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. 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. 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. 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. 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. 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. 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. 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). CMS has begun several initiatives to strengthen its oversight of state Medicaid dental services for children, but information on the oral health of and receipt of dental services by Medicaid children show that much more needs to be done. Although many states have reported moderate increases in access to Medicaid dental services, we reported in September 2008 that the extent of dental disease in children had not decreased and that millions of children were estimated to have untreated tooth decay. States responding to our survey reported that a lack of available funding, low provider participation, and administrative burdens—many of the same factors that contributed to the low use of dental services in 2000—still present barriers to access today. Through a series of focused reviews of states’ efforts to provide dental services to children in Medicaid, CMS has identified deficiencies in several state Medicaid programs. Although CMS made recommendations for improvement to the states, it required no corrective actions. Moreover, not all states with low rates of children’s dental utilization have been reviewed, nor are such reviews planned. These reviews have not only identified problem areas, but have also helped identify information on promising state dental practices that could be useful to other states seeking to improve their own programs. Finally, for Medicaid-enrolled children who receive dental services through managed care programs, CMS has found that certain states have not ensured that MCOs have adequate provider networks to provide covered dental services to their enrollees. Although CMS and states have taken steps to address long-standing barriers, continued attention and action is needed to ensure children’s access to Medicaid dental services. To strengthen monitoring of state Medicaid dental services for children and help states improve children’s access to Medicaid dental services, we are recommending that the Administrator of CMS take the following four actions: Develop a plan to review dental services for Medicaid children in all states with low utilization rates, such as those not meeting HHS’s Healthy People 2010 targets. Ensure that states found to have inadequate MCO dental provider networks take action to strengthen these networks. Work with stakeholders to develop needed guidance on topics of concern to states. Identify ways to improve sharing of promising practices among states. We provided a draft of this report for comment to HHS. Responding for HHS, CMS provided written comments. In summary, CMS concurred with three of our recommendations—specifically, to ensure that states found to have inadequate MCO provider networks take corrective action, to develop additional guidance on topics of concern to states, and to improve sharing of promising practices among states and other stakeholders. CMS described several initiatives planned or under way that would strengthen its oversight of state Medicaid dental services for children. CMS concurred in part with our fourth recommendation, to develop a plan to review Medicaid dental services in states with low utilization rates. In following up with CMS, an official clarified that CMS agreed with the need to review Medicaid dental services in these states but wanted this plan to be part of the agency’s broader plan to review all EPSDT services. As part of this broader plan, CMS would consider additional focused dental reviews as well as comprehensive EPSDT service reviews. 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. ● State did have this method of monitoring children’s dental care. ○ State did not have this method of monitoring children’s dental care. 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. 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. 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. 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. 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. 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.

Summary: 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 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.