37 percent according to  national survey data—was far below the Department of Health and Human  Services’ (HHS) target of having 66 percent of low-income children under  age 19 receive a preventive dental service.
Concerns about low-income children’s poor oral health and inadequate  access to dental services, low payment rates for dental services, and  insufficient federal and state efforts to address oral health access  problems are long-standing. Our reports dating back to 2000 highlight the  problem of chronic dental disease and the factors that contribute to low  use of dental services by low-income populations, including children in  Medicaid. A major concern has been the adequacy of the network of  dental providers who serve low-income populations, particularly for  children who receive Medicaid dental services under managed care. This  concern stems in part from investigations by the Subcommittee that found  that some managed care organizations (MCO) did not have adequate  provider networks—that is, a sufficient number and mix of dental  providers—to provide timely access to covered Medicaid dental services.  In September 2000, we reported that while several factors contributed to  the low use of dental services among low-income persons who had  coverage, the major factor was difficulty finding dentists to treat them.  During a Subcommittee hearing in May 2007, concerns were raised about  federal oversight of state Medicaid dental services for children by the  Centers for Medicare & Medicaid Services (CMS), the agency that oversees  Medicaid at the federal level.
You expressed concern about the state and federal actions taken to ensure  children in Medicaid receive recommended dental services. This report  examines (1) the strategies that state Medicaid programs employ to  monitor and improve access to dental services for children in Medicaid  and (2) CMS actions since 2007 to improve oversight of state Medicaid  dental services for children. To identify state strategies to improve  children’s access to Medicaid dental services, we conducted a Web-based  survey of state Medicaid directors in all 50 states and the District of  Columbia. The survey included both closed-ended and open-ended  questions regarding dental services for children, the methods states have  used for promoting and monitoring dental utilization (the use of dental  services), statewide goals for the delivery of dental services, and the  federal support provided to states for the provision of dental services. To  establish the reliability of our survey data, we consulted with  knowledgeable state officials in developing the survey and pre-tested the  survey questions with Medicaid officials from two states. The survey was  conducted from December 8, 2008, through January 30, 2009. We received  responses from all 50 states and the District of Columbia. We reviewed  survey responses for internal consistency and in certain cases where  responses were absent, unclear, or inconsistent, we contacted state  officials for clarification. We did not independently verify specific aspects  of responses or the effectiveness of programs reported through the survey.  We determined that the data submitted by states were sufficiently reliable  for the purposes of our engagement. In addition to the Web-based survey,  we reviewed studies and reports on state Medicaid dental-related  initiatives and conducted a review of current literature to obtain  information on these initiatives and on barriers to providing dental care in  Medicaid. To describe contractual provisions between states and MCOs  concerning network adequacy and timely access standards related to  dental services for children, we obtained and reviewed a non-generalizable  sample of contracts from the MCOs that covered dental services and that  served the most Medicaid beneficiaries in 9 states, including 5 states  whose dental programs had been reviewed by CMS in 2008.
To examine CMS’s oversight of state Medicaid dental services for children,  we interviewed CMS officials; reviewed federal laws, regulations, and  guidance that CMS provides to states; and interviewed key stakeholders,  including the Medicaid/SCHIP Dental Association, the National  Association of State Medicaid Directors (NASMD), and experts involved  with pediatric dental issues. We also reviewed data used by CMS to  monitor provision of dental services to children in state Medicaid  programs, including information in annual reports submitted by states on  the provision of dental and other services provided under Medicaid’s early  and periodic screening, diagnostic, and treatment (EPSDT) benefit. We  also examined CMS’s reviews of Medicaid dental programs in 17 states. To  obtain states’ perspectives of CMS oversight, we included several  questions about CMS’s guidance and activities in our survey of state  Medicaid programs. We conducted this performance audit from July 2008  through August 2009 in accordance with generally accepted government  auditing standards. Those standards require that we plan and perform the  audit to obtain sufficient, appropriate evidence to provide a reasonable  basis for our findings and conclusions based on our audit objectives. We  believe that the evidence obtained provides a reasonable basis for our  findings and conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: In 2000, the Surgeon General noted that tooth decay is the most common  chronic disease among children. Left untreated, the pain and infections  caused by tooth decay can lead to problems in eating, speaking, and  learning. Proper dental care can prevent tooth decay and associated  problems that can lead to dental disease and even death. Research has  shown that preventive dental care is cost effective and can make a  significant difference in health outcomes. For example, a 2004 study found  that, over a 5-year period, low-income children who had their first  preventive dental visit by age 1 had average dental-related costs of $262,  compared to $546 for children who received their first preventive visit at  age 4 through 5.
The American Academy of Pediatric Dentistry (AAPD) recommends that  each child see a dentist when the child’s first tooth erupts and no later  than the child’s first birthday, with subsequent visits occurring at 6-month  intervals or more frequently if recommended by a dentist. The early initial  visit establishes a “dental home” for the child, creating an opportunity to  build an ongoing relationship with a dental provider who can ensure  comprehensive, continuously accessible care. Comprehensive dental visits  can include both clinical assessments, such as for tooth decay and the  need for sealants, and appropriate discussion and counseling for oral  hygiene, injury prevention, and speech and language development, among  other topics. Because resistance to tooth decay is determined partly by  genetics and partly by behavior, delaying the onset of tooth decay may  also reduce long-term risk for decay.
Recognizing the importance of good oral health, HHS in 1990 established  oral health goals as part of its Healthy People 2000 initiative; and in 2000  updated these oral health goals for 2010. These include goals related to  oral health in children, for example, reducing the proportion of children  with untreated tooth decay. Another goal relates to the Medicaid  population: to increase the proportion of low-income children and  adolescents under the age of 19 who receive any preventive dental service  each year to 66 percent in 2010.
At the federal level, CMS oversees Medicaid, which provides health care  coverage for low-income families and aged, blind, and disabled people.  CMS oversight includes monitoring state Medicaid programs, issuing  guidance to states, and facilitating communication and collaboration  among stakeholders. Medicaid provided health coverage for over   30 million children under 21 in fiscal year 2008. The states operate their  Medicaid programs within broad federal requirements and may contract  with MCOs to provide Medicaid benefits. CMS estimated that in 2006 about  65 percent of Medicaid beneficiaries received benefits through some form  of managed care. State Medicaid programs are required to cover certain  populations and services under federal law. For instance, under the  Medicaid EPSDT benefit, state Medicaid programs generally must provide  coverage of dental screening, diagnostic, and related treatment services  for all eligible Medicaid beneficiaries under the age of 21. Other federal  requirements for the EPSDT benefit that are related to dental services  include the following:    Developing dental periodicity schedules. State Medicaid programs  have some flexibility in determining the frequency and timing of dental  screenings covered for children under the EPSDT benefit. Under federal  law, however, state Medicaid programs must provide these dental services  at intervals that meet reasonable standards of dental practice as  determined by the state after consultation with recognized dental  organizations involved in children’s health care. According to CMS  guidance, as an alternative to developing a state-specific periodicity  schedule, a state may adopt a nationally recognized dental periodicity  standard, such as the schedule recommended by AAPD. CMS considers  AAPD’s periodicity schedule a model for comparison and it is published in  CMS’s Guide to Children’s Dental Care in Medicaid.
Reporting on delivery of EPSDT services. Federal law requires states  to report annually on the provision of EPSDT services, including dental  services. The annual EPSDT participation report, Form CMS-416  (hereafter called the CMS 416), is the agency’s primary tool for gathering  data on the provision of dental services to children in state Medicaid  programs. It captures data on the number of children who received a  preventive dental service, a dental treatment service, or any dental service  each year. Information on the CMS 416 report is used to calculate a state’s  dental utilization rate—the percentage of children eligible for EPSDT that  received any dental service in a given year.
Inadequate access to dental services for low-income children has been a  longstanding concern. In April 2000, we reported that Medicaid  beneficiaries and other low-income people had low rates of dental visits  and high rates of dental disease relative to the rest of the population. In a  September 2000 report, we identified factors influencing the access that  low-income groups have to dental care: a primary factor was limited  dentist participation in Medicaid. As part of its oversight of state  Medicaid dental services for children, in January 2001 CMS issued a letter  to state Medicaid directors indicating that, through a series of state  reviews, CMS would increase its oversight activities and assess state  compliance with statutory requirements. CMS highlighted four areas for  review: outreach and administrative case management, adequacy of  Medicaid reimbursement rates, increasing provider participation, and  claims reporting and processing. CMS did not complete this initiative. In  September 2008, we reported that the extent of dental disease in Medicaid- enrolled children had not decreased between 1988 through 1994 and 1999  through 2004. We also reported that millions of Medicaid-enrolled  children were estimated to have untreated tooth decay, and that children  in Medicaid were often not receiving dental services.
The American Recovery and Reinvestment Act of 2009 (Recovery Act)  authorized an estimated $87 billion in additional federal Medicaid funding  for states in the form of a temporary increase in the funds that the federal  government contributes toward state Medicaid programs, including the  provision of Medicaid dental services for children. The Recovery Act  provides this money to states through a temporary, 27-month increase in  the federal medical assistance percentage formula—the formula that  determines the federal share of a state’s Medicaid service expenditures.  In July 2009, we reported that the receipt of an increased federal share  may reduce the states’ share of expenditures for their Medicaid program,  and states have reported using these available funds for a variety of  purposes, such as maintaining program eligibility, covering increased  Medicaid caseloads, and maintaining local health care reform initiatives.
section_title: State Medicaid Programs Reported They Employ Multiple Strategies to Monitor and Improve Access to Medicaid Dental Services, but Problems Persist
paragraphs: In response to our survey, most states reported using multiple strategies to  monitor and improve access to Medicaid dental services, but they also  reported that persistent barriers hinder improvements. All 21 states that  provided Medicaid dental services under managed care arrangements  reported that they set measurable access standards for MCOs, however  more than half also reported that MCOs in their state do not meet any, or  only meet some, of the state’s dental access standards. Further, some  states reported that they do not routinely verify the adequacy of MCO  provider networks. Almost all states described initiatives to recruit dental  providers and enhance outreach to beneficiaries’ families, but barriers  persist and access rates remain low.
subsections: section_title: State Medicaid Programs Reported They Use a Variety of Methods to Monitor Dental Services
paragraphs: In response to our survey, all 51 states reported that they monitor the  provision of dental care to Medicaid-enrolled children, but how they do so  varies. The majority (39 states) reported that they use multiple methods— often three or more—to monitor the provision of dental care. These  methods included surveys of oral health, monitoring dental claims, and  collecting utilization data (see table 1). See appendix I for a list of the  monitoring methods reported by each state.
States also reported using various measures to monitor children’s access  to Medicaid dental services. The most common reported measure—used  by 40 (of 51) states for their fee-for-service programs and by 18 (of 21)  states that also used managed care—was the percentage of children who  had a dental visit in the previous year (see table 2). In the 21 states where  both fee-for-service and managed care programs are used to provide  dental services to Medicaid-enrolled children, state monitoring can vary by  service delivery method. For example, one state reported that it monitors  the percentage of dentists who treat children through its managed care  program, but does not monitor the percentage of dentists who treat  children through its fee-for-service program. Conversely, another state  reported the opposite—that it monitors this percentage for its fee-for- service program, but not for managed care.
States reported setting statewide dental utilization goals related to the  provision of children’s dental services. In response to our survey, 42 states  reported that they have set at least one statewide utilization goal related to  the provision of children’s dental care in Medicaid and about half of these  42 states (20 states) have set three or more statewide goals (see table 3).  Nine states reported they had no goals related to children’s dental care.  See appendix II for a list of the utilization goals reported by each state.
section_title: All States with Managed Care Programs Reported They Set Measurable MCO Access Standards and about Half Routinely Verified Provider Networks
paragraphs: All of the 21 states that reported using managed care programs to deliver  Medicaid dental services reported that they had established one or more  measurable MCO access standards specific to each MCO dental network,  such as specifying maximum waiting times for scheduling appointments   or a minimum ratio of available providers to Medicaid beneficiaries (see  table 4). However, more than half—14 of the 21 states—reported that the  MCOs either did not meet any, or only met some, of their standards.  Seventeen states reported that they used incentives or penalties to  encourage the MCOs to meet or exceed state standards. However,  potential incentives or penalties did not always produce the desired result.  For example, one state reported MCOs had not met any of the established  standards even though MCOs could be paid a bonus if they met some or all  of the standards. Similarly, other states reported that only some standards  were being met, despite potential financial penalties if MCOs did not meet  all of the state’s standards.
State oversight of MCO provider networks varied. Approximately half of  the states using managed care—12 of 21 states—reported contacting a  selection of providers in their MCO provider networks on a regular basis  to determine if they accept new Medicaid patients. Eighteen states using  managed care reported that they examined the adequacy of their dental  networks in response to a complaint or concern. Two of the 21 states  using managed care did not report taking any action to verify MCO  provider networks in their state. See appendix III for a list of MCO  standards set by states and appendix IV for a description of the extent to  which MCOs meet state standards and the methods states use to verify  that MCO dental providers accept children in Medicaid.
State Medicaid agencies also set expectations for MCOs related to  provider networks and access to services through the contracts they  establish with the MCOs. We reported in 2001 that specific and  comprehensive contract language helps ensure that MCOs know their  responsibilities and that they can be held accountable for delivering  covered services. Our review of contracts between states and nine large  MCOs that provide Medicaid dental services illustrate variations in the  specificity of the standards that states established in their contracts  concerning network adequacy and access measures. Regarding one  measure of network adequacy—the maximum number of beneficiaries per  dental provider—some, but not all, contracts specified a maximum  allowed number of Medicaid enrollees per dental provider. One contract,  for example, specified a county-level maximum of 486 enrollees per dental  provider, while other contracts did not specify any maximum. Standards  related to timely access also varied; for example, one contract required  that routine dental appointments be scheduled within 30 calendar days, or  sooner if possible, while another contract required that routine dental  appointments be scheduled within 90 days of a formal request. Finally, the  specificity of the contracts with regard to standards for the proximity of  dental providers to beneficiaries varied. One contract, for example,  specified a maximum travel time of 30 minutes to a provider, while  another contract had no proximity standards.
section_title: State Medicaid Programs Reported Efforts to Improve Access, but Also Reported That Persistent Barriers Hinder Further Improvement in Children’s Access to Dental Care
paragraphs: Many of the 51 states we surveyed reported efforts to improve children’s  access to dental care, including efforts to provide outreach to the families  of children in Medicaid and recruit dental providers. Forty-eight states  reported that they have taken one or more actions to facilitate or  encourage parents to take their children to a dentist, including publishing  literature about the importance of oral health and establishing a hotline  that families can call for help in finding a dentist (see table 5). Studies in  the published literature have reported some successes in outreach  programs. One such study reported on a state program where dental  hygienist services provided in three schools resulted in an increase in the  percentage of children who had seen a dentist at least once a year from   59 percent to 78 percent in the first year of the program.
All but one of the 51 state Medicaid programs reported they have taken   at least one action since 2000 to recruit Medicaid dental providers (see  table 6), and some states provided evidence that their initiatives have  enhanced their Medicaid dental provider networks. For example, one state  Medicaid program implemented an initiative that included simplifying  claims processing, increasing reimbursement rates, educating and  recruiting providers, and educating beneficiaries. According to a study of  this program published in the Journal of Rural Health, from fiscal year  1999 to 2002, this state Medicaid program saw a 39 percent increase in the  number of dentists accepting Medicaid and a 57 percent increase in the  number of Medicaid-enrolled children receiving dental services after  implementing this initiative.
Although nearly all states reported that since 2000 they have undertaken  initiatives to improve children’s access to dental care, CMS 416 data on  children’s access to dental care show that access rates remain low, and  states report facing the same barriers they faced in 2000. CMS 416 data  show dental utilization rates have improved since 2000, from a national  average of 27 percent to 35 percent in 2007—but in 2007 only 1 state  reported a dental utilization rate above 50 percent and 12 states’ utilization  rates remained below 30 percent. Less than half of the states that reported  undertaking initiatives to improve children’s access to dental care (21  states) reported that all their initiatives met their expectations. Nearly all  (48 of 51 states) reported that the principal barriers that contributed to the  low use of dental services by Medicaid beneficiaries in 2000—including  low provider participation rates, administrative burdens, and insufficient  funding—continue to impede their current efforts. Apart from funding  concerns, states most often reported that a lack of provider and  beneficiary participation hindered their efforts to improve access to  Medicaid dental services in their state (see table 7). Twenty-six states  reported these and other barriers resulted in one or more of their  improvement initiatives not being implemented or their expectations not  being met.
When asked to describe the extent to which state goals were being met,  some states reported that successes in increasing the numbers of  providers enrolled in the Medicaid program have resulted in increasing  rates of utilization by children, but that more needs to be done to increase  the percentage of children receiving dental services beyond current levels.  States also described other challenges to meeting their goals and  improving children’s access to dental care, such as fluctuations in  eligibility for services, lack of beneficiary compliance, low oral health  awareness among beneficiaries, and a lack of demand for routine dental  care by beneficiaries.
In addition to barriers that hinder state initiatives, states report that access  rates could also be affected by two other types of barriers: those faced by  children seeking dental services and those faced by providers serving  Medicaid beneficiaries. For children seeking dental services, most states  reported that finding a provider that accepts Medicaid is a moderate or  major barrier. Comparatively fewer states reported that obtaining  transportation to and from the provider’s office or the ability of parents to  take time off work are moderate or major barriers for children seeking  dental care. For providers, most states also reported that beneficiaries not  showing up for appointments and a limited capacity to accept new  patients (reported by 45 and 30 states, respectively) are moderate to major  barriers. One state noted that these issues are particularly significant when  they are combined together, at which point they can become moderate to  major barriers for dental providers. See figure 1 for barriers faced by  children and providers.
section_title: CMS Has Taken Action to Improve Federal Oversight of State Medicaid Dental Services for Children, but Gaps Remain
paragraphs: Responding to congressional concern about CMS oversight of state  Medicaid dental services, CMS has taken a number of actions since May  2007 to strengthen its oversight of Medicaid dental services for children,  but gaps remain in the agency’s efforts.
subsections: section_title: CMS Has Taken Steps toward Improving Oversight of State Medicaid Dental Services for Children
paragraphs: In February 2008 and September 2008 Subcommittee hearings, CMS  officials described several initiatives under way by CMS to improve  monitoring of state programs and to provide guidance and facilitate  collaboration. At the time of our review, some of these initiatives had been  completed, while others were still under way. CMS initiatives include the  following:    Focused dental reviews in 17 states. Between October 2007 and May  2008, CMS conducted a series of focused dental reviews in 17 states. The  reviews were designed to examine state efforts to improve children’s  dental utilization rates, assess state compliance with federal Medicaid  statutes and regulations, and identify promising or notable state practices  to improve the delivery of oral health services. In January 2009, CMS  published a summary report of its findings and recommendations in 16  states (in February 2008, CMS had published a separate report on  Maryland). CMS had concerns that 11 of the 17 states were not adhering  to federal law or regulation, including multiple findings in some states. For  example, CMS found that 6 states had inadequate dental networks in  MCOs that provided Medicaid dental services, 2 states had not ensured  that all medically necessary dental services were provided, and 1 state had  inappropriately limited reimbursement for out-of-state emergency dental  services, leaving the remainder of the costs to the beneficiaries. CMS also  made recommendations to all 17 states it reviewed and identified several  promising practices, which it highlighted in its summary report.
Improved collection of CMS 416 reports. In June 2007, CMS began an  initiative to improve reporting by states that had not submitted timely or  reliable dental utilization data in their annual CMS 416 reports. CMS sent  formal requests to 22 states that had failed to submit complete CMS 416  reports for one or more years. CMS also contacted the states and provided  technical assistance on problems with data collection methodology. As of  March 2009, all 51 states had submitted their 2007 CMS 416 reports to  CMS. CMS 416 reports for 2008 were due to CMS in April 2009, however,  as of early June 2009, only 42 states had submitted their 2008 reports.
Review of state periodicity schedules. In 2008, CMS examined dental- related periodicity schedules from all states. CMS found that all but three  states reported having some type of periodicity schedule, but not all  schedules were in compliance with CMS requirements. For example, some  schedules indicated when a primary care provider should refer a child to a  dentist, but the schedule did not specify how often dental services should  occur. CMS also found that periodicity schedules in several states were  not readily accessible by providers or beneficiaries. For states that had not  submitted separate dental periodicity schedules as required by CMS, CMS  recommended that the states adopt AAPD’s periodicity schedule for  children.
Publication of a dental policy document. CMS posted a 16-page  document on Medicaid dental policy issues on its Web site in September  2008. This document covered a variety of questions from states on topics  including periodicity schedules, dental referral requirements, covered  services, and patient cost sharing. For example, one question asked if the  state could allow providers to bill patients for missed appointments. CMS  responded that Medicaid policy did not permit such billing, in part because  no service was delivered. Further, missed appointments are not a distinct,  reimbursable Medicaid service, but are instead considered part of a  provider’s overall cost of doing business.
Communications with states and stakeholders. From 2007 through  2009, CMS held several meetings and conference calls with state dental  representatives, provider associations, and other stakeholders to discuss  issues concerning Medicaid dental services for children. For example,  CMS presented information on Medicaid dental issues at the April 2008  National Oral Health Conference sponsored by the American Association  of Public Health Dentistry and the Association of State and Territorial  Dental Directors. Other groups involved in CMS partnership activities  included AAPD, the American Dental Association, and the Association of  Community Affiliated Plans.
Establishment of an Oral Health Technical Advisory Group. In  conjunction with NASMD, CMS established an Oral Health Technical  Advisory Group to address issues related to oral health services, including  access and quality. A NASMD member chairs the advisory group and, as of  January 2009, other members included CMS representatives, state  representatives from different regions of the country, and other NASMD  staff. Advisory group projects include examining the effects on oral health  programs of recent legislation, such as the Recovery Act and the  Children’s Health Insurance Program Reauthorization Act of 2009,  considering improvements to the CMS 416 annual reports, and improving  materials used to inform beneficiaries of their Medicaid dental benefits.
Sharing of promising state practices related to dental services. CMS  posted “promising practices”—described by CMS as successful state  programs that reflect innovative approaches to meeting common  problems—on its Web site. As of May 2009, CMS had posted promising  practices from 4 states related to Medicaid dental services:  Delaware increased reimbursement, reduced administrative burden on  providers, and increased provider outreach.
South Carolina increased reimbursement rates, reduced administrative  barriers, and began an outreach campaign to encourage dentists to  participate in Medicaid.
Tennessee increased reimbursement, separated (or “carved out”) the  dental benefit from Medicaid managed care contracts, and hired a  contractor to administer the dental benefit.
Virginia increased reimbursement, carved out the dental benefit from  Medicaid managed care contracts, and adopted incentives to increase  provider participation, such as establishment of a dedicated call center,  new billing options and quicker payment, streamlined prior authorization  for care, and simplified provider credentialing.
section_title: Gaps Remain in CMS Efforts to Monitor Provision of Dental Services to Children in Medicaid, Provide Guidance, and Facilitate Collaboration among States
paragraphs: Although CMS has taken a number of important steps, gaps in CMS  oversight point to opportunities for further action to improve access to  dental services for children in Medicaid. Remaining gaps in CMS oversight  include the following:    CMS does not have plans to conduct focused dental reviews in  additional states. CMS’s focused dental reviews targeted 15 states with  the lowest dental utilization rates, but 2006 CMS 416 reports showed that  in 24 additional states (including Georgia and Maryland) in that year,  between 31 and 40 percent of eligible children received any dental  service—well below HHS’s Healthy People 2010 goal of having 66 percent  of low-income children under age 19 receive a preventive dental service.  According to CMS officials, CMS, at the time or our review, did not plan to  conduct focused dental reviews in these states, potentially missing an  opportunity to identify important areas for improvement. When asked  what additional assistance CMS could provide, 6 states responding to our  survey reported that they believed that an independent review of dental  services would be helpful to their Medicaid programs.
CMS did not require corrective action in states found to have  inadequate MCO networks. CMS’s focused dental reviews identified 8  states that provided dental services through managed care that did not  ensure that MCO provider networks were adequate to afford access to  covered dental services. In 6 states, CMS presented its concerns as a  “finding,” that is, a concern that the state is not adhering to federal law or  regulation. In the remaining 2 states, CMS cited deficiencies in MCO  provider networks, but did not report its concerns as findings. CMS made  recommendations to strengthen MCO provider networks in all 8 states;  however, CMS did not require these states to take corrective action— rather, agency officials indicated they would follow up with states on the  status of CMS’s recommendations.
CMS 416 reports provide limited information on dental service  utilization. The CMS 416 report only gathers data on the number of  children who received a preventive dental service, a dental treatment  service, or any dental service. We have reported in the past that these data  are limited in their usefulness for oversight of Medicaid dental services for  children. For example, because dental services delivered to managed  care enrollees are not reported separately from services to fee-for-service  enrollees, the CMS 416 data does not provide information that could be  used to flag problems with a specific service delivery method. Further, it is  not possible to determine how many children in a state received all of the  recommended dental services included in the state’s periodicity schedule.  According to the CMS Deputy Administrator, the Oral Health Technical  Advisory Group has a project under way to consider improvements to the  CMS 416.
States report that additional guidance from CMS is needed. In  response to our survey, 2 states reported that CMS’s September 2008  policy paper on Medicaid dental issues was helpful, but nearly all states  (49 of 51) reported that additional CMS guidance could help them improve  delivery of Medicaid dental services. States cited a need for additional  information in several areas: for example, guidance on standards for  dental care, information on billing policies, better definitions for outreach  and transportation services in Medicaid programs, establishing  appropriate dental fee schedules, improving documentation and coding  practices, and information on quality and preventive initiatives.
CMS has posted relatively few promising practices on its Web site.
When asked what CMS assistance would be helpful to their state Medicaid  program, the most common answer (other than increasing the federal  medical assistance percentage), cited by 37 states, was information on  other states’ efforts to improve dental utilization. Although CMS maintains  a Web site to publicize promising state Medicaid dental practices, 11 states  reported that they were unaware of the promising practices posted on  CMS’s Web site. The 4 promising practices posted as of May 2009 are just a  few of the practices that could be shared with other states. For example,  during its focused dental reviews, CMS identified 17 additional promising  and notable practices, none of which were included on the CMS promising  practice Web site. Further, 26 states responding to our survey reported  that their states had “best practices” that could be shared with other  states, such as providing mobile dental vans, training and reimbursing  physicians to do oral screens and apply fluoride varnish, and establishing a  dental home for children (see app. V for brief descriptions of these  practices).
section_title: Conclusions
paragraphs: CMS has begun several initiatives to strengthen its oversight of state  Medicaid dental services for children, but information on the oral health of  and receipt of dental services by Medicaid children show that much more  needs to be done. Although many states have reported moderate increases  in access to Medicaid dental services, we reported in September 2008 that  the extent of dental disease in children had not decreased and that  millions of children were estimated to have untreated tooth decay. States  responding to our survey reported that a lack of available funding, low  provider participation, and administrative burdens—many of the same  factors that contributed to the low use of dental services in 2000—still  present barriers to access today. Through a series of focused reviews of  states’ efforts to provide dental services to children in Medicaid, CMS has  identified deficiencies in several state Medicaid programs. Although CMS  made recommendations for improvement to the states, it required no  corrective actions. Moreover, not all states with low rates of children’s  dental utilization have been reviewed, nor are such reviews planned.  These reviews have not only identified problem areas, but have also  helped identify information on promising state dental practices that could  be useful to other states seeking to improve their own programs. Finally,  for Medicaid-enrolled children who receive dental services through  managed care programs, CMS has found that certain states have not  ensured that MCOs have adequate provider networks to provide covered  dental services to their enrollees. Although CMS and states have taken  steps to address long-standing barriers, continued attention and action is  needed to ensure children’s access to Medicaid dental services.
section_title: Recommendations for Executive Action
paragraphs: To strengthen monitoring of state Medicaid dental services for children  and help states improve children’s access to Medicaid dental services, we  are recommending that the Administrator of CMS take the following four  actions:    Develop a plan to review dental services for Medicaid children in all states  with low utilization rates, such as those not meeting HHS’s Healthy People  2010 targets.
Ensure that states found to have inadequate MCO dental provider  networks take action to strengthen these networks.
Work with stakeholders to develop needed guidance on topics of concern  to states.
Identify ways to improve sharing of promising practices among states.
section_title: Agency Comments
paragraphs: We provided a draft of this report for comment to HHS. Responding for  HHS, CMS provided written comments. In summary, CMS concurred with  three of our recommendations—specifically, to ensure that states found to  have inadequate MCO provider networks take corrective action, to  develop additional guidance on topics of concern to states, and to improve  sharing of promising practices among states and other stakeholders. CMS  described several initiatives planned or under way that would strengthen  its oversight of state Medicaid dental services for children. CMS concurred  in part with our fourth recommendation, to develop a plan to review  Medicaid dental services in states with low utilization rates. In following  up with CMS, an official clarified that CMS agreed with the need to review  Medicaid dental services in these states but wanted this plan to be part of  the agency’s broader plan to review all EPSDT services. As part of this  broader plan, CMS would consider additional focused dental reviews as  well as comprehensive EPSDT service reviews. We believe that CMS’s  action will meet the intent of our recommendation. CMS also noted that  the Children’s Health Insurance Program Reauthorization Act of 2009  included a number of provisions related to dental services that the agency  was in the process of implementing, including requirements for states to  post a listing of participating Medicaid and CHIP dental providers on  HHS’s www.insurekidsnow.gov Web site, to publish new quality measures  for Medicaid and CHIP children, and to report additional information on  children receiving dental care under Medicaid. Finally, CMS provided one  technical comment, which we incorporated into the report. CMS’s letter is  reprinted in appendix VI.
As agreed with your offices, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies of this report to the Secretary  of HHS and other interested parties.
In addition, the report will be available at no charge on GAO’s Web site at  http://www.gao.gov. If you or your staffs have any questions about this  report, please contact me at (202) 512-7114 or cackleya@gao.gov. Contact  points for our Offices of Congressional Relations and Public Affairs may  be found on the last page of this report. GAO staff that made major  contributions to this report are listed in appendix VII.
section_title: Appendix I: Methods Used by State Medicaid Programs to Monitor the Statewide Provision of Dental Care to Children
subsections: section_title: Claims and/or
section_title: Claims and/or
paragraphs: ●  State did have this method of monitoring children’s dental care.  ○  State did not have this method of monitoring children’s dental care.
section_title: Appendix II: Statewide Utilization Goals for the Provision of Dental Care to Children in State Medicaid Programs
subsections: section_title: Percentage of children who
section_title: Percentage of children who
paragraphs: finding dental  care is to fall  dental providers in  Medicaid exceeds  a certain threshold problems exceeds  a certain threshold ●   State did have this access goal for children’s dental care.  ○  State did not have this access goal for children’s dental care.
These states reported they do not have goals related to the provision of dental care for children in  state Medicaid programs.
section_title: Appendix III: Access Standards Set by the 21 States That Provide Dental Services through Managed Care Organizations (MCOs)
paragraphs: Appendix III: Access Standards Set by the 21  States That Provide Dental Services through  Managed Care Organizations (MCOs)
Access Standards States Set For MCOs  ●  State did have this standard for MCO networks in their state.  ○  State did not have this standard for MCO networks in their state.
section_title: Appendix IV: Extent to Which Managed Care Organizations (MCO) Meet State Standards and State Verification of MCO Networks
subsections: section_title: Extent to which MCOs meet established
paragraphs: Degree to which MCOs meet standards.  ●   State did report using this method to verify MCO provider networks.  ○   State did not report using this method to verify MCO provider networks.
section_title: Appendix V: CMS Promising Practices and State Reported Best Practices
paragraphs: To promote information sharing and collaboration among states, the  Centers for Medicare & Medicaid Services (CMS) has created a Web site in  which it publishes notable “Promising Practices” related to Medicaid and  the State Children’s Health Insurance Program (SCHIP). Dental care is one  of the subject areas covered on this Web site. To nominate a promising  practice, a state must complete an application describing the underlying  problem, the approach taken, and the results obtained. A promising  practice is defined by CMS as an approach to meeting a challenge related  to Medicaid/SCHIP program operations, clinical practice, or functional  level that serves to enhance quality of care and/or life and may be of  interest to other states. Specifically, the practice must:    Be related to the improvement of quality of care and/or life for Medicaid  and/or SCHIP beneficiaries.
Address a significant problem in health status or functioning based on  trends in mortality, morbidity, quality of life, utilization, and/or costs.
Reflect an innovative approach to meeting a common problem.
Have been in operation for a sufficient period of time to demonstrate  effectiveness (e.g., minimum 12 months).
Have demonstrated success through tangible results (e.g., improvements  in beneficiary physical or mental well-being, savings).
Comply with federal Medicaid statute and regulations and CMS policy  direction.
As of May 2009, there were five dental practices listed on CMS’s  “Promising Practices” Web site, four of which pertained to Medicaid.  Each of the 4 states cited as having promising practices also indicated on our survey of state Medicaid programs that they consider their state to  have a dental best practice.
In addition to these 4 states, 22 states responding to our survey reported  that they had best practices that could be shared with other states. See  table 12 for brief descriptions of all 26 state-reported best practices.
section_title: Appendix VI: Comments from the Department of Health and Human Services
section_title: Appendix VII: GAO Contact and Staff Acknowledgments
subsections: section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Katherine Iritani, Acting Director;  Susannah Bloch; Sarah Burton; Martha Kelly; Ba Lin; Sarah Marshall; Terry  Saiki; Jessica Cobert Smith; Teresa Tam; and Hemi Tewarson made key  contributions to this report.
section_title: Related GAO Products
paragraphs: Medicaid: Extent of Dental Disease in Children Has Not Decreased, and  Millions Are Estimated to Have Untreated Tooth Decay. GAO-08-1121.  Washington, D.C.: September 23, 2008.
Medicaid: Extent of Dental Disease in Children Has Not Decreased.  GAO-08-1176T. Washington, D.C.: September 23, 2008.
Medicaid: Concerns Remain about Sufficiency of Data for Oversight of  Children’s Dental Services. GAO-07-826T. Washington, D.C.: May 2, 2007.
Medicaid Managed Care: Access and Quality Requirements Specific to  Low-Income and Other Special Needs Enrollees. GAO-05-44R.  Washington, D.C.: December 8, 2004.
Medicaid and SCHIP: States Use Varying Approaches to Monitor  Children’s Access to Care. GAO-03-222. Washington, D.C.: January 14,  2003.
Medicaid: Stronger Efforts Needed to Ensure Children’s Access to Health  Screening Services. GAO-01-749. Washington, D.C.: July 13, 2001.
Oral Health: Factors Contributing to Low Use of Dental Services by Low- Income Populations. GAO/HEHS-00-149. Washington, D.C.: September 11,  2000.
Oral Health: Dental Disease Is a Chronic Problem Among Low-Income  Populations. GAO/HEHS-00-72. Washington, D.C.: April 12, 2000.
Medicaid Managed Care: Challenge of Holding Plans Accountable  Requires Greater State Effort. GAO/HEHS-97-86. Washington, D.C.:   May 16, 1997.