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.