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Promising Practices
Issue Brief

Increasing Dentists' Participation in Medicaid and SCHIP
By Shelly Gehshan, Paetra Hauck, and Julie Scales

Introduction

Dentists' Participation in Medicaid

--Table 1. Changes in Dentists' Participation in Treating Medicaid Patients, 1998 and 2000.

The Supply of Providers

--Table 2. Dentists' Participation in Medicaid, 2000.

Barriers to Dentists' Participation

Reimbursement Rates

Administrative Simplification

Outreach for Dental Providers

Expanding the Use of Dental Hygienists

Conclusion

Appendix

Notes

Acknowledgments

Introduction

For many years, state and federal officials, providers and advocates have been very concerned about the difficulties faced by low-income families and children in obtaining dental care. The U.S. Surgeon General's Report on Oral Health in America said that, despite major improvements in oral health during the last 50 years, "...there are profound and consequential oral health disparities within the U.S. population."(1) Tooth decay is the single most common childhood disease: 59 percent of children have decayed teeth, compared to 11 percent who have asthma and 8 percent who have hay fever.(2) Poor children are more than twice as likely as their more affluent peers to have dental caries, and their disease is more likely to go untreated. Untreated cavities cause a significant amount of pain to children and cause difficulty eating, playing and learning as well as many missed days of school. Low-income adults face similar problems with pain and limitations on daily activities and are more likely than those with higher incomes to lose permanent teeth and have untreated dental disease.

Low-income children and families who meet state eligibility requirements receive their health care through Medicaid or the State Children's Health Insurance Program (SCHIP). If they are uninsured, they receive the health services that are available through the local public health system and charity providers. However, dental and medical services are delivered largely through separate systems. Under SCHIP, states that choose to establish a non-Medicaid program are not obligated to include oral health services in their benefit packages, although all state programs except Colorado, Delaware and one of Florida's three programs include some degree of dental coverage.(3) However, states are required under federal law to provide comprehensive oral health services for all children through age 20 who are enrolled in the Medicaid program. In 1998, only 19 percent of children eligible for preventive dental services under Medicaid received them; this is a decrease from 21 percent in 1996(4) States are not required to provide any services for dental problems other than emergency medical care for adults who are covered under Medicaid. However, many states provide other diagnostic, restorative and preventive dental services as well.(5) Few states provide public health dental services for adults, although some services are available through individual counties or philanthropic groups.

Both the problem of poor access to oral health care and the solution are complex. A big stumbling block is the low rate of participation by dentists in Medicaid and SCHIP. To gather information about steps states have taken to improve access to oral health services, the Forum for State Health Policy Leadership at the National Conference of State Legislatures (NCSL) surveyed dental contacts in state Medicaid and SCHIP programs in 1998 and 2000. This paper provides data from the 2000 survey on dentists' participation, compares data from both years' surveys, describes findings on selected state initiatives designed to increase participation and gives background on access to dental care for low-income people.

Dentists' Participation in Medicaid

Dentists are not required to enroll with their states as providers for Medicaid patients or other publicly funded clients. Those who choose to enroll as Medicaid providers may not actually treat Medicaid patients on a regular basis. To ascertain provider strength in Medicaid programs, NCSL collected information on the number of dentists enrolled as Medicaid providers in a year, the number who had billed the state for care delivered to Medicaid patients, and the number who billed more than $10,000.(6) Although $10,000 may seem like a substantial amount of care, national data shows that the average amount spent on dental care for a child was $437. This means that dentists who billed more than $10,000 are likely to have treated more than 23 children, or about two per month.(7) In most states, only a portion of practicing dentists enroll as Medicaid or SCHIP providers, a smaller portion see any Medicaid patients at all and a still smaller percentage see any significant number of Medicaid patients (see table 1).

Table 1.
Change in Dentists' Participation in Treating Medicaid Patients
1998 and 2000.

~ estimated

NA = Not Available

NR = No Response

1 SFY 2000 Data.

2 Calendar Year 1997 data.

3 SFY 1998 data.

4 The statistic for the number of dentists enrolled includes FFS and managed care while the other statistics for this state only include FFS.

5 Dental services are typically provided through public health clinics, since the local dental communities has not been interested in participating in Medicaid.

6 Calendar Year 1999 data.

7 These statistics include FFS providers only. They do not include the managed care sector in Hawaii.

8 Data from 1/99-9/99.

9 Includes Ortho Oral Surgeons.

10 Fee For Service only.

11 As of 7/1/00.

12 Provider numbers.

13 55 out of the 216 dentists were out of state providers.

14 Number represented is low because not all dentists that provide services through a dental care organization are enrolled directly with OMAP.

15 The number of dentists reported to be enrolled in Medicaid in SC come from FY 96-97 data, while the number who have received payment and the number who have received more than $10,000 come from Calendar year 1995 data.

16 TennCare contracts with nine managed care firms to provide this service. Since they pay the firms a capitation rate they do not have these statistics available.

17 Includes groups billing under one provider number.

18 Represents FFS data. Data for number receiving any type of payment and number receiving payment over $10,000 is from SFQ 1998. Numbers are low because they do not include payments made to clinics.

Sources: 1998 Survey of State Medicaid Departments by The Forum for State Health Policy Leadership, National Conference of State Legislatures; 2000 Survey of State SCHIP and Medicaid Departments by The Forum for State Health Policy Leadership, National Conference of State Legislatures

When compared with the same data from 1998:

--Of the 42 states with comparable data for both years, 14 states saw an increase in the percentage of enrolled dentists that received payment in the last year, and 27 states saw a decrease. One state maintained the same percentage. This shows that more states lost ground than gained ground in expanding the pool of dentists who actually provided dental care for Medicaid patients.

--Of the 38 states with comparable data, 24 experienced an increase in the percentage of enrolled dentists who billed more than $10,000 for care delivered to Medicaid patients in the most recent year, and 14 states experienced a decrease. Although the number of dentists who see Medicaid patients in most states may not have increased in the last two years, two-thirds of the states have increased the number of dentists for whom Medicaid is a regular part of their practice. This finding may indicate that reforms to the Medicaid dental program are less effective in bringing new dentists into the fold than in making it easier and more attractive for participating dentists to see more patients. In some states, the increase in the number of dentists billing more than $10,000 also may be due to the fact that the state raised reimbursement rates, so care costs more.

The Supply of Providers

The difficulty states face in increasing access to oral health services leads to the question of whether the supply of professionals is sufficient to meet demand. There is no consensus in the dental profession about whether there is a shortage of dentists, but there is agreement that there are too few dentists trained to treat children and too few who are willing to see a significant number of low-income clients. As table 2 shows, the percentage of dentists billing more than $10,000 in a year varies significantly across states. In five states-Alabama, Colorado, Connecticut, Pennsylvania, and Wisconsin-fewer than 10 percent of dentists bill more than $10,000. In contrast, six states-Alaska, Nebraska, North Carolina, Oregon, Vermont and West Virginia-have more than 40 percent of dentists billing more than $10,000, with Vermont in the lead with 72 percent.

The decline in the number of dentists has followed a decline in the incidence of tooth decay among children over the years, due primarily to fluoridation of much of the nation's drinking water. Although these improvements were a great public health victory, many graduating dentists in the late 1970s had difficulty starting a practice due to decreased demand for services. In response, in the 1980s states moved to reduce capacity at dental schools and some schools closed. As a result, the ratio of dentists to population has been dropping in the last 10 years. In the next 20 years, given the age of dentists now in practice and estimates on when they will retire, more dentists will leave the profession (85,000) than will enter it (81,000).(8) High demand for care and decreasing numbers of dentists relative to the population have meant that dentists' practices are full without their participation in public programs.

Table 2.
Dentists' Participation in Medicaid, 2000.

Reported data from SFY 1999 unless otherwise noted

Percentages over 100% are often due to dentists participating in Medicaid programs across state lines.

~ estimated

NA = Data Not Available

NR = No Response

Note: State lists of dentists enrolled in Medicaid vary in accuracy and may not be up to date.

State lists of dentists who have billed Medicaid use provider numbers and are more likely to be accurate.

1 American Dental Association, Survey Center, 1998 Distribution of Dentists in the United States by Region and State.

2 SFY 2000 Data.

3 Calendar Year 1997 data.

4 SFY 1998 data.

5 Calendar Year 1999 data.

6 IL does not differentiate between SCHIP and Medicaid providers, thus numbers may reflect some providers serving only children enrolled in SCHIP.

7 Represents FFS data. Data for number receiving any type of payment and number receiving payment over $10,000 is from SFQ 1998. Numbers are low because they do not include payments made to clinics.

8 Data from 1/99-9/99.

9 Includes Ortho Oral Surgeons.

10 Fee For Service only.

11 As of 7/1/00.

12 Provider numbers.

13 Number represented is low because not all dentists that provide services through a dental care organization are enrolled directly with OMAP.

Source: 2000 Survey of State SCHIP and Medicaid Departments by the Forum for State Health Policy Leadership, National Conference of State Legislatures.

Barriers to Dentists' Participation

The NCSL survey found that many states have worked with state dental societies to encourage participation and reduce barriers to practice. Dentists can legitimately point to low reimbursement rates--which traditionally have not covered actual costs--as a major factor. Dentistry is unlike medicine in the high cost of equipment needed to set up a practice, and the operation of a majority of dental practices as independent businesses. Physicians use expensive equipment as well, but it is located at hospitals or diagnostic centers and they, unlike dentists, rarely have to purchase it. Dentists also must hire staff, lease space, provide parking, and file all required forms and payments for employees. Many physicians work for institutions that provide those services. Reimbursements that are lower than the cost of delivering care make it difficult for dentists to pay for needed equipment and maintain a practice. Dentists also are much less likely than physicians to participate in managed care systems, which makes it difficult for states to organize their participation or negotiate fees. Dentists in many states also have complained about the administrative complexity, prior authorization requirements needed for providing even routine services and slow payment associated with public programs. In addition, a few state Medicaid programs forbid dentists to limit the size of their Medicaid and SCHIP practices, giving rise to fears that if they participate in Medicaid, they will have more patients than they can handle, whose care is reimbursed at rates that do not cover costs.

Less often discussed are clashes in cultural behavior and expectations between dental providers and Medicaid and SCHIP clients. Low-income people may be less educated about the importance of preventive dental care and proper hygiene, and may place them low on their list of priorities due to lack of time and scarce resources. By the time they see a dentist, they may have serious problems with decay and be difficult to treat, particularly if they have never seen a dentist before. In addition, many low-income people are accustomed to seeking care from clinics and emergency rooms, which, unlike dental offices, do not operate on an appointment schedule. They also may have difficulty with transportation and child care, which raises the frequency of missed appointments. Missed appointments waste valuable time for dental practices and result in lost revenue that cannot be easily replaced. A great deal of the care provided by dentists, unlike that provided by physicians, is surgical and rehabilitative rather than diagnostic and preventive, so they cannot simply fill a missed appointment with the next patient in the waiting room.

Despite federal requirements to ensure access to dental care under Medicaid and state efforts to comply, access problems have persisted and, in some states, have become worse. In January 2001, the Health Care Financing Administration (HCFA) issued new guidance to states about how it will assess compliance with the requirements to provide dental care to children. This communication applies to the Medicaid program and to SCHIP Medicaid expansions, but not to separate SCHIP programs. HCFA will examine state efforts in four areas: 1) informing Medicaid beneficiaries about their eligibility for dental services and facilitating referrals to dental providers; 2) paying adequate rates for dental services; 3) employing administrative strategies to enhance participation; and 4) improving claims processing.(9)

The NCSL survey found that many states have mounted efforts to increase dentists' participation in public programs. For this discussion, such efforts are grouped under reimbursement rates, administrative simplification, outreach to dental providers, and expanding the use of dental hygienists.

Reimbursement Rates

One of the most commonly cited barriers to dentists' participation in the Medicaid and SCHIP programs is low reimbursement for services. In most states, reimbursement rates do not cover overhead costs, and dentists lose money on each patient served. The American Dental Association calculates that 59 percent of the fees dentists' charge is needed to cover the cost of delivery care.(10) According to a study by the Department of Health and Human Services, states report that inadequate reimbursement is the most significant reason dentists do not accept Medicaid patients.(11) Of the 48 state Medicaid programs that responded to the survey, 30 indicated they had increased reimbursement rates in the last two years: Alabama, Arizona, Arkansas, California, Colorado, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Kansas, Kentucky, Louisiana, Maryland, Michigan, Minnesota, Mississippi, Indiana, Nebraska, New Mexico, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, South Carolina, South Dakota, Virginia and Wyoming. Eleven out of 22 SCHIP programs-Alabama, Arizona, Illinois, Indiana, Iowa, Kentucky, Maine, Massachusetts, Mississippi, New Hampshire and Wyoming-indicated they had increased reimbursement rates as well. The level of the rate hikes in these states was not collected in this survey, so it is not clear how many states are reimbursing dentists at a rate high enough for them to cover their costs.

According to a study conducted by Jim Crall, D.D.S. and Burt Edelstein, D.D.S., only five states-Alabama, Georgia, Indiana, Michigan and South Carolina - are paying rates that about 75 percent of dentists will accept. The study suggests there will be four stages of response when fees are raised above cost. First, the cost to the state of providing care increases because the cost of each unit of service has increased. Second, the dentists treating Medicaid kids begin to do more work on the existing kids because there is an incentive to provide comprehensive care. Third, the dentists who were treating Medicaid kids see more Medicaid kids. Finally, more dentists join in.(12)

Several states have experimented with various ways to raise rates. In 1995, Indiana eliminated several adult dental services and reduced the number of children's procedures that will be reimbursed regularly. With these savings, the state increased the fee for the remaining preventive and restorative procedures for children. The state will continue to cover all procedures deemed medically necessary, which is legally required under early and periodic screening, diagnosis and treatment (EPSDT). However, the state will require prior authorization for services and will pay only current rates for any procedures that have been eliminated for adults. These actions resulted from recommendations by the state dental association.(13)

Utah has a unique approach to providing care for both Medicaid and SCHIP patients. Utah's Medicaid program provides care directly to Medicaid beneficiaries through six dental clinics. These clinics are staffed and administered by the Medicaid program and see only Medicaid and SCHIP patients. Steven Steed, D.D.S., the Utah state dental director stated, "These clinics have been essential in minimizing the access crisis for Medicaid and SCHIP beneficiaries." Furthermore, as part of a bonus program, dentists in urban areas are given an additional 20 percent reimbursement after they see 100 Medicaid patients. They receive the bonus for the remainder of the year so long as they continue to see the required number of Medicaid patients. Dentists in rural areas are given the additional 20 percent if they see any Medicaid patients.(14)

In Wisconsin, general dental fee increases during the past few years have raised payments to approximately 61 percent of the statewide average charges. A bonus program pays $3.50 for the 20 dental procedures most frequently performed on children under age 21. In 1995, these additional payments were rolled over into further fee increases that apply only to claims for EPSDT services. These fees are approximately 75 percent of average charges. The increases were, in part, a result of the state's decision to eliminate some adult dental benefits and withhold fee increases for non-EPSDT dental services.(15)

In 1999, both Michigan (H 4802) and Missouri (H 296) enacted legislation that created a tax incentive for providers. Michigan provides a tax credit to dentists of either $5,000 or the amount equal to uncompensated dental treatment of indigent individuals. Missouri created a tax credit for dentists who provide services to Medicaid recipients.(16)

Administrative Simplification

In an effort to encourage more dentists to participate in the Medicaid and SCHIP programs, many states surveyed reported that they have implemented policies to reduce the administrative requirements imposed on participating dentists. NCSL found that the following states have implemented some sort of administrative simplification in the past year: Alabama, Alaska, Arizona, Georgia, Illinois, Indiana, Iowa, Kansas, Maine, Massachusetts, Michigan, Missouri, Montana, New Hampshire, North Dakota, Ohio, Oklahoma, Pennsylvania, Texas, Washington and Wyoming. States have used several different methods to streamline the administrative process. Some of the most commonly cited methods include eliminating or reducing prior authorization criteria, simplifying provider contracts, allowing dentists to file claims using the forms and billing codes accepted by the American Dental Association (ADA), and accepting bills filed electronically. Many states noted they have used a combination of these tactics in their efforts to encourage dentists to participate.

• Eliminating or reducing prior authorization criteria reduces the administrative burden for dentists' office staff and speeds up delivery of services. Although prior authorization requirements are intended to reduce overuse or misuse of services and to prevent services being provided to people who are not eligible, they may alienate providers and not result in substantial cost savings. States generally eliminate prior authorization for routine services and, less often, eliminate it for specialty or high-cost services. Ten states-Alabama, Illinois, Indiana, Iowa, Michigan, Montana, New Hampshire, North Carolina, Oklahoma and Washington-have eliminated or reduced some prior authorization criteria in their efforts to simplify the administrative burden on dentists. Texas recently established a "dental only" hotline, which allows dental offices speedier access to answers from the Medicaid agency, and links providers to an automated system they can use to verify patient eligibility and track claims.
• Simplifying provider contracts makes it easier for providers to enroll in Medicaid and SCHIP. Although states must ensure quality of care for beneficiaries and appropriate training and licensing for providers, lengthy and complex enrollment forms create a barrier to entry that is contrary to states' policy goal of recruiting providers. Alaska, Iowa, Maine, Montana, Texas and Wyoming described efforts to simplify their provider contracts. Texas worked to reduce its provider application form from 48 pages to five for individuals and to eight for corporate practices.
• Allowing dentists to file the ADA claim forms makes it easier for dentists to bill for services. The ADA claim form is the one commonly filed with private insurance companies. States have used this method so that dentists will not have to train office staff to fill out different forms for Medicaid and SCHIP patients than for private patients. Arizona, Georgia, Michigan and Missouri have switched to the ADA claim form to simplify the billing process.
• Using ADA billing codes creates less confusion for dentists in the billing process. Six states-Georgia, Illinois, Iowa, Michigan, Montana and North Carolina-noted they have used this method in an effort to create a universal set of procedure codes rather than separate procedure codes for Medicaid, SCHIP and private patients.
• Accepting electronic billing allows dentists to more quickly and easily bill for services. States that have begun to accept billing electronically hope to see an increase in turnaround time. Alaska, Georgia, Michigan, North Carolina and North Dakota noted that they accept bills electronically.

A number of states have worked to simplify administrative procedures. The Alaska Department of Health and Human Services has made several changes to ease the administrative burdens for dentists who participate in Medicaid. Alaska has focused on establishing billing requirements that are less burdensome for dentists in the hope that this will encourage more dentists to participate in the Medicaid program. Alaska has rewritten the provider billing manual, streamlined claims processing procedures and encouraged dentists to bill electronically.

Like Alaska, Illinois has simplified administrative procedures to make the process easier for dentists. Such changes include accepting the ADA claim form and billing codes, eliminating some prior approval requirements, and accepting claims filed electronically. Since these changes have been made, Illinois has seen an increase in the number of providers. Illinois also has been able to reduce to approximately 10 to 15 days the time it takes for bills to be reimbursed, an effort that has greatly pleased providers.

Iowa also has adopted a number of changes, including using the ADA billing codes, encouraging electronic billing, removing prior authorization requirements for nine procedures, and simplifying the provider manual. All these changes have occurred in the past year. Iowa hopes that data will show an increase in provider participation after the policy has been in place for a year. In the meantime, continuing efforts are under way to simplify the provider manual and billing procedures.

Outreach for Dental Providers

In response to the NCSL survey, states described a variety of methods to work with state dental associations, inform dentists about improvements in their programs and encourage dentists' participation. The strategies most commonly employed are creating dental task forces, presenting at dental schools and dental society meetings, and placing promotions in dental journals. NCSL found that during the last two years, seven states have formed task forces to address the problem of both Medicaid and SCHIP beneficiaries' limited access to dental services. Task forces provide momentum and support for future changes as well as help define specific problems and shape policy solutions to improve access. They typically are made up of representatives from professional and provider organizations, advocacy groups, state dental societies, legislators, health plans and dental schools. These groups are formed to discuss issues, identify politically feasible solutions and work with key agents of change such as legislatures, dental associations and dentists. They generally are created by a governor, state agency or private organization. NCSL found that Alabama, Arizona, Indiana, Maine, Maryland, New Mexico, Virginia and Wisconsin have used task forces to improve access to oral health care.

According to Mary McIntyre, M.D., associate medical director of Alabama Medicaid, the state's task force was formed, " ... after recognizing the need for a better relationship with the dental community as a whole." In 1997, the Alabama Medicaid agency contacted the Alabama Dental Association to identify dentists across the state- including those who participated in Medicaid and those who did not-to be appointed to a dental task force. The task force developed a set of recommendations that currently is being implemented by the state Medicaid agency. Those recommendations were to:

• Simplify the prior authorization process;
• Add coverage for a number of dental procedures that previously were not covered;
• Seek a target dental reimbursement rate increase;
• Clarify program limits with a revision of the Dental Provider Billing Manual; and
• Make targeted case management available for dental services to improve patients' rate of keeping appointments.(17)

In states with dental schools, recruiting dental students can help increase the supply of providers to care for Medicaid and SCHIP beneficiaries. Working with Medicaid and SCHIP patients during dental school may encourage dentists to continue working with them once they set up private practices. According to survey responses, California, Kentucky, Missouri, New Mexico and Oklahoma use this technique.

North Dakota uses a dental mentoring program in an attempt to improve access to underserved communities by recruiting in Minnesota dental schools since North Dakota does not have its own. All North Dakota residents who are in dental school in Minnesota receive a list of dental mentors in North Dakota. Dental residents from North Dakota have the option of working in a North Dakota dental office as part of their school experience. This program has proven to be mutually beneficial; local dentists receive assistance and dental school residents gain familiarity with rural practice. The desired goal is to improve dental access for everyone, including Medicaid patients.(18)

Making presentations to state dental societies is another method states have used to increase participation. Dave Michalik, senior administrator in Delaware's Department of Social Services, says, "The most important thing to recognize is the need to establish a collaborative and personal relationship with dental societies. In Delaware we were able to work together and break down the barriers of suspicion and distrust that have been built over the years." According to the NCSL survey, Alaska, Delaware, Pennsylvania and Virginia have used this approach.

Texas has successfully promoted its Medicaid and SCHIP programs through the state dental journal and other dental publications, expanding from 1,090 to 1,334 SCHIP providers in just three months. Similarly, the Texas Dental Foundation, a nonprofit philanthropic organization affiliated with the Texas Dental Association, is underwriting the cost of Medicaid provider recruitment workshops at dental meetings across the state. Jay Bond, director of policy at the Texas Dental Association, says "... the October Texas Dental Journal included a memo urging members to sign up for SCHIP and The United Concordia [the state contractor in charge of SCHIP outreach] provided enrollment applications. This had an excellent response. I believe it is a realistic goal to have equal numbers of SCHIP and Medicaid providers in our state."

States have implemented a number of effective strategies in light of the pressing need to increase the number of providers who participate in public programs. "Ideally, every dentist in the state would sign up. There are approximately 9,000 dentists in Texas." says Jay Bond. James Marshall, director of the Council on Dental Benefit Programs at the American Dental Association said, "I think it is important for states to be fully aware and approach the barriers that exist. There needs to be a common ground between Medicaid and the dental associations, a meeting of the minds to address common problems and seek solutions. If that is done it will create a climate where dentists are more inclined to participate."

Expanding the Use of Dental Hygienists

In an effort to address the problem of a shortage of dental providers who will care for low-income patients, some states are seeking ways to expand the use of dental hygienists, either by easing the rules on direct supervision by dentists or by changing reimbursements. According to survey responses, Connecticut, Iowa and Minnesota have implemented policies that allow dental hygienists to be reimbursed for specific services that are delivered without the general supervision of a dentist. Since each of these programs is still fairly new, it is difficult to assess their effectiveness. Cathy Coppes, a policy specialist with the Iowa Department of Human Services, comments that "... the dental access problem is so complex, it is not just a matter of funding, adequate personnel, or addressing a specific population. Because of this we need to use a multifaceted approach to addressing the problem of access. Allowing Medicaid reimbursement for dental hygienists for specific services in underserved areas is just one facet of an approach needed to address the problem of access."

The issue of expanding the use of dental hygienists is controversial and engenders fierce criticism from organized dentistry. Most dentists oppose independent practice for hygienists because they feel hygienists are not trained to diagnose and treat oral diseases, and they fear that independent practice will erode their patient base but will not adequately treat patients. Although hygienists are trained to clean teeth and can apply sealants and fluoride, they can do little more than refer to a dentist those patients who need further help.

On the other hand, the American Dental Hygienist Association (ADHA) strongly supports expanding the use of dental hygienists. The most commonly cited benefit of expanding hygienists' role is that they can provide high-quality preventive services to underserved patients.(19) Although it is not ideal to provide dental hygiene without the services of a dentist on site, the ADHA feels it is better for low-income patients to receive patient education, cleaning, fluoride and sealants than nothing at all. Under recent state practice site expansions, hygienists are able to go to schools, nursing homes, and other public health facilities to provide preventive services to the most vulnerable and underserved populations. Another argument states use to support expanded use of hygienists is that if they provide more preventive services, they can free time for restorative procedures by dentists who see publicly funded patients. The shortage of dentists who care for low-income patients makes this an attractive prospect for states.

Connecticut enacted legislation in 1999 to allow dental hygienists to practice in a public health facility without the general supervision of a dentist. In order to practice independently in those settings, a dental hygienist must be licensed and have two years of experience. Through Public Act 99-197, dental hygienists are permitted to perform the following procedures: complete prophylaxis; the removal of calcareous deposits, accretions and stains; the application of sealants and topical solutions; dental hygiene examinations and the charting of oral conditions; and dental hygiene assessment, treatment planning and evaluation. Since the enactment of this legislation, Connecticut has seen an increase in the number of children who are receiving dental services. Hartford County, which has started a school-based hygienist program, has seen the highest participation increase of all Connecticut counties. Martha Okafor, a program administration manager with the Connecticut Department of Social Services, notes that in the future she believes dental hygienists should play a critical role in providing primary dental services.

In 1997, the Iowa Department of Human Services began granting waivers to allow Medicaid reimbursement for specific services provided by dental hygienists. Exceptions are granted only to hygienists practicing in maternal and child health centers in counties where access problems are severe. The program was started in December 1997 and initially allowed Medicaid reimbursement only for screenings. Since then, the state has allowed reimbursement for the application of sealants and varnishes by dental hygienists. In some counties where there are serious access problems, the program has been expanded to pregnant women over age 21 in addition to children. The policy exceptions granted and the services allowed are made on a county-by-county basis. Preliminary results indicate an increase in the number of children served. Iowa expects to have data by the end of June 2001 that show improvement in the volume of services provided.

The Minnesota dental hygienist demonstration project became effective July 1, 1999. Under this project, the Legislature authorized extending dental services to those performed by a dental hygienist. Patients do not need to be seen by a dentist before going to a hygienist, but the services still must be authorized by a licensed dentist. Minnesota started the demonstration project in an attempt to address the issue of access. Patients who have limited access to dental care are eligible to take part in the program. Minnesota definition of limited access includes anyone who is " ... unable to receive regular dental services in a dental office due to age, disability, or geographic location."

Conclusion

States have had a great deal of difficulty ensuring that children and adults who are enrolled in Medicaid programs receive the dental benefits to which they are entitled. There are problems with inadequate and slow reimbursement, unwieldy administrative procedures, poor communication with state dental societies, a paucity of participating providers, maldistribution of providers and cultural and behavioral differences between dental practices and low-income patients. The NCSL survey shows that, although these problems are far from solved, states are taking them seriously and are working on many fronts to correct them. The survey found that:

• Of the 42 states with comparable data, between 1998 and 2000, 14 states experienced an increase and 27 experienced a decrease in the number of dentists who received payment for treating a Medicaid patient;
• Of the 38 states with comparable data, between 1998 and 2000, 24 states experienced an increase and 14 experienced a decrease in the number of dentists that billed the Medicaid program more than $10,000;
• Since 1999, 30 of 48 states that responded have raised Medicaid reimbursements for at least some dental services;
• Since 1999, 11 of 22 states that responded reported raising SCHIP reimbursements for dental services;
• Ten states reported reducing prior authorization requirements;
• Six states reported simplifying contracts to make it easier and quicker for dentists to enroll as Medicaid providers;
• Four states shifted to allow dentists to file the ADA claim form, as most do for privately insured patients;
• Six states shifted to using ADA billing codes, as most dental offices do for privately insured patients;
• Five states established a system to allow dentists to bill them electronically;
• Eight states have convened task forces to study the problem of lack of access to dental care for low-income people and to make recommendations to improve it;
• Six states have worked with dental schools to recruit dental students to provide care to Medicaid- and SCHIP-eligible patients;
• Five states have made presentations to state dental societies or advertised in their journals to improve relations with state providers and to recruit providers for Medicaid and SCHIP; and
• Three states have worked to expand the use of dental hygienists, either by easing direct supervision rules or by changing reimbursement policies.

It is clear from the NCSL survey that states are implementing a broad range of measures to improve access. More than half have raised reimbursement rates, which may be the single largest barrier to dentists' participation. In many states, however, rates are so far below the cost of providing care that this must be viewed as incremental progress rather than a final solution to the problem. Despite all state efforts, the survey shows that two-thirds of the states for which data is available lost ground in expanding the pool of dentists who actually provided dental care for Medicaid patients. In contrast, nearly half of all states experienced an increase in the number of dentists who billed the state for more than $10,000 of care. It is clear that, although progress has been made, much work remains to be done to comply with federal requirements to ensure access to dental services for Medicaid and SCHIP beneficiaries.

Appendix

1. What is the most recent full year for which you have statistics on Medicaid coverage of oral health services?

In the most recent year for which you have statistics:

2. How many dentists were enrolled in Medicaid in your state?
3. How many dentists received payment for more than $10,000 by Medicaid?
4. How many dentists received any type of payment by Medicaid?
5. How many children received one or more dental services through Medicaid?
6. In the last two years, has your state started any programs or initiatives designed to increase provider participation in oral health programs, i.e. fee increases or administrative simplification, etc.? (Please attach program descriptions, brochures or other materials if available.)
7. In the last two years, has your state started any programs or initiatives designed to increase access to oral health services by low-income children, i.e. coordination with WIC program, school fluoride programs, etc.? (Please attach program descriptions, brochures or other materials if available.)

 

SCHIP Oral Health Questionnaire

(Questions 1-7 are the same as above)

8. What is the most recent full year for which you have statistics on Medicaid coverage of oral health services?

In the most recent year for which you have statistics:

9. How many dentists received payment of any type for serving children in SCHIP?
10. How many children received 1 or more dental services through SCHIP?
11. What are the reimbursement rates that your state SCHIP program pays for the following services:

1. Periodic oral evaluation (00120)
2. Initial comprehensive oral exam (00150)
3. Introral radiographs - complete series, including bitewings (00210)
4. Bitewings - 2 films (00272)
5. Panoramic film (00330)

Preventive

6. Prophylaxis (cleaning) - child (01120)
7. Topical application of fluoride, prophylaxis not included - child (01203)
8. Sealant - per tooth (01351)

Restorative

9. Amalgam - 2 surface, permanent (02150)
10. Resin - 2 surfaces, anterior (02331)
11. Crown - Porcelain fused to predominantly base metal (02751)
12. Prefabricates stainless steel crown - primary tooth (02930)

Endodontics

13. Therapeutic pulpotomy, excluding final restoration (03110)
14. Anterior endodontic therapy, excluding final restoration (03310)

Surgery

15. Extraction - single tooth (07110)

1. In the past two years, has your state started any programs or initiatives designed to increase provider participation in oral health programs, i.e. fee increases or administrative simplification, etc.? (Please attach program descriptions, brochures or other materials if available.)
2. In the past two years, has your state started any programs or initiatives designed to increase access to oral health services by low-income children, i.e. coordination with WIC program, school fluoride programs, etc.? (Please attach program descriptions, brochures or other materials if available.)  

Notes

1 Department of Health and Human Services, Oral Health in America: A Report of the Surgeon General, (Rockville, Md.: National Institutes of Health, 2000).

2 National Center for Health Statistics, Prevalence of Selected Chronic Conditions, (DHHS Pub. No. PH-S97-1522, Hyattsville, Md: U.S. Department of Health and Human Services, 1996).

3 For a complete list of dental benefits available in SCHIP programs, see the chart posted on the NCSL website at www.stateserv.hpts.org.

4 Health Care Financing Administration, HCFA-416 reports annual summary.

5 American Dental Association, 1998 Survey of Dental Programs in Medicaid, (Chicago, Ill.: American Dental Association, August 1998), p. 3; Although states are not required to provide dental services for adults, they are required to provide emergency dental services to beneficiaries in nursing homes.

6 State data on the number of dentists enrolled as Medicaid providers varies in accuracy and reliability. States may not verify this information on a regular basis to check for duplicate entries or for dentists who have retired, moved or stopped accepting Medicaid. State data on the number of dentists billing for services is based on provider numbers rather than names and is more likely to be accurate.

7 Agency for Healthcare Research and Quality, Health Care Expenses in the United States, (Rockville, Md.: U.S. Department of Health and Human Services, 1996), MEPS Research Findings #12, p.20; The figure cited is the average expenditure for dental expenses among children ages 6-17.

8 Richard W. Valachovic, Dental Workforce Trends Impacting Oral Health Services for Children, (Washington, DC: American Association of Dental Schools, March 2000), p. 2.

9 A copy of this letter is available on the HCFA Web site at: http://www.hcfa.gov/medicaid/smd118a1.pdf.

10 American Dental Association, Income from the Private Practice of Dentistry, Survey of Dental Practice, (Chicago, Illinois: American Dental Association, 1999).

11 Office of Inspector General, Children's Dental Services Under Medicaid: Access and Utilization, (San Francisco, Calif.: U.S. Department of Health and Human Services, 1996).

12 Burton Edelstein, director, Children's Dental Health Project, Washington, DC, Interview with the author, January 2001.

13 Ibid.

14 Camm Epstein, States' Approaches to Increasing Medicaid Beneficiaries' Access to Dental Services, (Princeton, New Jersey: Center for Health Care Strategies, Inc., 1999).

15 Op cit. Inspector General. (1996).

16 Center for Policy Alternatives, State of the States: Overview of 1999 State Legislation on Access to Oral Health, (Washington, D.C.: Center for Policy Alternatives, 2000).

17 Mary McIntyre, Associate Medical Director, Alabama. Interview with the author, January 2001.

18 Op cit. Camm Epstein. (2000).

19 American Dental Hygienist Association, The Future of Oral Health: Barriers to Care, www.adha.org/profissues/future/page5.htm.

Acknowledgements

This report was prepared with the generous support of the Robert Wood Johnson Foundation. The authors would like to thank Don Schneider, D.D.S., M.Sc.D., chief dental officer, Health Care Financing Administration; Burton Edelstein, D.D.S., director, Children's Dental Health Project; Jim Crall, D.D.S. director, HRSA/MCHB National Oral Health Policy Center; Carree Moore, dental program manager, State of Washington; and Laura Tobler, senior policy specialist, National Conference of State Legislatures, for their helpful comments on drafts of this report. Thanks also to Leann Stelzer for editing and Greg Martin for formatting the report.  

The National Conference of State Legislatures serves the legislators and staffs of the nation's 50 states, its commonwealths, and territories. NCSL is a bipartisan organization with three objectives:

• To improve the quality and effectiveness of state legislatures,

• To foster interstate communication and cooperation,

• To ensure states a strong cohesive voice in the federal system.

The Conference operates form offices in Denver, Colorado, and Washington, D.C.

The Forum for State Health Policy Leadership (the Forum) is a unit within the National Conference of State Legislatures (NCSL) whose mission is to enhance the capacity for informed decision making and legislative leadership regarding the financing, organization and delivery of health care services to low -income and vulnerable populations. Established in 1995, the Forum carries out a variety of initiatives that serve targeted constituents within NCSL and responds to emerging issues and complex problems facing state legislatures.

The Forum for State Health Policy Leadership is funded by grants from the California HealthCare Foundation, the Henry J. Kaiser Family Foundation, the Robert Wood Johnson Foundation, the David and Lucile Packard Foundation, the W.K. Kellogg Foundation, and Merck & Co. Inc.

© 2001 by the National Conference of State Legislatures. All rights reserved.

Item #: 6778-0001
ISBN 1-58024-162-X
Price: $15.00

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