greater richmond and petersburg oral health alliance...lauren gray, program and engagement manager,...

Greater Richmond and Petersburg

Oral Health Alliance Tuesday, July 10, 2018 | 1:00 pm – 3:00 pm

McCabe Room- Cameron Foundation, Petersburg, VA

Agenda 1:00 pm – 1:15 pm Welcome & Introductions

Lauren Gray, Program and Engagement Manager, Virginia Oral Health Coalition

1:15 pm – 1:35 pm Policy Update Sarah Bedard Holland, Chief Executive Officer, Virginia Oral Health Coalition

1:35 pm – 2:00 pm Workgroup Updates

2:00 pm – 2:45 pm At-Home Visits with Legislators: Promoting an Adult Dental Benefit in Medicaid

2:45 pm – 3:00 pm Next Steps & Close

Greater Richmond and Petersburg Oral Health Alliance

Tuesday, July 10, 2018Petersburg, VA

Desired Outcomes

• Shared understanding of current policy context around oral health coverage and access

• Shared understanding of what each Alliance workgroup is working on and next steps

• Consensus on an Alliance-wide strategy for advocacy to increase dental coverage

Virginia Oral Health Coalition

Striving to ensure all Virginians have access to affordable comprehensive health care that is

inclusive of oral health

3

Advocacy | Provider Education | Public Awareness

Guiding PrinciplesVirginians know that good oral health is essential to overall health.

The prevalence of dental disease is reduced in Virginia through prevention activities and early diagnosis and treatment.

The oral health workforce in Virginia adequately meets the needs of its citizens by working to the full extent of their education and training.

Medical and dental providers and educators understand the links between oral health and overall health and work to ensure Virginians receive comprehensive care.

Virginians have access to quality, affordable, and comprehensive dental insurance coverage.

Provider EducationPregnancy and Early Childhood• Partnering with CHIP of Virginia to train CHWs and home visitors• Fluoride varnish and oral health integration training for pediatric

medical providers

Special Needs• Providing continuing education to dental professionals on techniques

and resources to care for individuals with special health care needs

Oral Health Integration• Safety Net Learning Collaborative• Oral Health Integration Toolkit

5

Virginia Oral Health Report Card

Regional Alliances• Working groups with different

structures and focus areas• Measurable goals and action

plans • Data-Driven • System change focus

• not just programs and education

• Timeframe for implementation depends on the stakeholders involved

Determined not to recreate the wheel or develop more silos

Crater Health District

• 38% of adults have no dental coverage.• 49% of adults have lost at least one tooth to

decay or disease• 51% of adults have complete tooth loss.• 62% of adults report having a dental visit in

the past year.

8

Coverage Gains by Locality

*Uninsured nonelderly adults up to 138 percent FPL residing in localities, some may not meet all eligibility requirements. Source: TCI analysis of US Census Bureau ACS 5-year data, 2012-2018. Updated: January 3, 2018.

Locality Could Gain Coverage*Charles City 300Chesterfield 8,500Colonial Heights 700Dinwiddie 1,200Goochland 200Hanover 1,600Henrico 10,800Hopewell 800New Kent 300Petersburg 2,000Powhatan 400Richmond 14,700Total 41,500

The Coalition’s Role in the AlliancesWe provide the backbone supportto enable local and regional partners to collaborate more effectively to improve oral health.• Convener• Facilitator• Topical expertise• Resources and tools

Register by August 14: http://bit.ly/VaOHCAug2018

http://bit.ly/VaOHCAug2018

Medallion, Expansion, Public ChargeOH MY!

Greater Petersburg Richmond Oral Health Alliance

This Afternoon…

• Medicaid Expansion• Medallion roll-out• Public Charge• Census• Dental Benefit in Medicaid

2

Medicaid ExpansionThis is a BIG deal!

3

Coverage in Virginia

Medicare• No dental benefitsMedicaid and FAMIS• Comprehensive dental coverage

for children & pregnant women• Extraction benefit for adults

– Caretaker adults– Aged, blind and disabled

• CCC+/Medallion 4.0 Traditional Dental Benefit• Prevention services are free• Yearly capExchange Dental Benefit• Adult

– No mandate– No subsidies

What does this actually mean?• 400,000 newly eligible

adults• Effective Jan 1 or

before.• SPA • 1115 waiver

– Work requirements

– Cost sharing

5

Dental Coverage - Medicaid

6

Medallion 4.0Also a big deal

7

Medallion 4.0• 740,000 Virginians• Managed by 6 MCO/available in all

regions– Aetna – Optima – Anthem – UnitedHealthcare – Magellan – Virginia Premier

• 100,000 will receive a new plan– Can change within first 90 days or open

enrollment– Providers can begin credentialing now

8

Medallion 4.0 Managed Care

Regions Proposed Dates*

Tidewater Region August 1, 2018

Central Region September 1, 2018

Northern/Winchester October 1, 2018

Charlottesville/Western November 1, 2018

Roanoke/Alleghany December 1, 2018

Southwest Region December 1, 2018

https://www.google.com/imgres?imgurl=http://www.dmas.virginia.gov/Images/Transparent%20Header%20Test.png&imgrefurl=http://www.dmas.virginia.gov/Content_pgs/medallion_4-home.aspx&docid=fkjTCfA126qH3M&tbnid=3Dtqjju1ZmHqYM:&vet=10ahUKEwiF1e2kwM7bAhUK7IMKHcygCrYQMwg-KAAwAA..i&w=1372&h=643&bih=854&biw=1697&q=virginia%20medallion%204.0%20medicaid&ved=0ahUKEwiF1e2kwM7bAhUK7IMKHcygCrYQMwg-KAAwAA&iact=mrc&uact=8


Medallion 4.0 will also include some of these

services

FAQ coming

9

CCC+ Value Add Services

Public ChargeAnother Big Deal!

10

Public Charge

11

“public charge” means an individual who is likely to become dependent on the government for subsistence, as demonstrated by either the receipt of public cash assistance for income maintenance or institutionalization for long-term care at governmentProposed changes would include consideration of use health and nutrition programs (Medicaid and SNAP) AND benefit use by the individual and dependents

• 2 in 5 US born children meet this criteria

• 600,000 Virginians live in a family with a non citizen who could be considered public charge under new criteria

• Comparison – 5% of the current population falls under existing criteria.



The 2020 Census

12

• Determines allocation of Federal resources

• Determines number of seats in House of Representatives

• People of color and young children underrepresented

• Testing underway now• Citizenship Question – Virginia

part of lawsuit



But What about Dental in Medicaid??

13

Medicaid –Adult Dental

• Partner Letters• Agency and Executive

Branch meetings• Grassroots Advocacy• Message Development

14

How can you Help?

• Tell people – share info• Write a letter• Meet with your legislator this summer

15

16

Upcoming Events!

The Coalition is focused on deepening the leadership capacity of regional oral health alliance members and co-creating a sustainable infrastructure to continue their work.

Participants from regional oral health alliances will gain or build upon the skills to

• Lead community-driven, collaborative initiatives,

• Garner support for collective action and policy change, and

• Build the infrastructure for sustainable system change.

Register by August 14: http://bit.ly/VaOHCAug2018


2018 Virginia Oral Health Summit

When: Thursday, November 8Where: Richmond, VA Who: All who are interested in oral health, population health, or policy change.

Policy & Programmatic Updates| Networking Idea-

sharing

18

Dr. Camara Jones

Dr. Matt Allen

Ensuring access to affordable care for all of Central Virginia means adding a comprehensive dental benefit for all adults to Medicaid. • In our Senate district, 12,500 adults are newly eligible for Medicaid, but these adults won’t

have access to dental coverage under the current Medicaid system. • In Crater Health District, 38% of adults report having no dental coverage. Some groups,

such as Hispanics, seniors over 65, and individuals with a household income less than $25,000, are disproportionately affected by lack of dental coverage.

Questions or requests for more information may be directed to Sarah Bedard Holland,

VaOHC CEO, at 804.269.8721 or [email protected], or to Nicole Pugar Lawter,

Williams Mullen, at 804.420.6437 or [email protected].

Virginia Oral Health Coalition (VaOHC) partners believe oral health is an essential part of overall health care. We strive to ensure Virginians’ oral health needs are met through

integrated care and adequate coverage.

Improving chronic disease outcomes In Petersburg, 12% of adults have diabetes. Studies show when a person with diabetes’ dental disease is treated they are 39% less likely to visit the hospital, 13% less likely to visit the doctor, and they save $2,840 in annual medical costs compared to a person with diabetes who has untreated dental disease.

Increasing dental care utilization for children and their parents Only 50% of children in Petersburg enrolled in Medicaid and FAMIS had a preventive dental visit last year, despite having a comprehensive dental benefit. Research shows parents with dental coverage are more likely to take children to see the dentist, improving long-term health outcomes and saving costs.

Reducing time away from work In Virginia, 11% of adults report an inability to work or perform regular activities in the past year due to dental pain. With the proposed Medicaid work requirement it’s paramount eligible adults have dental coverage to find and maintain employment.

A Comprehensive Dental Benefit For All Adults Will Save Money in Petersburg

By:

Learn more about VaOHC at www.vaoralhealth.org.

comprehensive health care for all

Include Oral health in Medicaid for

Stacy Campbell, Chair Scott Burnette, Treasurer Tegwyn Brickhouse, DDS, PhD Trish Bonwell, RDH, BSDH, MSH, PhD Patrick Finnerty Denise Claiborne, RDH, BSDH, MS Frank Iuorno, Jr., DDS, MS, PC Robin Haldiman

Natalie Pennywell, MPH, CHES Robert Klink, MD, MMM, FACOG Carole Pratt, DDS Tyler Perkinson, DDS Tricia Rodgers Helen Ragazzi, MD, FAAP Sarah Holland, CEO

Board of Directors

Find us online | www.vaoralhealth.org |

Patrick Finnerty Trish Bonwell, RDS, BSDH, MSH, PhD Donovan Caves, DDS Howard Chapman Kelly Cannon Brittany DeWitt Julie Durreger Cheryl Harris Sutton

Robert Klink, MD, MMM, FACOG Kathy Miller Maghboeba Mosavel Bill Murray Margie Tomann Tricia Rodgers Anubhuti Shukla, DDS

Legislative Committee

Virginia Oral Health Coalition Guiding Principles

Public Awareness

Virginians know that good oral health is essential to overall health.

Prevention/Early Diagnosis and Treatment

The prevalence of dental disease is reduced in Virginia through prevention activities and early diagnosis and treatment.

Medical and Dental Collaboration

Medical and dental providers and educators understand the links between oral health and overall health and work together to ensure Virginians receive comprehensive care.

Insurance and Reimbursement

Virginians have access to quality, affordable, and comprehensive dental coverage.

Workforce

The oral health workforce in Virginia adequately meets the needs of its citizens by working to the full extent of their education and training.

Questions or requests for more information may be directed to Sarah Bedard Holland,

VaOHC CEO, at 804.269.8721 or [email protected], or to Nicole Pugar Lawter, Wil-

liams Mullen, at 804.420.6437 or [email protected].

Virginia Oral Health Coalition, July 2018 Home Office Visits – Sen. Rosalyn Dance (D), 16th District

Meeting Tips

• Introduce yourself and the Virginia Oral Health Coalition (and your fellow group members). • Provide a brief background on your role with VaOHC or with oral health. • Explain talking points. • Hand out Leave Behind, Report Card and chattering teeth. • Thank policy makers for their time.

Talking Points Overall message: In our district, 12,500 residents will be newly eligible for affordable health care through Medicaid but won’t have access to dental coverage. Key Points: Virginia earned a C+ for oral health. By including a comprehensive dental benefit for all adults in Medicaid we can help improve this grade, ultimately saving the Commonwealth money and improving the health of all Virginians. • Thank you for supporting Medicaid expansion! In our district, 12,500 residents will be

newly eligible for affordable health care through Medicaid.

• The Virginia Oral Health Report Card (copies included in packet) Virginia got a C+ when compared to the nation on nine key oral health indicators. We can improve our grade and ensure access to affordable dental coverage for

Petersburg’s most vulnerable by adding a comprehensive adult dental benefit to Medicaid. In our local health district 38% of adults report having no dental coverage.

Improving access to affordable oral health coverage reduces costs for the state by addressing oral health needs early.

• The current Medicaid system does not include a comprehensive dental benefit for all adults Only children and pregnant women are eligible for comprehensive dental benefits in

Medicaid/FAMIS currently. All other adults only have an emergency extraction benefit. Adding comprehensive dental benefits will not only reduce costs by keeping people

out of emergency departments, which according to 2016 claims data cost Virginia’s Medicaid $3.31 million, it will also help Petersburg adults find and secure employment, meeting the new Medicaid work requirement in the process.

A comprehensive dental benefit for all adults will also improve health outcomes for Virginia’s children. In Central Virginia, 50% of third graders experience tooth decay.

• Please keep oral health part of health care as you continue to ensure Medicaid is efficient and effective.

Virginia Oral Health Coalition, July 2018 Home Office Visits – Sen. Rosalyn Dance (D), 16th District

Petersburg-Specific Data

• In Crater Health District 38% of adult’s report having no dental coverage. Some groups, such as Hispanics, older adults over 65, and individuals with a household income less than $25,000, are disproportionately affected by lack of dental coverage.

• In Virginia 11% of adults report an inability to work or perform regular activities in the past year due to dental pain.

• Children enrolled in Medicaid/FAMIS have comprehensive dental benefits, but only 50% of children in Petersburg utilize preventive dental care. Research shows that parents are more likely to take children to see the dentist if they have dental coverage themselves, and children who begin seeing the dentist by age one have improved long-term health outcomes and save money.

Coalition Background

• VaOHC’s mission is to ensure all Virginians have access to affordable, comprehensive health care that includes oral health.

• We do this through advocacy and provider education to support clinics and providers to better integrate oral health services, referrals and information.

• VaOHC is made up of over 150 individual and organizational partners. • VaOHC and our partners advocate for policy changes that will impact access to oral health

services; we seek to ensure every Virginian can access comprehensive health care that includes oral health.

Medicaid Expansion Timeline

• Following passage of Medicaid expansion, the Commonwealth will submit a State Plan Amendment (SPA) to CMS to inform the agency of Medicaid expansion. CMS has 90 days to respond with questions and the Commonwealth has 90 days to address CMS’ comments.

• Virginia will also submit a 1115 waiver to CMS; this allows Virginia to include work requirements, cost-sharing, and other changes agreed to in the Medicaid expansion legislation.

• Expanded eligibility begins on January 1, 2019. The Virginia Oral Coalition Guiding Principles

Public Awareness Virginians know that good oral health is essential to overall health.

Prevention/Early Diagnosis and Treatment The prevalence of dental disease is reduced in Virginia through prevention activities and early diagnosis and treatment.

Medical and Dental Collaboration Medical and dental providers and educators understand the links between oral health and overall health and work together to ensure Virginians receive comprehensive care.

Insurance and Reimbursement Virginians have access to quality, affordable, and comprehensive dental coverage.

Workforce The oral health workforce in Virginia adequately meets the needs of its citizens by working to the full extent of their education and training.

Oral health is health

Dental Disease Costs Virginia.

Dental-related illnesses cause approximately 2 million lost work hours per year in Virginia.

Studies show adults visit the emergency department for dental issues more than any other diagnoses; 81% receive opiates on discharge.

54% of older adults cited dental care as their most frequent unmet need. Medicare does not provide any dental coverage.

H






H






H






H

PLEASE PLACE STAMP HERE




FAMILIESUSA.ORG

Issue Brief

Treating Pain Is Not Enough: Why States’ Emergency-Only Dental Benefits Fall Short

July 2018

Thirty-eight million adults with low incomes rely on the Medicaid program for their health care, and their states’ Medicaid benefits are a crucial factor in their access to oral health care.1 While Medicaid covers a fairly comprehensive set of services to address most health needs, the scope of dental benefits that Medicaid provides to adults varies from state to state. States that provide emergency-only dental coverage omit care that is important to health and well-being.

Unlike pediatric dental benefits, which must be covered in every state Medicaid program under federal law, dental care for adults is an “optional” benefit under the law: if states elect to cover adult dental care through their Medicaid programs, the federal government will match states’ investment. However, states have great latitude to determine the scope of covered adult dental services, and some offer none at all.

Researchers use the following four categories to describe the extent of states’ dental benefits for adults: none (in 3 states); emergency-only (in 14 states); limited* (in 17 states); and extensive (in 17 states.)2 When state budgets are tight, states often cut back their adult dental coverage to very limited or emergency-only coverage.

This variation in dental coverage matters. Oral health and overall health are linked: when the body is healthy, the mouth is more likely to be healthy; and conversely, disease in the mouth can spread to other parts of the body.3 People facing barriers to oral health, such as their state cutting back their dental coverage or offering none at all, ultimately face barriers to their overall health and well-being. To better understand the consequences of insufficient dental coverage, Families USA investigated the limitations of emergency-only coverage.

Families USA conducted a survey of the 14 states that cover emergency-only dental services: Arizona, Florida, Georgia, Hawaii, Idaho, Maine, Maryland, Mississippi, Nevada, New Hampshire, Oklahoma, Texas, Utah, and West Virginia. We received responses from state dental directors and/or oral health coalitions in 10 of these states.

By Cheryl Fish-Parcham. Director of Access Initiatives, Families USA

*Medicaid pays for oral health care beyond emergencies, but still covers a limited number of procedures up to an annual expenditure cap of $1,000 per person or less.

FAMILIESUSA.ORG

2

» Low-income seniors and people with disabilities who rely on Medicaid and Medicare for health coverage are among those affected by the lack of dental coverage. While some Medicare beneficiaries would be helped by more extensive Medicaid benefits, a comprehensive Medicare dental benefit is also needed to meet this population’s needs.

Which states responded to the survey?Arizona, Georgia, Hawaii, Idaho, Maine, Maryland, Nevada, New Hampshire, Texas, and West Virginia are included in this analysis. Idaho is in the process of expanding its benefits, but provided mainly emergency coverage in its “basic” benefit for adults at the time of our survey.

Florida was in the process of rebidding Medicaid managed care contracts, and could not be interviewed while that effort was underway. We were unable to speak with representatives in Oklahoma, Utah, and Mississippi.

What can we learn from states with “emergency-only” dental coverage? In most states that limit coverage to oral health “emergencies”—generally, situations where a person is in severe pain or has an acute oral infection—Medicaid-covered care often consists of extracting an infected tooth, but not filling or restoring a tooth. Some states face challenges making even this minimal care accessible. Through this survey, we sought to learn more about: how emergency-only coverage varies in each state, how widely the benefits are used, where the care is provided, what oral health coalitions and dental directors see as unmet needs (especially for people who have other medical problems that are worsened by their oral health conditions), and what work is underway to improve the coverage through either Medicaid’s managed care or fee-for-service system.

Key findings include:

» Emergency-only states all cover limited services to address severe pain, generally including extractions. A few states provide dentures up to a dollar limit, but most emergency-only states do not provide restorative care (such as root canal treatment or filling a cavity), nor cleanings that would address underlying disease.

» In some states, Medicaid managed care plans provide plan-specific extra offerings for adults as “value added” benefits.

» Finding appropriate providers for emergency-only dental services can be difficult. State Medicaid programs end up paying for expensive hospital emergency department visits when appropriate dental services are not available.

» More comprehensive benefits and fewer prior authorization requirements would encourage provider participation.

Ultimately, this survey reinforces the fact that emergency-only dental coverage is better than nothing, but that states should invest in comprehensive Medicaid dental coverage for adults if they want to effectively keep their populations healthier and reduce other health care costs.

FAMILIESUSA.ORG

3

How did the responding emergency-only coverage states’ dental benefits differ?These 10 states all covered some care to alleviate acute pain and infections—predominantly a limited exam to identify the source of the problem, extraction of teeth, and drainage of abscesses. Antibiotics were covered either as a dental or medical benefit. Medicaid coverage of restorative care, however, was rare in these states. Without preventive care and without treatment of gum disease and tooth decay, emergencies can and do recur.

Some states provide more dental care to certain adult populations, such as pregnant women and people residing in long-term care facilities or receiving care through home- and community-based services programs.

West Virginia limited emergency extractions to two per year, a limit not found in other states.

While the following table is not conclusive, since we did not review provider billing manuals and other program documents, it does identify some differences in benefits that emerged:

StateKey emergency benefits in addition to problem-focused exam, extraction, drainage of abscesses

Types of adult Medicaid enrollees who can receive more than emergency dental care

Arizona Services including crowns, caps, re-cementation up to $1,000

Long-term care facility residents; home- and community-based services waiver participants; and Tribes (up to an additional $1,000 cap). Limited exceptions for transplant and cancer cases.

Georgia Pregnant women, with referral from OB/GYN

Hawaii

Dental services are limited to emergency treatment which does not include services aimed at restoring and replacing teeth. Includes only services for the following: Relief of pain; elimination of infection; and treatment of acute injuries to teeth and supporting structures of the oro-facial complex

Transplant patients; individuals with developmental disabilities

FAMILIESUSA.ORG

4



Idaho

Note: At the time of our survey, Idaho had an emergency-only benefit which has since expended.

Prior to July 2018: Can move into an enhanced benefit category if there are special health needs.

As of July 1, 2018, all Medicaid-eligible adults will receive enhanced dental benefits regardless of which Medicaid plan they are on.

People with special health care needs (this can include people with referrals from dentists for acute periodontal disease, broken teeth, or need for dentures)

As of July 1, 2018, all Medicaid-eligible adults will receive enhanced dental benefits regardless of which Medicaid plan they are on.

Maine Services to prevent imminent tooth loss or correct an underlying medical condition

People with certain qualifying medical conditions are eligible for dentures; residents of intermediate care facilities for individuals with intellectual disabilities

Maryland

Maryland recently enacted legislation to establish a pilot Medicaid adult dental program that will provide more benefits (Chapter 621, 2018).

People with rare health conditions or expensive diagnoses through the “Rare and Expensive Case Management” program; pregnant women

NevadaDentures; restoration of abutting teeth to hold a partial; treatment to avoid life-threatening health complications4

Long-term care facility residents; pregnant women

New Hampshire

Treatment of severe trauma in an emergency

Texas

Unless a managed care plan has opted to cover more, care is required only if the dental diagnosis is causally related to a life-threatening medical condition, has been specifically authorized, or would be payable under Medicare. (Texas Rule 354.1149)

Long-term care residents; home- and community-based services waiver recipients

FAMILIESUSA.ORG

5

Value-added benefits have provided a “baby step” toward improving dental benefits in a few states, and additional states may be considering this approach in the near future:

» In Texas, some managed care plans do not elect to provide adult dental coverage among their value-added services, while others provide services ranging from a dental kit, to low-cost dental services for adults, to annual dental benefits of anywhere between $250 and $500 of dental checkups, cleanings, and X-rays, either for pregnant members or for all adults.

» In Maryland, all managed care organizations (MCOs) cover an oral exam and cleaning twice a year for adults; and six out of the nine MCOs provide fillings. (Some list benefit maximums and/or cost sharing.)6

Some managed care plans include additional benefits for a subset of adult members needing certain oral health procedures that are shown to improve other health outcomes:

» In West Virginia, managed care plans cover some additional cleanings, exams, and X-rays for pregnant women. For instance, one plan notes in its member handbook that it covers two preventive oral health visits for pregnant women.7 This is not a prominently advertised



West Virginia Biopsy and removal of tumors

None through Medicaid, but the Temporary Assistance for Needy Families (TANF) program can pay for some restorative work to support adults’ employability

In some emergency-only coverage states, managed care plans provide adults with various extra offerings Some states invite or encourage managed care plans to provide what are known as “value-added” services beyond the standard benefits to adults in order to improve the overall health of plan enrollees. Plans have discretion over the specific value-added services they will offer and what amount they will pay for, and whether they will offer them at all. The plans provide these services at no additional cost to the state; the services are not considered in the rate-setting process, which sets plans’ payments based on the cost and likely use of services that are part of the Medicaid state plan. Instead, plans offer these benefits out of their overhead or profits, and assume financial risk for these benefits because they determine that there are other advantages to doing so:

» Plans may determine that providing value-added benefits will prevent other costly health problems.5

» Providing value-added benefits may make plans more competitive in a state’s procurement process.

» These benefits also attract members, and states list them in plan comparison charts that Medicaid enrollees can view when they are choosing their health plan.

FAMILIESUSA.ORG

6

benefit unless funding for it is carefully built into plans’ rates. Even if adding a more comprehensive benefit increases overall Medicaid costs, states will be able to claim federal matching funds that offset much of the increased costs for these services.

Finding appropriate care providers for emergency-only dental services can be difficult. State Medicaid programs end up paying for expensive hospital emergency department visits when appropriate dental services are not available. A recent study of hospital emergency department (ED) visits by adults for chronic dental conditions in Maryland found that in 2016 alone, more than 22,000 adults covered by Medicaid visited hospital EDs for their dental conditions. Medicaid paid nearly $10 million for those ED visits, in addition to $1.4 million for adults who required hospitalization for their dental needs. Hospital EDs are usually not equipped to provide appropriate treatment for chronic dental conditions. Moreover, they are costly, the study noted; since people usually only get palliative care in the ED (that is, treatment of pain but not its underlying cause), they often return with another episode of severe dental pain. In fact, 25% of the adults who were treated in hospital EDs returned within a year with a similar dental complaint.10

Oral health advocates and officials in other states echo this concern. Representatives from the Maine Oral Health Coalition (MOHC) noted that EDs may provide prescriptions for antibiotics to treat an infection and/or pain medication, and instruct the person to see a dentist to get the tooth treated—but without a specific referral to a dental provider who accepts Medicaid, patients may not find care. Moreover, dentists who accept adult Medicaid benefits are in short supply.

benefit, but it is in the interest of the plan, the state, and the members: oral health care during pregnancy improves the oral health of the woman, prevents complications of dental disease during pregnancy, can decrease early childhood caries, and may reduce preterm and low-birth-weight deliveries.8

» In Nevada, the dental plan provides additional dental cleaning visits for pregnant women, beyond what the state reimburses, and also provides periodic oral evaluations and cleaning for other adults.9

Some state officials noted that this approach is not practical everywhere. In some states and counties, Medicaid is not provided through managed care. In some other counties, where there is little competition among managed care plans or where most enrollees are auto-assigned to plans, MCOs have little incentive to increase their benefits to be more attractive to enrollees. They may, however, determine that it is cost-effective to offer more dental benefits, at least to some populations, since oral disease effects overall health, and a state can encourage this in its request for proposals. One state noted that the costs of additional benefits to effectively address its enrollees’ enormous unmet needs could not actually be absorbed by plans without additional funding, and the state would need to increase its Medicaid budget in order to offer responsive benefits. The limited nature of value-added benefits is reflected in the state examples we found.

There are definite advantages to adding more comprehensive adult dental benefits to a state’s Medicaid program instead of leaving add-ons to managed care plans’ discretion. For one, defining the benefits at the state level ensures uniformity and can result in a more stable benefit structure. More broadly, plans cannot sustain a comprehensive

FAMILIESUSA.ORG

7

A fuller benefit and less prior authorization would encourage provider participationRespondents from several states reported that the extremely limited services for which providers could claim reimbursement discouraged dental providers for adults from participating in Medicaid. In some states, burdensome prior authorization requirements also discourage providers. Mostly, respondents said, the only providers who would agree to see adults are those who already serve children and federally qualified health centers (FQHCs). However, those providers and their resources are already stretched thin.

For example, the New Hampshire Oral Health Coalition conducted a baseline survey of community-based oral health programs in 2015-2016. For adults, service models included oral health and dental programs in a variety of settings including senior centers, mobile/van programs, free-standing and FQHC operatories, nursing homes, and hospitals. There are also a few voucher programs that pay for limited services within a cap. These providers offered limited services, and two-thirds of responding programs reported that it was difficult to find a dentist to provide urgent care.12

There are few alternative oral health care resources for adultsWhen Medicaid does not cover an oral health care need, there are few other resources for low-income adults to get that need met. Though some FQHCs provide dental care on a sliding fee scale, the resources they use to pay for the multiple needs of uninsured and underinsured patients are stretched very thin—especially in states that have not expanded Medicaid. As a consequence, the fee scales some states set for dental care are still too high for many low-income adults, and there may be waiting lists for care.

Outreach to dental providers could improve their participation in Medicaid, the MOHC believes. A survey of Maine dentists a few years ago found that a majority did not know what Medicaid covered or how to get reimbursed, and more might accept Medicaid if they received additional information. The Coalition suggested legislation requiring such education and annual outreach to dental providers.11 This was included in a proposal introduced in the legislative session in 2017 and carried over into 2018.

Nevada is taking concrete steps to improve ED referrals to dentists who participate in Medicaid. It has contracted with a new statewide dental plan, which will be responsible for this coordination. Meanwhile, Nevada EDs vary in their ability to handle dental cases. One has improved services by using dental residents on rotation.

Respondents from some states reported that multiple managed care and/or dental plans added complexity to referral systems. The ED, dentist, or patient had to determine which plan the patient was in, which providers to use, and how to get authorization under that plan for basic or value-added services.

When Medicaid does not cover an oral health care need, there are few other resources for low-income adults to get that need met.

FAMILIESUSA.ORG

8

States’ emergency-only dental care may not provide the oral health services needed by people with serious medical conditionsWe asked survey respondents if their states’ Medicaid coverage for oral health emergencies allowed for care in such “medically necessary” circumstances, and what changes they would recommend. While this coverage is better than nothing, we heard about many shortfalls, including:

» “A patient could not be cleared for knee replacement surgery until gum disease was resolved, and the state’s emergency dental benefit did not cover that; another needed treatment prior to heart surgery. The patients had to rely on a charitable “donated dental” program, and that has a long waiting list.”

» “The research showing the link between diabetes, Alzheimer’s, heart disease, etc. and periodontal disease grows every day. The fact is that an elderly individual cannot maintain their overall health without access to care. Oral health quickly erodes without regular access to oral health care. Preventive oral health care is critical to the health of the Medicare population.” (This person was noting the needs for people dually eligible for Medicare and Medicaid.)

» “We can drain an infection and extract, but that is all. Studies show that diabetic patients in particular need regular scaling and cleaning.”

» “Medicaid in this state is not paying for exams to give people clearance for surgeries. For people with medical needs such as heart, joint, kidney, cancer, hospitals refer to the one dental school in the state for an exam to get the medical clearance, and that school

Some state dental directors compile lists of community resources for dental care. These show that neither discounted nor sliding-fee-scale care is available in some counties, and that charitable resources including mobile clinics are only periodically available.

Implications for low-income Medicare beneficiariesMedicare beneficiaries with low incomes and limited assets often qualify for Medicaid in addition to Medicare. The “dually eligible” include seniors and people with total disabilities who meet the Medicaid income standards in a state. Medicare does not currently include an oral health benefit. Nationally, advocacy groups are urging the federal government to allow Medicare to cover medically necessary oral health care for beneficiaries, particularly when a dental condition poses a serious risk to a patient’s health or treatment for an underlying medical condition. Enacting a comprehensive Medicare dental benefit federally would go further to keep seniors healthier and reduce other health care costs.

Some states have documented large unmet needs for oral health care among low-income seniors, and these data point out the need both for care that is related to other medical conditions, and for comprehensive oral health care more broadly. For example, in West Virginia, 34 percent of seniors screened at congregate meal sites had not seen a dentist for five or more years, 77 percent were missing six or more teeth, and 32 percent had untreated tooth decay.13 In a survey of Maryland senior centers, nutrition sites, assisted living centers, and nursing homes, rates of untreated decay ranged from 21 percent in senior centers to 40 percent in nursing homes.14

FAMILIESUSA.ORG

9

Maine covers several categories of oral health service that provide flexibility to assist someone with other medical needs:

C. Extraction of teeth that are severely decayed and pose a serious threat of infection during a major surgical procedure of the cardiovascular system, the skeletal system or during radiation therapy for a malignant tumor.

D. Treatment necessary to relieve pain, eliminate infection or prevent imminent tooth loss.

E. Other dental services, including full and partial dentures, medically necessary to correct or ameliorate an underlying medical condition, if the Department determines that the provision of those services will be cost-effective in comparison to the provision of other covered medical services for the treatment of that condition.15

However, actually receiving Medicaid reimbursement for these services depends on the competency and persistence of the biller in a dental office. The dental office must obtain prior approval for certain services, as well as determining how to best code them. Further, low reimbursement rates limit access to care.

ends up providing uncompensated care to ready such patients—the school spends $6 million on uncompensated care annually, while the hospitals are compensated for their own services. The wait for clearance ties up hospital operations and creates workflow problems. In this state that covers a limited number of extractions per year, six patients are in a hospital right now that need multiple extractions prior to chemotherapy.”

Two states felt that their Medicaid programs could address some underlying conditions through the “medically necessary” exceptions to their emergency-only benefits. Idaho, which has an enhanced benefit for people with special health needs in addition to its basic health benefit, can provide an array of medically necessary care with justification—but its income eligibility guidelines are far below the poverty line, leaving many low-income Medicare beneficiaries without additional coverage. Idaho’s adult dental coverage will improve further this year: as of July 1, 2018, all Medicaid-eligible adults will receive enhanced dental benefits, which are reinstated under Idaho House Bill 465.

Medicaid in this state is not paying for exams to give people clearance for surgeries. In this state that covers a limited number of extractions per year, six patients are in a hospital right now that need multiple extractions prior to chemotherapy.

FAMILIESUSA.ORG

10

In the end, emergency care is better than nothing, but Medicaid and Medicare should cover comprehensive dental care for adults to truly address Americans’ health needs and reduce avoidable health care costs.Respondents pointed to many serious unmet needs. In particular, extracting teeth to deal with pain, and not filling or replacing them, eventually leaves people edentulous—that is, without teeth to chew, and with an appearance that impedes their social interactions and ability to get jobs. In some states, people are left without any teeth to which to connect a partial denture. Extraction-focused coverage leads to complete edentulism in a patient. This results in a situation where a complete denture is the only treatment option—and that is only if the patient can afford it.

Thanks to the following and others for the information they so generously provided: Tara Plese, Arizona Alliance for Community Health Centers; Siman Qaasim, Children’s Action Alliance; Alicia Thompson, Southern Arizona Oral Health Coalition; Dr. Adam Barefoot, Carol Smith, and Jorge Barnal, Georgia Department of Public Health; Lee Flinn, Idaho Primary Care Association; David Taylor, Medicaid Division, Idaho Department of Public Welfare; Kalie Hess, Maine Primary Care Association; Judy Feinstein, Maine Oral Health Coalition; Mary Backley, Maryland Dental Action Coalition; Jane Casper and Katy Battani, Office of Oral Health, Maryland Department of Health; Dr. Sarah Finne, Dental Director, NH Department of Human Services; Gail Brown, New Hampshire Oral Health Coalition; Beth Stewart, Texas Oral Health Coalition; Teresa Marks, Office of Maternal, Child and Family Health, and Dr. Jason Roush, Oral Health Program, West Virginia Department of Health and Human Resources.

Likewise, the lack of preventive care is a serious problem. An increasing body of research shows a link between oral health and chronic illnesses such as diabetes.16 “Even though we have this limited benefit, the key to me is that you are treating the downstream problem, and symptoms rather than the disease. Expanding to include preventive services would provide more cost-efficient care and better outcomes,” said one respondent. Another noted, “It makes no sense to provide comprehensive care up to age 21 and then cut it off—we should at least protect the state’s investment by providing preventive care to adults.”

States have taken creative steps to expand care by enlarging the list of services that can be provided in an emergency situation, allowing managed care plans to provide add-on benefits, and providing pathways for people with special health needs to receive more care. But state oral health coalitions and state dental directors are acutely aware of unmet needs that could best be addressed by adding comprehensive oral health benefits in the Medicaid and Medicare programs.

FAMILIESUSA.ORG

OH070818

Endnotes

1 Medicaid.gov, March 2018 Medicaid and CHIP Enrollment Data Highlights (Baltimore, MD: Centers for Medicare and Medicaid Services, 2018), available online at https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html.

2 Center for Health Care Strategies, Inc. (CHCS), Medicaid Adult Dental Benefits: An Overview (Hamilton, NJ: CHCS), available online at https://www.chcs.org/media/Adult-Oral-Health-Fact-Sheet_011618.pdf.

3 See, for example, L. Casanova, F.J. Hughes, and P.M. Preshaw, “Diabetes and periodontal disease: a two-way relationship,” British Dental Journal 217 (October 2014): 433–43, available online at https://www.nature.com/articles/sj.bdj.2014.907, and Marjorie Jeffcoat, Robert Jeffcoat, Patricia Gladowski, James Bramson, and Jerome Blum, “Impact of periodontal therapy on general health: evidence from insurance data for five systemic conditions,” American Journal of Preventive Medicine 47 (August 2014): 166–174, available online at https://www.ajpmonline.org/article/S0749-3797(14)00153-6/fulltext.

4 Nevada Department of Health and Human Services (NDHHS), Medicaid Services Manual (Carson City: NDHHS, revised June 28, 2017), Chapter 1000, available online at http://dhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/AdminSupport/Manuals/MSM/C1000/MSM_1000_17_06_29.pdf.

5 Although value-added services cannot be considered in setting capitation rates, plans can claim them on the medical side of the equation in their medical loss ratios. See 42 Code of Federal Regulations, Sections 438.4-438.8; also see T. McGinnis, et al, Implementing Social Determinants of Health Interventions in Medicaid Managed Care (AcademyHealth, Robert Wood Johnson Foundation, Nemours Children’s Health System, 2018), available online at https://www.academyhealth.org/sites/default/files/implementing_sdoh_medicaid_managed_care_may2018.pdf. An example of request for proposal language is at Section 2.3.5 of Texas’ Star and CHIP Managed Care Services Draft, available online at http://www.texasbids.net/government-agencies/travis/texas-health-and-human-services-commission-procurement--contracting-services-938509/8386490-star-and-chip-managed-care-services-draft.html.

6 HealthChoice, MCO Comparison Chart (Baltimore, MD: Maryland Department of Health, 2018), available online at https://mmcp.health.maryland.gov/healthchoice/Documents/MCOComparisonChart_Jan.2018.pdf.

7 Aetna Better Health of West Virginia (ABHWV), 2017-2018 Member Handbook (Charleston, WV: ABHWV, 2017), available online at https://www.aetnabetterhealth.com/westvirginia/assets/pdf/members/WV%20Member%20Handbook%202017.pdf.

8 March of Dimes and West Virginia University School of Dentistry (WVUSD), Oral Health Care during Pregnancy: At-a-Glance Reference Guide (March of Dimes/WVUSD), available online at https://www.mchoralhealth.org/PDFs/WV_PregnancyRefGuide.pdf.

9 Liberty Dental Plan (LDP), Dental Care Services Information Sheet (Las Vegas, NV: LDP, 2017), available online at http://dhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Members/BLU/NVMedicaid_Dental_Plan_Fact_Sheet_English-Spanish_12.21.17.pdf.

10 Maryland Dental Action Coalition (MDAC) and Dentaquest Institute, Financial Impact of Emergency Department Visits by Adults for Dental Conditions in Maryland (Columbia, MD: MDAC), available online at http://www.mdac.us/pdf/Financial%20Impact%20of%20Hospital%20Visits%20for%20Dental%20Conditions%20in%20MD%20Revised%20Legislative.pdf.

11 An Act To Improve Access to Preventive, Cost-saving Dental Services, Maine Law H.P. 898, 2017, available online at http://www.mainelegislature.org/legis/bills/getPDF.aper=HP0898&item=1&snum=128. This bill would also expand Medicaid dental benefits.

12 New Hampshire Oral Health Coalition (NHOHC), NH Oral Health Baseline Survey I: Identifying Oral Health Resources and Promising Practices in Community-based, Non-traditional Settings (Concord, NH: NHOHC, April 1, 2017), available online at http://nhoralhealth.org/blog/wp-content/uploads/2017/03/NH_Oral_Health_Baseline_Survey_I_FINAL_April-1-2017.pdf.

13 Joan C. Edwards School of Medicine at Marshall University (JCESMMU), Departments of Family and Community Health and Dentistry and Oral and Maxillofacial Surgery, Final Report: West Virginia Older Adult Oral Health Survey, 2015-2016 (Huntington, WV: JCESMMU, 2016)..

14 Maryland Office of Oral Health (MOOH) and Maryland Department of Aging (MDA), Maryland Oral Health Survey of Older Adults: 2013-2014 (Baltimore, MD: MOOH/MDA, 2014), available online at https://phpa.health.maryland.gov/oralhealth/Documents/BasicScreeningSurveyOlderAdults2013_2014.pdf.

15 Maine Department of Health and Human Services (MDHHS), MaineCare Benefits Manual (Augusta: MDHHS: July 2014), Chapter II, Section 25.04, available online at https://www.maine.gov/sos/cec/rules/10/ch101.htm.

FAMILIESUSA.ORG

OH070818

16 See Filippo Graziani, Stefano Gennai, Anna Solini, and Morena Petrini, “A systematic review and meta‐analysis of epidemiologic observational evidence on the effect of periodontitis on diabetes,” Journal of Clinical Periodontology 45, Issue 2 (February 2018): pp. 167-18, available online at https://onlinelibrary.wiley.com/doi/10.1111/jcpe.12837; C.J. Carter, J. France, S. Crean, and S.K. Singhrao, “The Porphyromonas gingivalis/Host Interactome Shows Enrichment in GWASdb Genes Related to Alzheimer’s Disease, Diabetes and Cardiovascular Diseases,” Frontiers in Aging Neuroscience 9 (December 2017): p. 408, available online at https://www.ncbi.nlm.nih.gov/pubmed/29311898; and M. Sanz, A. Ceriello, and M. Buysschaert, et al, “Scientific evidence on the links between periodontal diseases and diabetes: Consensus report and guidelines of the joint workshop on periodontal diseases and diabetes by the International Diabetes Federation and the European Federation of Periodontology,“ Journal of Clinical Periodontology 45, no. 2 (August 2017): pp. 138-149.

This publication was written by: Cheryl Fish-Parcham, Director of Access Initiatives, Families USA

The following Families USA staff contributed to the preparation of this material (listed alphabetically):

Melissa Burroughs, Oral Health Campaign Manager

Nichole Edralin, Senior Designer

Eliot Fishman, Senior Director of Health Policy

Raven Gomez, Campaign Associate

Produced as a resource from the OH 2020 Network,

http://www.oralhealth.network/ with support from the

DentaQuest Foundation.

1225 New York Avenue NW, Suite 800 Washington, DC 20005 [email protected] / FamiliesUSA twitter / @FamiliesUSA

Hundreds of thousands of Virginians aged 19 to 64 will soon be able to sign up for health coverage that will give them access to

services to prevent illness and improve health, including a limited dental benefit, at a very low cost. Visit www.coverva.org for

updates and more information about how to enroll.










http://www.coverva.org




Who Qualifies for Virginia Medicaid?

To view eligibility information visit: www.coverva.org/expansion

*Income limits vary by family size










Workshop: Collaboration and Leadership to Improve Oral Health

Tuesday, August 21 - Wednesday, August 22, 2018 | Richmond, VA

About the Workshop This 2-day workshop is presented by the Virginia Oral Health Coalition and Community Tool Box to bring together partners from around the state who are change agents for oral health in their community. During the workshop attendees will gain or enhance their skills to:

Lead community-driven, collaborative initiatives, Garner support for collective action and policy change, and Build the infrastructure for sustainable system change. The workshop is best suited for those who are involved in regional oral health alliances, or those who would like to become involved, including: advocates, service providers, public health practitioners, and anyone with an interest in

9:00am: Check-in and coffee

9:30am: Welcome, introduction and orientation

10:00am: Building Leadership

12:00pm: Lunch (provided)

1:00pm: Increasing Participation and Membership

3:00pm: Regional Breakout Sessions

4:00pm: Group Discussion

4:30pm: Day 1 Wrap-Up

Day 1: Tuesday, August 21, 2018 9:00 am—5:00 pm

8:30am: Coffee and networking

9:00am: Advocating for Change

11:00am: Regional Breakout Session

12:00pm: Lunch (provided)

1:00pm: Sustaining the Work or Initiative

3:00pm: Day 2 Wrap-Up and Close

Day 2: Wednesday, August 22, 2018 8:30 am—3:30 pm

Tentative Agenda

Presented by:

Contact: Lauren Gray | Virginia Oral Health Coalition 804-299-5506 | [email protected]

Register Now!


Event Information

When: August 21-22, 2018 Where: Mayland Drive, Richmond, VA

Cost: $15 per person to attend and includes lunch on both days for registered participants.

Registration deadline: Tuesday, August 14, 2018.

2018 VIRGINIA ORAL HEALTH SUMMIT Presented by the Virginia Oral Health Coalition

Richmond

NOVEMBER 8 Thursday

keynote speaker

health equity scholar and physician

featured presenter

dentist and expert in motivational interviewing and patient engagement


Richmond

NOVEMBER 8 Thursday

keynote speaker


featured presenter



Richmond

NOVEMBER 8 Thursday

keynote speaker


featured presenter



Richmond

NOVEMBER 8 Thursday

keynote speaker


featured presenter


#OralHealth18 www.vaoralhealth.org | [email protected] | 804.269.8720

Premier Sponsor

Distinguished Sponsors


Premier Sponsor



Premier Sponsor



Premier Sponsor
