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Forum for State Health Policy Leadership National Conference of State Legislatures

NATIONAL CONFERENCE of STATE LEGISLATURES

Promising PracticesIssue BriefFORUM for STATE HEALTH POLICY LEADERSHIP

Increasing Dentists’ Participation inMedicaid and SCHIP

by Shelly Gehshan, Paetra Hauck and Julie Scales

INTRODUCTION

For many years, state and federal officials, providers and advocates have been very concerned aboutthe 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 inoral health during the last 50 years, “…there are profound and consequential oral health dispari-ties within the U.S. population.” Tooth decay is the single most common childhood disease: 59percent of children have decayed teeth, compared to 11 percent who have asthma and 8 percentwho have hay fever. Poor children are more than twice as likely as their more affluent peers to havedental caries, and their disease is more likely to go untreated. Untreated cavities cause a significantamount of pain to children and cause difficulty eating, playing and learning as well as many misseddays of school. Low-income adults face similar problems with pain and limitations on daily activi-ties and are more likely than those with higher incomes to lose permanent teeth and have un-treated dental disease.

Low-income children and families who meet state eligibility requirements receive their health carethrough Medicaid or the State Children’s Health Insurance Program (SCHIP). If they are unin-sured, they receive the health services that are available through the local public health system andcharity providers. However, dental and medical services are delivered largely through separatesystems. Under SCHIP, states that choose to establish a non-Medicaid program are not obligatedto include oral health services in their benefit packages, although all state programs except Colo-rado, Delaware and one of Florida’s three programs include some degree of dental coverage. How-ever, states are required under federal law to provide comprehensive oral health services for allchildren through age 20 who are enrolled in the Medicaid program. In 1998, only 19 percent ofchildren eligible for preventive dental services under Medicaid received them; this is a decreasefrom 21 percent in 1996. States are not required to provide any services for dental problemsother than emergency medical care for adults who are covered under Medicaid. However, manystates provide other diagnostic, restorative and preventive dental services as well. Few states pro-vide public health dental services for adults, although some services are available through indi-vidual counties or philanthropic groups.

2 Forum for State Health Policy Leadership National Conference of State Legislatures

Methods: In 1998 and 2000, surveys were sent to Medic-aid agencies in each state and the District of Columbia. In2000, similar surveys were sent to the 35 directors of SCHIPprograms in states that established a non-Medicaid program.Altogether, 48 of 51 Medicaid agencies and 29 of 32 SCHIPagencies responded. Data was collected for the most recentyear available. In addition to questions about workforceparticipation and reimbursement rates, states were asked twoopen-ended questions about whether they had initiated anyefforts to increase dentists’ participation or increase access tooral health services for children. Since states responded withdiffering degrees of detail to these questions, it is possiblethat more states have implemented changes described herethan are reported. A summary of the survey instrument isincluded in the appendix.

Both the problem of poor access to oral health care and the solution are complex. A big stumblingblock is the low rate of participation by dentists in Medicaid and SCHIP. To gather informationabout steps states have taken toimprove access to oral healthservices, the Forum for StateHealth Policy Leadership at theNational Conference of StateLegislatures (NCSL) surveyeddental contacts in state Med-icaid and SCHIP programs in1998 and 2000. This paperprovides data from the 2000survey on dentists’ participa-tion, compares data from bothyears’ surveys, describes find-ings on selected state initiativesdesigned to increase participa-tion and gives background onaccess 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 otherpublicly funded clients. Those who choose to enroll as Medicaid providers may not actually treatMedicaid patients on a regular basis. To ascertain provider strength in Medicaid programs, NCSLcollected information on the number of dentists enrolled as Medicaid providers in a year, thenumber who had billed the state for care delivered to Medicaid patients, and the number whobilled more than $10,000. Although $10,000 may seem like a substantial amount of care, na-tional data shows that the average amount spent on dental care for a child was $437. This meansthat dentists who billed more than $10,000 are likely to have treated more than 23 children, orabout two per month. In most states, only a portion of practicing dentists enroll as Medicaid orSCHIP providers, a smaller portion see any Medicaid patients at all and a still smaller percentagesee any significant number of Medicaid patients (see table 1).

3Forum for State Health Policy Leadership National Conference of State Legislatures

1998 2000 1998 2000AL 343 302 -12%-12% 132 152 15%AK1 396 301 -24%-24% 119 159 34%AR 366 370 1% 190 171 -10%-10%AZ2 ~ 1000 NA NA NA NA NACA3 9,373 12,669 35% 4,722 5,623 19%CO 409 459 12% 75 124 65%CT4 511 445 -13%-13% 96 100 4%DE1,5 1 61 6000% 1 35 3400%DC 2,040 NR NA 26 NR NAFL3 1,466 1,372 -6%-6% 875 873 -0.2%-0.2%GA6 902 840 -7%-7% 520 494 -5%-5%HI4 349 NR NA 3 NR NAID 579 402 -31%-31% 219 217 -1%-1%IL1 2,700 NA NA ~ 100 NA NAIN6 910 1,132 24% 200 520 7 160%IA6 1,393 1,219 -12%-12% NA 429 NAKS6 410 408 -0.5%-0.5% 145 176 21%KY 1,273 684 -46%-46% 667 389 -42%-42%LA 864 714 -17%-17% 442 359 -19%-19%ME1 327 317 8 -3%-3% 96 123 8 28%MD NA NA NA NA NA NAMA 1,116 930 -17%-17% 662 NA NAMI 2,100 1,900 -10%-10% 865 686 -21%-21%MN3 2,203 1,930 -12%-12% 660 333 9 -50%-50%MS1 464 450 -3%-3% 264 307 10 16%MO 748 581 -22%-22% 298 225 -24%-24%MT 408 300 -26%-26% 112 118 5%NE6 798 964 11 21% 231 387 11 68%NV 216 12 171 -21%-21% 65 82 26%NH 356 308 -13%-13% 100 145 45%NJ 1,089 NR NA 249 NR NANM 236 215 -9%-9% 92 134 46%NY 8,640 2,918 -66%-66% 1,410 1,185 -16%-16%NC 1,696 3,351 98% 526 1,115 112%ND 288 288 0% 107 68 -36%-36%OH3 1,835 1,433 -22%-22% 504 NA NAOK 287 263 -8%-8% 86 140 63%OR 1,417 1497 13 6% NA 847 NAPA NR 1,424 NA NR 439 NARI NR 338 NA NR 122 NASC14 635 718 13% 309 434 40%

Number of Dentists WhoHave Received Payment

During the Last YearPercentChange

PercentChange

Number of Dentists WhoHave Received PaymentGreater Than $10,000

STATE

Table 1.Change in Dentists’ Participation in Treating Medicaid Patients

1998 and 2000


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 percentageof enrolled dentists that received payment in the last year, and 27 states saw a decrease. One statemaintained the same percentage. This shows that more states lost ground than gained ground inexpanding 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 enrolleddentists who billed more than $10,000 for care delivered to Medicaid patients in the most recent

SD6 277 315 14% 77 93 21%TN NA15 NA NA NA15 N/A NATX 1,923 1,972 3% 1,132 1,523 35%UT 750 702 -6% 156 177 13%VT 297 312 5% 130 16 234 80%VA 659 759 15% 193 313 62%WA 2,150 1,692 -21% 772 713 -8%WV 618 573 -7% 330 299 -9%WI17 1,639 1,158 -29% 329 238 -28%WY 150 169 13% 40 52 30%

Table 1. Continued

Key~ EstimatedNA = Not AvailableNR = No Response

Notes1 State Fiscal Year (SFY) 2000 Data.2 Calendar year 1997 data.3 SFY 1998 data.4 The data includes Fee-For-Service (FFS) providers only and does not represent the managed care sector.5 Dental services typically are provided through public health clinics, since the local dental community has not showninterest in participating in Medicaid.6 Calendar Year (CY) 1999 data.7 Data from 1/99-9/99.8 Includes ortho oral surgeons.9 FFS only.10 As of 7/1/00.11 Provider numbers.12 Of the 216 dentists, 55 were out-of-state providers.13 Number represented is low because not all dentists who provide services through a dental care organization areenrolled directly with OMAP.14 CY 1995 data.15 TennCare contracts with nine managed care firms to provide services. Since they pay the firms a capitation rate, theydo not have these statistics available.16 Includes groups billing under one provider number.17 Represents FFS data 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, NationalConference of State Legislatures; 2000 Survey of State SCHIP and Medicaid Departments by The Forum for StateHealth Policy Leadership, National Conference of State Legislatures.


year, and 14 states experienced a decrease. Although the number of dentists who see Medicaidpatients in most states may not have increased in the last two years, two-thirds of the states haveincreased the number of dentists for whom Medicaid is a regular part of their practice. This findingmay indicate that reforms to the Medicaid dental program are less effective in bringing new den-tists into the fold than in making it easier and more attractive for participating dentists to see morepatients. In some states, the increase in the number of dentists billing more than $10,000 alsomay 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 whetherthe supply of professionals is sufficient to meet demand. There is no consensus in the dentalprofession about whether there is a shortage of dentists, but there is agreement that there are toofew dentists trained to treat children and too few who are willing to see a significant number oflow-income clients. As table 2 shows, the percentage of dentists billing more than $10,000 in ayear varies significantly across states. In five states—Alabama, Colorado, Connecticut, Pennsylva-nia, and Wisconsin—fewer than 10 percent of dentists bill more than $10,000. In contrast, sixstates—Alaska, Nebraska, North Carolina, Oregon, Vermont and West Virginia–have more than40 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 amongchildren 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 thelate 1970s had difficulty starting a practice due to decreased demand for services. In response, inthe 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 willleave the profession (85,000) than will enter it (81,000). High demand for care and decreasingnumbers of dentists relative to the population have meant that dentists’ practices are full withouttheir participation in public programs. �


AL 1,648 302 18% 152 9%AK2 336 301 90% 159 47%AR 966 370 38% 171 18%AZ3 1,885 NA NA NA NACA4 19,103 12,669 66% 5,623 29%CO 2,346 459 20% 124 5%CT 2,237 445 20% 100 4%DE2 308 61 20% 35 11%DC 530 NR NA NR NAFL4 6,574 1,372 21% 873 13%GA5 2,820 840 30% 494 18%HI 857 NR NA NR NAID 616 402 65% 217 35%IL2 7,069 NA NA NA NAIN5 2,663 1,132 43% 520 8 20%IA5 1,357 1,219 90% 429 32%KS5 1,179 408 35% 176 15%KY 1,835 684 37% 389 21%LA 1,815 714 39% 359 20%ME2 561 317 9 57% 123 9 22%MD 3,105 NA NA NA NAMA 4,064 930 23% NA NAMI 5,225 1,900 36% 686 13%MN4 2,600 1,930 74% 333 10 13%MS2 914 450 49% 307 11 34%MO 2,356 581 25% 225 10%MT 433 300 69% 118 27%NE5 913 964 14 106% 387 12 42%NV 592 171 29% 82 14%NH 627 308 49% 145 23%NJ 5,574 NR NA NR NANM 581 215 37% 134 23%NY 12,308 2,918 24% 1,185 10%NC 2,685 3,351 125% 1,115 42%ND 283 288 102% 68 24%OH4 5,410 1,433 26% NA NAOK 1,390 263 19% 140 10%OR 1,907 1497 13 79% 847 44%PA 6,866 1,424 21% 439 6%RI 512 338 66% 122 24%SC 1,433 718 50% 434 30%

STATE

Total Number ofActive PrivatePractitioners1

Number ofDentists WhoHave Received

Payment Duringthe Last Year

Dentists ReceivingPayment as a

Percentage of TotalActive PrivatePractitioners

Number ofDentists WhoHave Received

Payment GreaterThan $10,000

Dentists BillingMore than

$10,000 as aPercentage of Total

Active PrivatePractitioners

Table 2.Dentists’ Participation in Medicaid 2000


BARRIERS TO DENTISTS’ PARTICIPATION

The NCSL survey found that many states have worked with state dental societies to encourageparticipation and reduce barriers to practice. Dentists can legitimately point to low reimburse-ment rates—which traditionally have not covered actual costs—as a major factor. Dentistry isunlike medicine in the high cost of equipment needed to set up a practice, and the operation of amajority of dental practices as independent businesses. Physicians use expensive equipment aswell, but it is located at hospitals or diagnostic centers and they, unlike dentists, rarely have to

SD5 307 315 103% 93 30%TN 2,391 NA NA NA NATX 7,791 1,972 25% 1,523 20%UT 1,184 702 59% 177 15%VT 324 312 96% 234 72%VA 3,239 759 23% 313 10%WA 3,148 1,692 54% 713 23%WV 697 573 82% 299 43%WI 7 2,745 1,158 42% 238 9%WY 228 169 74% 52 23%

Table 2. Continued

KeyReported data from State Fiscal Year (SFY) 1999 unless otherwise noted.Percentages over 100 percent often are due to dentists who participate in Medicaid programs across state lines.

~ EstimatedNA = Data not availableNR = No responseNote: 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.

Notes1 Distribution of Dentists in the United States, by Region and State 1998, Chicago: American Dental AssociationSurvey Center, 1998.2 State Fiscal Year 2000 data.3 Calendar Year 1997 data.4 State Fiscal Year 1998 data.5 Calendar Year 1999 data.6 Illinois does not differentiate between SCHIP and Medicaid providers, thus numbers may reflect some providerswho serve only children enrolled in SCHIP.7 Represents Fee-For-Service (FFS) data. Data for number receiving any type of payment and number receivingpayment 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 data only.11 As of 7/1/00.12 Provider numbers.13 Number represented is low because not all dentists who provide services through a dental care organization areenrolled 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.


purchase it. Dentists also must hire staff, lease space, provide parking, and file all required formsand 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 payfor needed equipment and maintain a practice. Dentists also are much less likely than physiciansto participate in managed care systems, which makes it difficult for states to organize their partici-pation or negotiate fees. Dentists in many states also have complained about the administrativecomplexity, prior authorization requirements needed for providing even routine services and slowpayment associated with public programs. In addition, a few state Medicaid programs forbiddentists to limit the size of their Medicaid and SCHIP practices, giving rise to fears that if theyparticipate in Medicaid, they will have more patients than they can handle, whose care is reim-bursed at rates that do not cover costs.

Less often discussed are clashes in cultural behavior and expectations between dental providers andMedicaid and SCHIP clients. Low-income people may be less educated about the importance ofpreventive dental care and proper hygiene, and may place them low on their list of priorities due tolack of time and scarce resources. By the time they see a dentist, they may have serious problemswith decay and be difficult to treat, particularly if they have never seen a dentist before. Inaddition, many low-income people are accustomed to seeking care from clinics and emergencyrooms, which, unlike dental offices, do not operate on an appointment schedule. They also mayhave difficulty with transportation and child care, which raises the frequency of missed appoint-ments. Missed appointments waste valuable time for dental practices and result in lost revenuethat cannot be easily replaced. A great deal of the care provided by dentists, unlike that providedby physicians, is surgical and rehabilitative rather than diagnostic and preventive, so they cannotsimply 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 tocomply, 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 willassess compliance with the requirements to provide dental care to children. This communicationapplies to the Medicaid program and to SCHIP Medicaid expansions, but not to separate SCHIPprograms. HCFA will examine state efforts in four areas: 1) informing Medicaid beneficiariesabout their eligibility for dental services and facilitating referrals to dental providers; 2) payingadequate rates for dental services; 3) employing administrative strategies to enhance participation;and 4) improving claims processing.

The NCSL survey found that many states have mounted efforts to increase dentists’ participationin public programs. For this discussion, such efforts are grouped under reimbursement rates,administrative simplification, outreach to dental providers, and expanding the use of dental hy-gienists. �

REIMBURSEMENT RATES

One of the most commonly cited barriers to dentists’ participation in the Medicaid and SCHIPprograms is low reimbursement for services. In most states, reimbursement rates do not coveroverhead costs, and dentists lose money on each patient served. The American Dental Associationcalculates that 59 percent of the fees dentists’ charge is needed to cover the cost of delivery care.According to a study by the Department of Health and Human Services, states report that inad-equate reimbursement is the most significant reason dentists do not accept Medicaid patients. Ofthe 48 states that responded to the Medicaid survey, 23 indicated they had increased reimburse-


ment rates for Medicaid only in the last two years: Arkansas, California, Colorado, Delaware,Florida, Georgia, Idaho, Kansas, Louisiana, Maryland, Michigan, Minnesota, Nebraska, New Mexico,North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, South Carolina, South Dakota, and Vir-ginia. Four out of 22 states responding to the SCHIP survey—Iowa, Maine, Massachusetts andNew Hampshire—indicated they had increased reimbursement rates for SCHIP programs only.Seven states indicated they increased reimbursement levels for both programs over the past twoyears: Alabama, Arizona, Illinois, Indiana, Kentucky, Mississippi and Wyoming. The level of therate hikes in these states was not collected in this survey, so it is not clear how many states arereimbursing 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 per-cent of dentists will accept. The study suggests there will be four stages of response when fees areraised above cost. First, the cost to the state of providing care increases because the cost of eachunit of service has increased. Second, the dentists treating Medicaid kids begin to do more workon the existing kids because there is an incentive to provide comprehensive care. Third, the den-tists who were treating Medicaid kids see more Medicaid kids. Finally, more dentists join in.

Several states have experimented with various ways to raise rates. In 1995, Indiana eliminatedseveral adult dental services and reduced the number of children’s procedures that will be reim-

Figure 1.States That Have Increased

Reimbursement Rates Over Past Two Years 2000

Medicaid Only (23):

Both Programs (7):

Arkansas, California, Colorado, Delaware, Florida, Georgia, Idaho, Kansas, Louisiana,Maryland, Michigan, Minnesota, Nebraska, New Mexico, North Dakota, Ohio, Oklahoma,Oregon, Pennsylvania, South Carolina, South Dakota, Virginia.

SCHIP Only (4): Iowa, Maine, Massachusetts, New Hampshire.

Alabama, Arizona, Illinois, Indiana, Kentucky, Mississippi and Wyoming.

No Increase/No Response (17):

Alaska, Connecticut, District of Columbia, Hawaii, Missouri, Montana, Nevada, New Jersey,New York, North Carolina, Rhode Island, Tennessee, Texas, Utah, Vermont, West Virginia,Wisconsin

Note: Hawaii and New Jersey did not respond to the Medicaid survey; Florida, New Jersey, Oregon and Utah did not respond to the SCHIP survey.

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


bursed regularly. With these savings, the state increased the fee for the remaining preventive andrestorative procedures for children. The state will continue to cover all procedures deemed medi-cally necessary, which is legally required under early and periodic screening, diagnosis and treat-ment (EPSDT). However, the state will require prior authorization for services and will pay onlycurrent rates for any procedures that have been eliminated for adults. These actions resulted fromrecommendations by the state dental association.

Utah has a unique approach to providing care for both Medicaid and SCHIP patients. Utah’sMedicaid program provides care directly to Medicaid beneficiaries through six dental clinics. Theseclinics are staffed and administered by the Medicaid program and see only Medicaid and SCHIPpatients. Steven Steed, D.D.S., the Utah state dental director stated, “These clinics have beenessential in minimizing the access crisis for Medicaid and SCHIP beneficiaries.” Furthermore, aspart of a bonus program, dentists in urban areas are given an additional 20 percent reimbursementafter they see 100 Medicaid patients. They receive the bonus for the remainder of the year so longas they continue to see the required number of Medicaid patients. Dentists in rural areas are giventhe additional 20 percent if they see any Medicaid patients.

In Wisconsin, general dental fee increases during the past few years have raised payments to ap-proximately 61 percent of the statewide average charges. A bonus program pays $3.50 for the 20dental procedures most frequently performed on children under age 21. In 1995, these additionalpayments 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 ofthe state’s decision to eliminate some adult dental benefits and withhold fee increases for non-EPSDT dental services.

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

ADMINISTRATIVE SIMPLIFICATION

In an effort to encourage more dentists to participate in the Medicaid and SCHIP programs, manystates surveyed reported that they have implemented policies to reduce the administrative require-ments imposed on participating dentists. NCSL found that the following states have imple-mented 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 Wyo-ming. States have used several different methods to streamline the administrative process. Some ofthe most commonly cited methods include eliminating or reducing prior authorization criteria,simplifying provider contracts, allowing dentists to file claims using the forms and billing codesaccepted by the American Dental Association (ADA), and accepting bills filed electronically. Manystates noted they have used a combination of these tactics in their efforts to encourage dentists toparticipate.

· Eliminating or reducing prior authorization criteria reduces the administrative burden fordentists’ office staff and speeds up delivery of services. Although prior authorization require-ments are intended to reduce overuse or misuse of services and to prevent services being pro-vided 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—haveeliminated or reduced some prior authorization criteria in their efforts to simplify the admin-istrative burden on dentists. Texas recently established a “dental only” hotline, which allowsdental offices speedier access to answers from the Medicaid agency, and links providers to anautomated 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 andlicensing for providers, lengthy and complex enrollment forms create a barrier to entry that iscontrary to states’ policy goal of recruiting providers. Alaska, Iowa, Maine, Montana, Texasand Wyoming described efforts to simplify their provider contracts. Texas worked to reduce itsprovider application form from 48 pages to five for individuals and to eight for corporatepractices.

· 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 haveused this method so that dentists will not have to train office staff to fill out different forms forMedicaid and SCHIP patients than for private patients. Arizona, Georgia, Michigan andMissouri 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 thismethod in an effort to create a universal set of procedure codes rather than separate procedurecodes for Medicaid, SCHIP and private patients.

· Accepting electronic billing allows dentists to more quickly and easily bill for services. Statesthat 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 billselectronically.

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

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

Iowa also has adopted a number of changes, including using the ADA billing codes, encouragingelectronic billing, removing prior authorization requirements for nine procedures, and simplifyingthe provider manual. All these changes have occurred in the past year. Iowa hopes that data willshow an increase in provider participation after the policy has been in place for a year. In themeantime, continuing efforts are under way to simplify the provider manual and billing proce-dures. �


OUTREACH FOR DENTAL PROVIDERS

In response to the NCSL survey, states described a variety of methods to work with state dentalassociations, inform dentists about improvements in their programs and encourage dentists’ par-ticipation. The strategies most commonly employed are creating dental task forces, presenting atdental schools and dental society meetings, and placing promotions in dental journals. NCSLfound that during the last two years, seven states have formed task forces to address the problem ofboth Medicaid and SCHIP beneficiaries’ limited access to dental services. Task forces provide mo-mentum and support for future changes as well as help define specific problems and shape policysolutions to improve access. They typically are made up of representatives from professional andprovider organizations, advocacy groups, state dental societies, legislators, health plans and dentalschools. These groups are formed to discuss issues, identify politically feasible solutions and workwith key agents of change such as legislatures, dental associations and dentists. They generally arecreated 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 improveaccess to oral health care.

According to Mary McIntyre, M.D., associate medical director of Alabama Medicaid, the state’stask force was formed, “ … after recognizing the need for a better relationship with the dentalcommunity as a whole.” In 1997, the Alabama Medicaid agency contacted the Alabama DentalAssociation to identify dentists across the state— including those who participated in Medicaidand those who did not—to be appointed to a dental task force. The task force developed a set ofrecommendations that currently is being implemented by the state Medicaid agency. Those rec-ommendations 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 keep-

ing appointments.

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

North Dakota uses a dental mentoring program in an attempt to improve access to underservedcommunities 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 mentorsin North Dakota. Dental residents from North Dakota have the option of working in a NorthDakota dental office as part of their school experience. This program has proven to be mutuallybeneficial; local dentists receive assistance and dental school residents gain familiarity with ruralpractice. The desired goal is to improve dental access for everyone, including Medicaid patients.

Making presentations to state dental societies is another method states have used to increase par-ticipation. 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 thebarriers of suspicion and distrust that have been built over the years.” According to the NCSLsurvey, Alaska, Delaware, Pennsylvania and Virginia have used this approach.

Texas has successfully promoted its Medicaid and SCHIP programs through the state dental jour-nal and other dental publications, expanding from 1,090 to 1,334 SCHIP providers in just threemonths. Similarly, the Texas Dental Foundation, a nonprofit philanthropic organization affiliatedwith the Texas Dental Association, is underwriting the cost of Medicaid provider recruitmentworkshops at dental meetings across the state. Jay Bond, director of policy at the Texas DentalAssociation, says “… the October Texas Dental Journal included a memo urging members to signup 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 tohave 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 increasethe number of providers who participate in public programs. “Ideally, every dentist in the statewould 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, “Ithink it is important for states to be fully aware and approach the barriers that exist. There needsto be a common ground between Medicaid and the dental associations, a meeting of the minds toaddress common problems and seek solutions. If that is done it will create a climate where dentistsare 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-incomepatients, some states are seeking ways to expand the use of dental hygienists, either by easing therules on direct supervision by dentists or by changing reimbursements. According to survey re-sponses, Connecticut, Iowa and Minnesota have implemented policies that allow dental hygieniststo 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. CathyCoppes, a policy specialist with the Iowa Department of Human Services, comments that “… thedental access problem is so complex, it is not just a matter of funding, adequate personnel, oraddressing a specific population. Because of this we need to use a multifaceted approach to ad-dressing the problem of access. Allowing Medicaid reimbursement for dental hygienists for spe-cific services in underserved areas is just one facet of an approach needed to address the problem ofaccess.”

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

On the other hand, the American Dental Hygienist Association (ADHA) strongly supports ex-panding 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.xv Although itis 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 thannothing 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 vulner-able and underserved populations. Another argument states use to support expanded use of hy-gienists is that if they provide more preventive services, they can free time for restorative proceduresby dentists who see publicly funded patients. The shortage of dentists who care for low-incomepatients makes this an attractive prospect for states.

Connecticut enacted legislation in 1999 to allow dental hygienists to practice in a public healthfacility without the general supervision of a dentist. In order to practice independently in thosesettings, a dental hygienist must be licensed and have two years of experience. Through Public Act99-197, dental hygienists are permitted to perform the following procedures: complete prophy-laxis; the removal of calcareous deposits, accretions and stains; the application of sealants andtopical solutions; dental hygiene examinations and the charting of oral conditions; and dentalhygiene 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 partici-pation increase of all Connecticut counties. Martha Okafor, a program administration managerwith the Connecticut Department of Social Services, notes that in the future she believes dentalhygienists should play a critical role in providing primary dental services.

In 1997, the Iowa Department of Human Services began granting waivers to allow Medicaidreimbursement for specific services provided by dental hygienists. Exceptions are granted only tohygienists practicing in maternal and child health centers in counties where access problems aresevere. The program was started in December 1997 and initially allowed Medicaid reimburse-ment only for screenings. Since then, the state has allowed reimbursement for the application ofsealants and varnishes by dental hygienists. In some counties where there are serious access prob-lems, the program has been expanded to pregnant women over age 21 in addition to children. Thepolicy exceptions granted and the services allowed are made on a county-by-county basis. Pre-liminary results indicate an increase in the number of children served. Iowa expects to have databy 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 thisproject, the Legislature authorized extending dental services to those performed by a dental hy-gienist. Patients do not need to be seen by a dentist before going to a hygienist, but the servicesstill must be authorized by a licensed dentist. Minnesota started the demonstration project in anattempt to address the issue of access. Patients who have limited access to dental care are eligibleto 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 geographiclocation.”� �


CONCLUSION

States have had a great deal of difficulty ensuring that children and adults who are enrolled inMedicaid programs receive the dental benefits to which they are entitled. There are problems withinadequate and slow reimbursement, unwieldy administrative procedures, poor communicationwith state dental societies, a paucity of participating providers, maldistribution of providers andcultural and behavioral differences between dental practices and low-income patients. The NCSLsurvey shows that, although these problems are far from solved, states are taking them seriouslyand 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 anincrease and 27 experienced a decrease in the number of dentists who received payment fortreating a Medicaid patient;

· Of the 38 states with comparable data, between 1998 and 2000, 24 states experienced anincrease and 14 experienced a decrease in the number of dentists that billed the Medicaidprogram more than $10,000;

· Since 1999, 30 of 48 states that responded have raised Medicaid reimbursements for at leastsome dental services;

· Since 1999, 11 of 22 states that responded reported raising SCHIP reimbursements for dentalservices;

· 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 Medic-

aid- 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 super-

vision rules or by changing reimbursement policies.

It is clear from the NCSL survey that states are implementing a broad range of measures to improveaccess. More than half have raised reimbursement rates, which may be the single largest barrier todentists’ participation. In many states, however, rates are so far below the cost of providing carethat 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 availablelost ground in expanding the pool of dentists who actually provided dental care for Medicaidpatients. In contrast, nearly half of all states experienced an increase in the number of dentists whobilled 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 dentalservices for Medicaid and SCHIP beneficiaries. �


APPENDIX A

Medicaid Oral Health Questionnaire

1. What is the most recent full year for which you have statistics on Medicaid coverage of oralhealth 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 increaseprovider participation in oral health programs, i.e. fee increases or administrative simplifica-tion, 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 increaseaccess 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 mate-rials if available.)


APPENDIX B

SCHIP Oral Health Questionnaire

Questions 1-7 are the same as Medicaid Oral Health Questionnaire (see Appendix A).

8. What is the most recent full year for which you have statistics on Medicaid coverage of oralhealth 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 followingservices:

Diagnostica. Periodic oral evaluation (00120)b. Initial comprehensive oral exam (00150)c. Introral radiographs – complete series, including bitewings (00210)d. Bitewings – 2 films (00272)e. Panoramic film (00330)Preventivef. Prophylaxis (cleaning) – child (01120)

g. Topical application of fluoride, prophylaxis not included – child (01203)h. Sealant – per tooth (01351)Restorativei. Amalgam – 2 surface, permanent (02150)j. Resin – 2 surfaces, anterior (02331)k. Crown – Porcelain fused to predominantly base metal (02751)l. Prefabricates stainless steel crown – primary tooth (02930)Endodonticsm. Therapeutic pulpotomy, excluding final restoration (03110)n. Anterior endodontic therapy, excluding final restoration (03310)Surgeryo. Extraction – single tooth (07110)

1. In the past two years, has your state started any programs or initiatives designed to increaseprovider participation in oral health programs, i.e. fee increases or administrative simplifica-tion, 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 increaseaccess 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 mate-rials if available.)


NOTES

1 Department of Health and Human Services, Oral Health in America: A Report of the SurgeonGeneral, (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 theNCSL 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 providedental services for adults, they are required to provide emergency dental services to beneficiariesin nursing homes.

6 State data on the number of dentists enrolled as Medicaid providers varies in accuracy andreliability. States may not verify this information on a regular basis to check for duplicateentries or for dentists who have retired, moved or stopped accepting Medicaid. State data onthe number of dentists billing for services is based on provider numbers rather than names andis 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 ResearchFindings #12, p.20; The figure cited is the average expenditure for dental expenses amongchildren 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 DentalPractice, (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, Interviewwith 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 toOral Health, (Washington, D.C.: Center for Policy Alternatives, 2000).

17 Mary McIntyre, Associate Medical Director, Alabama. Interview with the author, January2001.

18 Op cit. Camm Epstein. (2000).

xv 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. Theauthors would like to thank Don Schneider, D.D.S., M.Sc.D., chief dental officer, Health CareFinancing 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, NationalConference of State Legislatures, for their helpful comments on drafts of this report. Thanks also toLeann Stelzer for editing and Greg Martin for formatting the report. �

The National Conference of State Legislatures serves the legislators and staffs of the nation’s50 states, its commonwealths, and territories. NCSL is a bipartisan organization withthree 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 for State Health Policy Leadership (the Forum) is a unit within the NationalConference of State Legislatures (NCSL) whose mission is to enhance the capacity forinformed decision making and legislative leadership regarding the financing, organizationand delivery of health care services to low -income and vulnerable populations. Estab-lished in 1995, the Forum carries out a variety of initiatives that serve targeted constitu-ents within NCSL and responds to emerging issues and complex problems facing statelegislatures.

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

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