Oral Health
Services
Fact Sheet
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1. Purpose of this Document
The purpose of this document is to assist State and
local health officials, as they work with State and
local Medicaid officials, in understanding how Medicaid
works, and how Medicaid can help improve access to
oral health services for low-income and underserved
populations. This document explains how Medicaid can
be a source of support for State, local and community-based
oral health services. The appropriate use of Medicaid
funding can make these services more accessible and
available to serve more persons who need services.
Medicaid is a critically important source of financing
for health care services, especially for low-income
children, adolescents and families. No other program
supports more health care for this population group.
For children and adolescents, comprehensive dental
coverage is required in all Medicaid programs under
the provisions of the Early and Periodic Screening,
Diagnostic and Treatment (EPSDT) Program. For adults,
States have the option to cover various dental services,
including dentures. States vary widely in their coverage
of adult dental services, from no coverage or coverage
for only emergency services to reasonably comprehensive
care.
Many medical and dental providers, and health officials
have found Medicaid rules complex and confusing. This
should not discourage the pursuit of Medicaid funding.
The goal of this document is to provide information,
in simplified terms, that can help all parties understand
what the opportunities are. This should help as agreements
are negotiated, policy decisions made, and strategic
plans formulated.
2. About Medicaid: A Brief Overview
Medicaid serves more people than any other U.S. health
program. Over 40 million persons had Medicaid coverage
during 1999. In general terms, about half were children,
about a quarter were adults responsible for the care
of the children, and about a quarter were adults who
were disabled or elderly.
Medicaid is a Federal-State program for financing
medical and long-term care services for low-income
Americans. Established in 1965 as Title XIX under
the Social Security Act, Medicaid was designed to
provide health insurance for persons with low incomes
and to help States pay for the costs of their health
programs.
At the Federal level, the Centers for Medicare and Medicaid Services
(CMS) pays the Federal share of these costs by providing
matching funds to the States. The Federal matching
rate (the "Federal Medical Assistance Percentage,"
or FMAP) for medical or dental services is at least
50% and as much as 77% of these costs. The exact percentage
in each State is recalculated each year based on a
formula that considers the level of personal income
in that State compared to the national average. The
Federal share of Medicaid administrative costs is
the same for all States at 50% for most administrative
functions, with certain expenditures qualifying for
higher matching rates. Federal Medicaid payments to
States for services or administrative costs are not
capped. Eligible individuals are entitled to services
covered in their State, and State Medicaid programs
are obligated to pay for covered services when they
are provided and a claim is submitted in accordance
with policies set by the State.
States design and administer Medicaid within Federally-defined
boundaries. Within these guidelines, each State defines
who is eligible for coverage, what medical services
are covered, which medical providers can participate
and the amount providers are paid when they provide
a service. As a result, each State Medicaid program
is unique. However, comprehensive dental care for
children and adolescents is covered under Medicaid
in all States under the requirements of EPSDT. EPSDT
requires Medicaid coverage for treatment of any dental
problem identified through an EPSDT medical or dental
screening, regardless of whether the needed service
is otherwise covered under that State's Medicaid plan.
Medicaid is the largest single
expenditure item in most State budgets.
Medicaid helps finance 77% of all State health-related
expenditures.
--National Association of State Budget Officers |
3. Oral Health Services: How Medicaid Can Help
Medicaid is a significant source of financing for
oral health services, particularly for children and
adolescents. Almost universally, however, Medicaid
programs identify access to dental care as a significant
and persistent problem for persons with Medicaid.
Oral health status and access to dental services
are issues for all populations served by Medicaid.
Certainly, oral health is a priority issue for all
young children, but especially for those of low income
where common dental diseases like tooth decay are
concentrated. Since Medicaid is the health coverage
for about one-fourth of all children in the U.S.,
Medicaid has a special role in dental coverage for
this group. Oral health is no less a priority for
other population groups served by Medicaid, including
low-income women, pregnant women, disabled adults
and the elderly.
According to a recent Report prepared by the Office
of the Inspector General, U.S. Department of Health
and Human Services (DHHS), only one-in-five Medicaid
children received even one preventive dental service
in 1996.[1] Another
study found that only 30% of all children in households
under 200% of the Federal Poverty Level saw a dentist
for any reason in 1996.[2]
According to the U.S. Surgeon General Report in 2000,
dental caries is the single most common chronic disease
of childhood, with a prevalence five times greater
than asthma.[3] Tooth
decay (the most common oral health problem of children)
is concentrated in low-income children, who are most
likely eligible for Medicaid coverage. Recent surveys
indicate that Medicaid eligible children have three
times greater unmet need for dental care than children
in higher income families.[4]
Oral health presents a unique opportunity for beneficial
collaboration between Medicaid, and HRSA-funded programs
and other public health programs at the national,
State and local levels. Public health programs can
work with Medicaid to implement initiatives to improve
access to dental services. At the same time, Medicaid
can provide a source of financing for dental services
that can enhance the success of public health efforts
to improve oral health.
According to a survey of State Medicaid dental programs
in 1999, all but two of 44 responding States indicated
that there is a problem with access to dental care
for Medicaid-enrolled children in their State. Reflecting
the priority placed by States on improving access
to dental services, almost every State has undertaken
activities intended to improve access to dental care
for Medicaid beneficiaries.[5]
The issues in improving oral health and access to
dental services are complex and challenging to address.
Barriers include:
1) Low or declining participation of dentists in
State Medicaid Programs;
2) Declining supply of dentists and dental hygienists
for the general population, particularly in inner
city and rural areas;
3) Dental service capacity of safety net providers
which is inadequate;
4) Medicaid dental coverage, billing procedures and
reimbursement levels that are not comparable to other
dental insurance;
5) Dentists' perceptions of Medicaid patients which
are sometimes negative; and
6) State budget limitations that make it difficult
for Medicaid programs to match mainstream dental insurance
in terms of reimbursement levels, services covered,
authorization procedures or billing requirements.
Experience has shown that the situation in each State
is unique, so the most appropriate approach in one
State may not be the exactly the right one in another
State. The problem is usually so significant that
it will require a comprehensive set of strategies
involving many different approaches.
Beginning on the next page are key strategies that
Medicaid can use to help improve access to oral health
services and improve the oral health of low-income
adults and children. The specific strategies are organized
as follows:
(A) Ensuring adequacy of coverage;
(B) Ensuring adequacy of payment;
(C) Improving dentist participation;
(D) Ensuring that eligible persons are enrolled;
and
(E) Improving eligibility standards for Medicaid
and the State Children's Health Insurance Program.
Strategies to Expand Access to Oral Health Services
A. Ensuring Adequacy of Coverage
- Adult dental coverage
- Child dental coverage, including EPSDT requirements
- Services for children with special health care
needs
- School-based health services
Adult dental coverage: Under Medicaid
law, dental services for adults are classified as
an "optional service." The most recent Federal
report shows that dental services for adults were
specifically listed as a covered service in the Medicaid
State plan in 42 States in 1996.[6]
(Note: In some states, adult dental services may also
be covered under another coverage, such as clinic
services, or under a Section 1115 waiver program.)
However, the fact that a State covers adult dental
services does not mean that all services are covered.
A State can select the dental services it wishes to
cover for adults. In some States coverage is comprehensive,
including regular cleanings, X-rays and dental repair
similar to employer-sponsored dental insurance. In
other States, coverage is limited to the immediate
relief of pain and infection.
It is important that Medicaid dental coverage is
reviewed periodically. This review can focus on the
extent Medicaid dental coverage can help to improve
oral health among adults, whether the coverage reflects
modern dental practice and how dental coverage can
influence the willingness of dentists to serve Medicaid
patients.
Appropriate dental care and good oral health enhance
employability among adults on Medicaid and increase
the likelihood that they will get a job, keep their
job and achieve independence from the welfare system.
In this way good dental coverage for adults can contribute
to increasing employment and success in welfare reform,
and offset some of the costs of dental services for
this population.
Under Medicaid law, coverage for dentures for adults
is a separate optional coverage. The most recent information
indicates that 34 States listed dentures for adults
as a covered service in 1996. [7]
Mainstream dental coverage for adults can also be
expected to make the program more attractive to dentists
and contribute to improved participation by dentists
in the program. In this way improving dental coverage
for adults can be both a strategy to improve oral
health and improve access to needed services for persons
of all ages.
Child dental coverage, including Early and
Periodic Screening, Diagnostic and Treatment (EPSDT)
Program requirements: Under the requirements
of EPSDT, Medicaid must provide comprehensive coverage
of all needed dental services for children and adolescents
from birth through age 20.
EPSDT is a specific program under Medicaid that provides
well-child and comprehensive pediatric care for children
and adolescents through age 20. EPSDT requires comprehensive
coverage of physical and mental health, growth and
developmental assessments, including lab and other
diagnostic tests, immunizations, health education
and anticipatory guidance. EPSDT also includes comprehensive
dental, vision and hearing screenings. EPSDT screenings,
including dental, are covered for each age group based
on a clinically-sound periodicity schedule adopted
by each State with consultation from professional
medical and dental groups.[8]
The screenings are also covered "as needed"
at any age.
EPSDT also requires coverage of any necessary medical
or dental service reimbursable under Medicaid for
the treatment of a condition identified under a periodic
or "as needed" exam, even if the service
is not otherwise a covered benefit in that State.
Under EPSDT, dental coverage includes complete preventive
care, restorative services, medically necessary orthodontic
care, and emergency care.
A common complaint among dentists concerns patients
who do not keep their appointments. Missed appointments
cause resentment among dentists because of the office
management and financial problems they create. More
importantly, the patient does not receive a needed
service. The likelihood of a patient keeping a dental
appointment is improved with a system of case management
that addresses the logistical, cultural and behavioral
barriers to dental care. Medicaid can pay for case
management as a medical service or as an administrative
activity.
Case management services are an integral component
of EPSDT and (at the discretion of the State Medicaid
agency) can be provided directly by the Medicaid agency,
by participating providers, or by case managers employed
by State or local public health agencies. State and
local maternal and child health providers can and
do play a very beneficial role in providing case management
services. Case management can assist parents in scheduling
appointments for screening, diagnosis or treatment,
can arrange transportation and follow-up to ensure
that appointments are kept, re-schedule missed appointments,
and work with the parent and the dental office to
be sure the child obtains care.
Under EPSDT, Medicaid can also reimburse the cost
of transportation to and from a covered dental exam
or service. Depending on how a State chooses to provide
transportation, it can be reimbursed as a service
or as a component of Medicaid administration.
Services for children with special health care
needs: Medicaid can play an important role
in paying for portions of the required medical and
dental services for children with special health care
needs (CSHCN), many of whom are enrolled in the Title
V Program. The Maternal and Child Health Program was
enacted as Title V of the Social Security Act in 1935
as a health services safety net for all women and
children. Today, Title V is administered by the Health
Resources and Services Administration (HRSA).
Between 1967 and 1989, Congress added a number of
requirements to Title V to work closely with and assist
Medicaid in a number of activities, including finding
and enrolling both children and providers. Title V
State offices are required to establish memorandums
of agreement with their State Medicaid offices. In
2000, the Administrators of CMS and HRSA signed a
data sharing agreement to enhance cooperation at the
State level between the Medicaid and Title V programs
and improve access to health care for low-income women
and children. Cooperation between State Medicaid and
Title V Programs can enhance the coordination and
case management of sources, result in better care,
and provide a financial resource for dental, primary,
and specialty care.
Many children and adolescents with serious or complex
health needs are enrolled both in Medicaid and in
the Title V Maternal and Child Health Program. Medicaid
is a key source of funding for most medically necessary
services for CSHCN for conditions identified through
an EPSDT screening. Medicaid is especially important
for the coverage of services, such as durable medical
equipment, medical supplies and prescription drugs.
The Title V Program is able to provide other services,
not otherwise covered by Medicaid, which may include
case management or other services or supplies not
included in the Medicaid benefit package.
For children with special health care needs, it is
sometimes difficult to locate a dentist who is equipped
to serve those with certain conditions. The State
Title V and Medicaid agencies may need to work together
to make special arrangements with dentists so all
Medicaid-enrolled children with special health care
needs can receive needed preventive and specialty
dental services.
Oral health services in Federally Qualified
Health Centers (FQHCs): FQHCs are able to
provide dental services, and about one-in-three do.
State Medicaid agencies are allowed to pay FQHCs up
to 100% of reasonable costs, but must pay them at
least 95% of reasonable costs in Fiscal Years (FY)
2001 and 2002, 90% in FY 2003 and 85% in FY 2004.
FQHCs that provide dental services play a crucial
role in the availability of these services, especially
in underserved areas where they may be the only provider.
Expanding the availability and capacity of dental
services in FQHCs can be a significant strategy in
increasing service availability for Medicaid populations,
especially in areas where there are few dental providers.
School-based health services: Medicaid
can reimburse for medical and dental services covered
under a State's Medicaid program when they are provided
in school-based health clinics or settings to children,
including adolescents who are enrolled in Medicaid
and are qualified for services under the Individuals
with Disabilities Education Act (IDEA). However, school-based
dental facilities face barriers because they may be
expensive to operate, difficult to staff and may require
substantial space commitment. For these reasons, a
program of "school-linked" dental services
may be preferred, where prevention programs and screenings
are provided in schools and students are "linked"
to community based dental providers for any needed
reparative and surgical care. These programs and services
may qualify for Medicaid reimbursement, depending
on how they are structured and provided and the extent
the students are enrolled in Medicaid.
In addition to Medicaid, the Title V Maternal and
Child Health Program and other HRSA funding supports
nearly 150 dental sealant programs which utilize portable
dental equipment to serve about 1000 classrooms consisting
primarily of Medicaid eligible children. These programs
provide dental sealants for underserved children,
assist children in enrolling in Medicaid and SCHIP,
and refer children for follow-up restorative care,
if required.
Local public health early intervention programs and
school districts may enroll as Medicaid providers
and receive payment for covered services for eligible
children and adolescents. Services often covered in
school settings include: therapies; case management;
transportation; screening and evaluation; health education;
dental sealant application; and other services that
may fall under EPSDT.
Schools may also assist the Medicaid program in certain
administrative activities. Examples of Medicaid reimbursable
administrative activities include: 1) Medicaid outreach;
2) providing information about how to enroll; 3) assisting
parents in completing application forms; 4) assisting
with documentation needed for enrollment; 5) referral
to dentists or medical providers; 6) coordinating
and monitoring of health services; or 7) assisting
in arranging for or providing transportation for medical
or dental services. These administrative activities
must be part of the Medicaid State Plan that is approved
by CMS in order to qualify for Medicaid reimbursement.
Schools and school districts do not submit claims
for individual services for administrative activities.
A cost allocation plan is used to determine the share
of total costs for approved activities that is attributable
to Medicaid-eligible children and adolescents. The
Medicaid share is the amount that qualifies for Federal
Medicaid matching funds.[9]
Medicaid reimbursement for services in school settings
may be limited when children are enrolled in a managed
care organization (MCO) unless the State Medicaid
agency has agreed to pay for these services on a fee-for-service
basis. The key factor is what medical or dental services
are included in the Medicaid capitation rate to the
MCO. When a service is included in the capitation
rate, a medical or dental provider will need to seek
payment for services for an enrolled Medicaid patient
from the MCO instead of the Medicaid agency. Some
States "carve out" certain services from
the MCO capitation rate, so payment may be made directly
to schools on a fee-for-service basis.
Important issues have arisen in some States relating
to the claim for Federal Medicaid reimbursement for
services in schools. These issues have related both
to medical services and for administrative activities.
CMS has disallowed certain claims for Medicaid reimbursement
when it was found that all conditions for payment
were not met. The lesson to be learned from these
experiences is that Medicaid funding should be claimed
only for services that are covered for children who
are enrolled, and that administrative overhead costs
associated with medical or dental services should
not also be claimed as administrative costs.
B. Ensuring Adequacy of Payment
- Fee-for-service payment rates to dental providers
- Managed care payment rates to dental providers
Fee-for-service payment rates to dental providers:
Participation in Medicaid and serving Medicaid patients
is voluntary for all providers. Those who do participate
must agree to accept Medicaid payment as payment in
full. The amount that Medicaid pays for services is
a key factor in a dentist's decision to serve Medicaid
patients. Low payment is one of the most frequently
cited reasons for not participating in Medicaid. Dentists
have indicated that Medicaid reimbursement often does
not cover the direct cost of providing services. Federal
law requires that State Medicaid payments to providers
be "sufficient to enlist enough providers so
that care and services are available under the plan
at least to the extent that such care and services
are available to the general population in the geographic
area." To achieve the desired level of dental
participation, dental services merit special attention
in Medicaid rate setting.[10]
For dental and medical services provided by Federally
Qualified Health Centers (FQHCs) and Rural Health
Clinics (RHCs), Federal law requires Medicaid payment
to be based on reasonable costs. Medicaid also has
the option to pay local health departments, community
mental health clinics or other public providers on
a reasonable cost basis. However, many of these clinics
and health centers do not provide dental services,
and those that do are unlikely to have enough capacity
to meet all the needs of the community. Substantial
participation of dentists in the community will likely
be required to achieve adequate coverage of oral health
services.
To have Medicaid payment rates regarded as acceptable
to dental providers is necessary to dental participation,
but it is not likely to be sufficient. Dental providers
are often concerned about program administrative requirements
and procedures. Program improvements and administrative
streamlining are an important adjunct to adequate
reimbursement in increasing dentists' service to Medicaid
patients. (See Section C below for a discussion of
these approaches.)
Managed care payment rates to dental providers:
In many States, almost all families on Medicaid receive
medical care through a managed care organization.
In these States, the Medicaid program has several
options for covering dental services. Medicaid can
include dental care as a service covered by the medical
managed care organization, can contract directly with
dental managed care vendors, or can "carve out"
(exclude) dental services from managed care. When
Medicaid decides to contract dental services through
managed care, Medicaid must have a contract with the
managed care organization that spells out the expected
coverage, the required network of dental providers
and the required levels of performance. The specific
provisions of this contract are critical to the success
of this approach to dental coverage.
A key issue is whether the amount Medicaid pays to
the managed care organization for dental services
is sufficient for the expected use of services, and
whether payment rates used by the managed care organization
to reimburse dentists are sufficient to assure access.
The amount in the managed care organization's capitation
rate targeted to dental services is usually based
on an actuarial assumption that the use of dental
services will be the same in managed care as it was
under the state-administered fee-for-service program.
This assumption will not be correct when the use of
dental services was low due to limited access under
the State-administered fee-for-service program, and
where the managed care plan improves access and the
use of dental services. In this case, the amount of
money available to the managed care organization for
dental care will be inadequate. The Medicaid agency
must address this issue when the managed care rates
are being set, and do so within the Federal "upper
payment limit" requirements. The upper payment
limit constrains the State Medicaid program's capacity
to enhance funding for a specific service such as
dental in its managed care rate setting.
Managed care offers an opportunity to address several
key issues relating to good oral health care. The
Medicaid agency can use the contract with managed
care organizations to address oral health standards
of access, quality, utilization, reimbursement and
data reporting, and can require a relationship with
Title V and other public health agencies.
C. Improving Dentists' Participation
In recent years, States have invested considerable
resources in addressing low dental provider participation
in Medicaid and poor access to dental services. Several
strategies are being used in an effort to improve
access and availability of dental services. The clear
message from recent State experience is that the problem
is complex, multifaceted and difficult to resolve.
Reimbursement issues are important, yet improving
reimbursement alone may not improve dental access.
Strategies to Improve Dentists' Participation
in Medicaid: A number of issues need to be
addressed to successfully establish and improve dentists'
participation in Medicaid. These include the issues
cited above relating to adequate coverage and reimbursement,
plus others that relate to improving the business
relationship between Medicaid and the dentist. Success
requires a comprehensive set of strategies. Strategies
identified in a recent survey of all States include
the following:[11]
* Improved reimbursement: Three-fourths of
States increased payment rates to dental providers
in 1998 or 1999. Dentists often cite low reimbursement
as a primary reason for not serving Medicaid patients.
Small increases may not improve payment levels to
a point that a dentist believes actual costs are covered
by Medicaid payment.
* Administrative streamlining: Many States
have tried to improve the business relationship with
dentists by minimizing the hassle of being a provider
with Medicaid. Actions have included: 1) simplifying
the process of becoming a Medicaid provider; 2) providing
a simple process to verify patient enrollment with
Medicaid; 3) simplifying the process for prior authorization
for services, or eliminating prior authorization entirely
for many services; 4) reducing the number of services
requiring prior authorization; 5) adopting the American
Dental Association coding structure and standard claim
forms; 6) establishing provider hot-lines; 7) establishing
patient ombudsmen; and 8) simplifying provider manuals
and program requirements.
* Creating mainstream benefit structure:
The more Medicaid dental coverage is comparable to
employer-sponsored dental insurance, the greater likelihood
dentists will participate and serve Medicaid patients.
Achieving dental coverage regarded as mainstream by
the dental community may involve adding or updating
covered services and procedures so they reflect modern
dental practice and terminology.
* Creating a special advisory committee or task
force to recommend strategies: Participation in
an advisory committee or task force can raise awareness
within the dental community of the urgency and need
to serve this population. Significant contributions
of a State oral health coalitions include: 1) helping
to educate beneficiaries about the importance of oral
health; 2) working with the dental community to improve
participation and availability of services; 3) bringing
the problems and issues to the attention of State
officials and legislators; 4) engaging the public
in advocacy for oral health; and 5) identifying best
practices that can be adopted for State and local
use.
* Outreach and marketing to dental providers:
The distribution and supply of dental providers is
often problematic. Many inner city and rural areas
(where large numbers of Medicaid beneficiaries reside)
may have few or no dental providers. Special efforts
need to be focused where there is a shortage of dental
providers. These efforts may include: 1) special articles
in dental journals; 2) letters to individual dentists;
3) meeting with local dental societies; 4) seeking
input from dentists on how to recruit additional providers;
5) improving the conditions of participation in Medicaid;
and 6) using Head Start and WIC programs to assist
in recruiting dentists for Medicaid.
* Case management to reduce missed appointments:
Missed appointments are a serious issue for dentists.
Reducing the rate of "no shows" for scheduled
dental appointments can be a very important part of
an overall strategy to improve dentists' participation.
Medicaid can pay for case management provided by health
departments, managed care organizations, state and
local maternal and child health programs, FQHCs, other
providers, enrollment brokers or the Medicaid agency
can provide case management itself. Case management
can include: 1) sending reminder postcards; 2) using
case managers to assist is setting up appointments
and emphasizing the importance of keeping their appointments;
3) following up on appointments whether kept or missed;
and 4) creating a toll-free hotline for dentists to
call if a patient misses an appointment.
* Outreach to parents of children: Medicaid
can help educate parents about the importance of oral
health, the need for early care to prevent common
dental problems and how to use the dental delivery
system. Medicaid can provide this outreach directly
or contract with other organizations, such as local
health departments, schools, managed care organizations
or dental provider groups.
* Transportation and making appointments:
Medicaid can pay for transportation and the scheduling
of appointments. A State agency or a private provider
can provide both, and both can be classified as a
service or an administrative activity.
* Working with schools and Head Start programs:
Medicaid can provide schools and Head Start programs
with literature and information to encourage early
and continuing good oral health and dental check ups.
* Working with managed care: Managed care
organizations under contract with Medicaid must guarantee
access and quality, and comply with specific contract
performance requirements. Medicaid is obliged to enforce
these requirements.
Where dental services are the responsibility of managed
care organizations, Medicaid can facilitate good oral
health services through adequate capitation rates
and contract requirements for access and quality that
are that are clear and enforceable.
* Working with safety net providers: Dental
services often are available through community providers.
FQHCs, Rural Health Clinics and hospitals may serve
as safety net providers of dental care. Encouraging
safety net providers to offer dental services can
be an important part of an overall strategy, together
with measures to encourage good participation of community-based
dentists.
D. Ensuring that Eligible Persons are Enrolled
- Adults and children eligible for Medicaid
- Children eligible for the State Children's Health
Insurance Program
Adults and children eligible for Medicaid:
A primary strategy for fully utilizing Medicaid is
to enroll all persons who are eligible under existing
eligibility standards. Medicaid cannot pay for services
for persons who are not enrolled, even if they are
eligible. Experience has shown that many eligible
persons are not enrolled. A number of strategies can
increase the likelihood of their enrollment. These
strategies include: 1) outreach, public service announcements
and paid radio and TV ads; 2) simplified application
forms and enrollment procedures; and 3) assistance
for persons applying for Medicaid. These strategies
apply to enrollment of adults, as well as children.
The key to getting children enrolled seems to be
providing good information and making the process
as easy as possible for the parent. Research has shown
the following strategies improve the likelihood that
parents will enroll their child:[12]
- Allowing enrollment by mail or phone;
- Permitting immediate enrollment ("Presumptive
Eligibility") with forms completed later;
- Extending enrollment office hours;
- Improving the way applicants believe they are
treated at enrollment centers;
- Allowing enrollment at a clinic, doctor's office
or dentist's office;
- Allowing enrollment at Head Start programs, WIC
clinics and faith centers;
- Allowing enrollment at school or day care center;
- Using a toll-free telephone information line;
and/or
- Simplifying and shortening the enrollment form.
Other policies adopted by many States include:
- Dropping the assets test;
- Adopting presumptive eligibility;
- Not requiring a face-to-face interview;
- Providing continuous 12-month eligibility;
- Providing information and outreach;
- Adopting common policies for both Medicaid and
the State Children's Health Insurance Program (SCHIP);
and
- Making the program as much like mainstream health
and dental insurance as possible. States have found
that creating an image of Medicaid that is more
like private health and dental insurance can help
overcome a lingering stigma in the minds of some
potential beneficiaries.
E. Improving Eligibility Standards for Medicaid
or the State Children's Health Insurance Program
Medicaid Eligibility for Children to Age 18:
States have the opportunity to expand eligibility
specifically for children. Federal law requires that
States cover children to age 6 at 133% of the Federal
Poverty Level (FPL). For children age six and above,
Federal law specifies eligibility at 100% of the FPL
for children born after September 30, 1983. This provision
will fully phase in eligibility at 100% of the FPL
for children to their 19th birthday in the year 2002.
Many States have taken advantage of the opportunity
to expand Medicaid eligibility above the levels required
by Federal law. Under Section 1902(r)(2) or Section
1931 of the Social Security Act, a State can expand
eligibility to the level it chooses. A few States
have expanded eligibility under Medicaid to 275% or
300% of the FPL using this approach. Other States
are using their State Children's Health Insurance
Program as the vehicle to expand coverage for children.
State Children's Health Insurance Program (SCHIP):
SCHIP has provided an excellent opportunity to expand
access to needed health and dental care for children.
Background: Since enactment of SCHIP as Title
XXI of the Social Security Act in 1997, States have
focused on implementing their SCHIP programs and getting
eligible children enrolled. In the year from December
1998 to December 1999, the number of children enrolled
in SCHIP programs more than doubled, from about 0.8
million to 1.8 million. An estimated 2.6 million children
are eligible for SCHIP nationally.[13]
Many States have found that SCHIP outreach and enrollment
has a Medicaid case-finding effect, with one or more
children enrolled in Medicaid for every child enrolled
in SCHIP.
SCHIP programs qualify for an enhanced Federal matching
rate that is higher than the Medicaid. Federal matching
rates for SCHIP range from 65% up to 84%.
Children, including adolescents who are eligible
for Medicaid (whether they are enrolled or not) are
by law not allowed to be enrolled in SCHIP. Similarly,
children with any other health insurance coverage
are not eligible to enroll in SCHIP. This is a serious
issue for oral health services, since some children
are excluded from SCHIP because they have health insurance
coverage, but their health insurance does not cover
dental care. Under current law, it is not possible
for SCHIP to provide dental coverage for these children.
A State can implement SCHIP as a Medicaid expansion,
or as a separate program based in the private health
insurance market, or it can implement both. To the
beneficiary, a Medicaid expansion SCHIP program is
often indistinguishable from Medicaid, and it includes
the same comprehensive dental services covered by
Medicaid. A separate SCHIP program may be based on
private health insurance coverage, and unlike Medicaid,
have a nominal premium, copayments for children and
limits on benefits, including limits on dental services.
Enrolling children in SCHIP provides significant
coverage that can bridge the gap between Medicaid
and private employer-sponsored health insurance. A
State can include a different benefit package and
pay different reimbursement levels for dental services
under SCHIP than under Medicaid. Some States have
seen improvements in dental access under a more mainstream
SCHIP coverage and payment arrangement. From these
experiences, States can learn important lessons about
how to improve dental participation and access to
oral health services.
Note: SCHIP programs that are Medicaid expansions
are required to cover dental services, but separate
SCHIP programs are not. All separate SCHIP programs
(except one) offer dental coverage even though the
SCHIP dental coverage may not be comparable to that
provided under Medicaid. Dental coverage under separate
SCHIP programs may have premiums, copayments, annual
service limits, exclusions or other restrictions.
States can also provide medical and dental coverage
for the adults associated with SCHIP-covered children.
Until recently, this coverage could only be arranged
under a Medicaid expansion or a Section 1115 Medicaid
waiver. CMS announced on July 31, 2000 that it would
consider waiver requests under Title XXI to provide
coverage under SCHIP.[14]
This would allow States to provide "family coverage"
as an extension of SCHIP coverage for children.
Conclusion
There is great potential for State and local health
programs to work with Medicaid to improve access to
dental services and improve oral health. Medicaid
can be a source of financing for dental services for
children and adults. Public health services can assist
Medicaid in addressing issues of access and dental
provider participation.
Medicaid has become a significant source of funding
for almost every health-related service in the U.S.
that serves low-income persons. A State should conduct
a review periodically to be sure it is fully using
Medicaid as a source of support to help finance these
services.
Other Opportunities to Use Medicaid
In addition to oral health, Medicaid is a potential
source of financing for a number of other State and
local health services. Specific areas where Medicaid
can be a source of funding include: maternal and child
health services, rural health services, services for
persons living with HIV/AIDS, and mental health and
substance abuse services.
Contact for More Information
If you have questions or wish to obtain additional
information on implementation strategies, contact
HRSA at:
Alexander Ross
U.S. Department of Health and Human Services
Health Resources and Services Administration
Center for Health Services Financing and Managed Care
5600 Fishers Lane, Room 10-29
Rockville, Maryland 20857
Phone: 301-443-1512
Fax: 301-443-5641
E-mail: aross@hrsa.gov
For copies of this document, contact:
HRSA Information Center
P.O. Box 2910
Merrifield, VA 22116
Phone: 1-888-Ask-HRSA
Fax: 703-821-2098
TTY: 877-4TY-HRSA
Se Habla Espanol
OR
Visit the HRSA Website at: www.hrsa.gov/medicaidprimer
HRSA has an Oral Health Initiative. For more information
on this Initiative, see Website: www.hrsa.gov/oralhealth
The coordinator of the HRSA Oral Health Initiative
is Jim Sutherland and the HRSA consultant for oral
health is Burton Edelstein.
This document was prepared by Health
Management Associates under a contract with HRSA.
4. Attachment: A Basic Description
of the Medicaid Program
Federal law provides that a State may qualify for
Federal Medicaid matching funds only if it designs
its program within specific Federal requirements.
These include eligibility for specific population
groups, coverage for certain medical services and
medical providers, and adherence to specific rules
relating to payment methodologies, payment amounts,
and cost-sharing for Medicaid beneficiaries.
To qualify for Federal Medicaid matching funds, a
State must obtain the U.S. Department of Health and
Human Services, Centers for Medicare and Medicaid Services
(CMS) approval of its Medicaid State Plan. The State
Plan is the contract between the Federal government
and the State, which spells out the terms and conditions
under which the State will receive Federal Medicaid
matching funds. Every change in eligibility for beneficiaries,
change in coverage of services or change in methodology
of reimbursement in a State's Medicaid program requires
a State Plan Amendment that must be approved by CMS.
Waivers of Federal Requirements
Federal law requires that Medicaid beneficiaries
have freedom of choice of providers, that the program
is statewide, and that services are available in an
amount, duration and scope sufficient to achieve their
purpose.
The Federal law provides flexibility to States to
cover optional services and eligibility groups. Some
options are specifically described in the Federal
law. Other options may be available through "waivers."
CMS has authority to "waive" certain statutory
requirements so a State can, for example, cover certain
benefits or eligibility groups that could not otherwise
be covered under Medicaid.
CMS may grant "program waivers" or "research
and demonstration waivers". The most common program
waiver is under Section 1915(b), which waives the
freedom of choice requirement so a State can implement
a managed care program. Recently, the Balanced Budget
Act of 1997 provided that a State has a choice of
a managed care waiver or a State Plan Amendment. Either
approach will be approved with a set of specific terms
and conditions. Section 1915(c) waivers provide for
Home and Community Based Services waivers. Research
and demonstration waivers are granted under Section
1115 for more comprehensive programs of health reform.
Section 1115 waivers may involve restructuring the
State's Medicaid program, as well as the terms and
conditions of Federal funding.
The Impact of Medicaid Managed Care
Increasingly, Medicaid programs have moved toward
the use of managed care arrangements as delivery systems
for Medicaid beneficiaries. Medicaid managed care
may involve enrollment with health maintenance organizations
(HMOs) and managed care organizations (MCOs) which
are paid on a capitated basis, or a Primary Care Case
Management (PCCM) system, which is a fee-for-service
program that the state develops and manages itself.
Some states have found that a PCCM works well in rural
areas that may be served by few or no HMOs.
An HMO, a MCO or a PCCM system will require the Medicaid
beneficiary to enroll with a specific primary care
provider, who by contract with the Medicaid agency
accepts certain responsibilities for providing and
authorizing needed medical care. Providers not in
the HMO network, or not referred by the primary care
provider in a PCCM system, may not be able to be reimbursed
for services provided to Medicaid beneficiaries.
The use of managed care can raise significant issues
for Medicaid reimbursement of services delivered by
public health agencies, mental health agencies, health
centers or other publicly assisted agencies. This
is particularly true for care provided through capitated
HMOs and MCOs. Public providers may need to negotiate
participation and reimbursement arrangements with
an HMO instead of with the Medicaid agency. Public
providers would be well served to monitor the development
of State Medicaid policy to be sure their interests
are taken into account as managed care policy is developed.
It is sometimes possible and advantageous to the State
agency and the State budget to arrange for certain
services to be "carved out" of capitated
managed care contracts and directly reimbursed by
Medicaid. Services often considered for a carve-out
include: family planning; prenatal care and other
pregnancy services; selected Early and Periodic Screening,
Diagnostic and Treatment (EPSDT) services; immunizations;
or mental health services.
Qualifying for Federal Medicaid Matching Funds
Medicaid is a program that provides open-ended Federal
contributions according to a statutory formula to
participating States with approved plans. CMS reimburses
the State Medicaid Agency for a portion of actual
expenditures made under the provisions of the State
Plan. Federal reimbursements (Federal financial participation,
or "FFP") are based on qualifying expenditures
for either "medical assistance" (i.e., medical
services) or for program administration.
The amount of Federal payments to a State for medical
services depends on two factors. The first is the
actual amount spent that qualifies as matchable under
Medicaid. In general, this means that:
- The expenditure is for a covered service;
- Provided by a qualified provider enrolled with
the Medicaid program; and
- To a person eligible for and enrolled in Medicaid
at the time of service.
The second factor is the Federal Medical Assistance
Percentage (FMAP) for each State. The FMAP percentage
is computed from a formula that takes into account
the average per capita income for each State relative
to the national average. By law, the FMAP cannot be
less than 50%. States with per capita personal incomes
below the national average have a FMAP rate as high
as 77% in fiscal year 2000. This means, for example,
for every $1 in qualifying Medicaid expenditures made
by a State, the State is able to claim and receive
at least $0.50 and as much as $0.77, depending on
the State FMAP. Expenditures for Medicaid-related
administrative activities also qualify for Federal
matching funds. For administrative expenditures to
qualify, the activities must be related to the administration
of the State Medicaid program. Unlike the FMAP for
medical services, which is different for each State,
the administrative matching rates are the same for
all States. Expenditures necessary for the administration
of the program generally are reimbursed at 50%. Certain
administrative expenditures qualify for higher Federal
matching rates. For example, certain activities requiring
skilled medical professionals qualify for 75% Federal
matching. Some expenditures relating to the development
of new information technology systems may qualify
for Federal matching rates of 75% or 90%.
Medicaid allows State and local agencies that provide
or arrange for covered services to Medicaid enrollees
to receive Federal payments toward the cost of such
services. For these expenditures to qualify for Federal
Medicaid payments, service delivery and administrative
activities must be carried out under the terms of
an inter-agency agreement with the Medicaid agency.
The agreement is a contract that spells out the medical
and administrative services that will be treated by
the Medicaid agency as Medicaid expenditures; and
thus, will qualify for Federal funds. The Medicaid
agency will include those qualifying expenditures
identified in the agreement in its claim for Federal
funds. The agreement usually holds the service delivery
agency responsible for any potential future recoveries
if an audit should find the claim for Federal matching
funds included non-qualifying expenditures.
Opportunities to Use Medicaid
Federal Medicaid matching funds have proven to be
a rich source of financing for many State and local
health programs. Federal Medicaid funds may help finance
a new program or coverage, or the expansion of an
existing program. In some cases, where an existing
health program was previously financed entirely from
State or local funds, the availability of Federal
Medicaid matching funds may reduce the cost of general
fund dollars borne by State or local government.
The opportunity to use Medicaid as a source of financing
for State or local health programs depends on the
ability of policymakers to design programs (or redefine
on-going programs) that meet the Medicaid requirements.
How to Increase Medicaid Funding for State and
Local Health Services
Policy changes that will permit a State program to
qualify its expenditures for Medicaid matching funds
can be classified as follows:
Increase the Number of Persons Who Qualify
for Medicaid Coverage: Expenditures cannot
qualify for Federal Medicaid matching funds when services
are provided to persons who are not enrolled in Medicaid.
Thus, one avenue for increasing Medicaid support for
a program is for eligibility to be expanded so a greater
number of persons served by a program may qualify.
Many persons who are eligible for Medicaid do not
apply because they do not know they are eligible,
or they regard the application process as difficult.
State residency requirements are not allowed under
Medicaid. This means, for example, that migrant workers
and their children are able to qualify on the same
terms as any other person in a specific State.
Medicaid eligibility is determined in general by
two key factors. First, persons must be in a qualifying
category. Second, persons must meet State-defined
income and asset criteria. (Other requirements also
apply, such as being a legal U.S. resident.) Each
Medicaid program must cover certain groups of persons,
but has the opportunity to offer coverage to other
optional eligibility categories.
Medicaid eligibility rules are complex. The following
is a general description of Medicaid eligibility categories
and rules:
Mandatory Eligibility Groups: Federal law
specifies that States must cover certain eligibility
categories, including:
- Low-income families with children who would have
qualified for Aid to Families with Dependent Children
(AFDC) cash assistance in July 1996. These persons
may or may not be receiving Temporary Assistance
to Needy Families (TANF) cash assistance now.
- Children under age 6 in families with incomes
below 133% of the federal poverty level (FPL).
- Children ages 6 to 17 in families with incomes
below 100% of the FPL (to age 18 in 2001).
- Pregnant women with family income below 133% of
the FPL.
- Elderly, blind or disabled adults and children
receiving Supplemental Security Income (SSI) payments.
- Children receiving foster care or adoption assistance
under Title IV of the Social Security Act.
- Persons who lose eligibility for AFDC/TANF due
to earnings (i.e., leave welfare for work) may continue
on Medicaid for up to a year; those who leave due
to increases in child support payments, may continue
on Medicaid up to four months.
- Certain Medicare beneficiaries, with benefits
depending upon income up to 175% of FPL are also
eligible for Medicaid. "Dual Eligibles"
are a group enrolled in both Medicaid and Medicare.
Depending on the individual's income, these persons
qualify for various levels of Medicaid coverage
and support. Persons who qualify under SSI income
standards qualify for full Medicaid coverage. Persons
above this level may not receive full Medicaid benefits.
Medicaid pays for all or a portion of Medicare premiums,
deductibles, and coinsurance, depending on the income
level of the beneficiary. (An asset test also applies
such that countable assets cannot exceed $4,000
for an individual, or $6,000 for a couple.)
- Qualified Medicare Beneficiaries (QMBs): Income
up to 100% of the FPL. Medicaid pays Medicare
part A and B premiums, deductibles and cost sharing
related to Medicare covered benefits.
- Specified Low-Income Medicare Beneficiaries
(SLIMBs): Income between 100% and 120% of the
FPL. Medicaid pays only for the Medicare Part
B premium.
- Qualified Individuals (QIs): Medicaid pays all
or part of the Medicare Part B premium for persons
who would be eligible to be a QMB except their
income is between 120% and 135%, or at state option
up to 175% of the FPL.
- Qualified Disabled and Working Individuals (QDWIs):
Persons who are disabled, but who lost their Medicare
Part A benefit due to increased earnings, and
whose income is between 100% and 200% of the FPL.
Medicaid pays the only the Part A premium.
Optional Eligibility Groups: Federal law specifies
that States may, at the option of the State, cover
low-income persons in a number of specified eligibility
groups. These include (but are not limited to) the
following:
- Pregnant women, infants, children and parents
of any Medicaid-eligible child, including parents
in two-parent families with income and assets at
or below state-defined levels.
- Disabled children who would be eligible under
criteria in effect in July 1996.
- Persons in institutions with incomes less than
300% of the SSI Federal benefit level.
- Recipients of SSI payments, and disabled or elderly
persons with incomes below100% of the FPL.
- Certain working disabled persons who would qualify
for SSI if they were not working, up to 250% of
the FPL.
- Children under a "Medicaid Expansion"
State Child Health Insurance Program.
- Persons who are "Medically Needy".
The "Medically Needy" category provides
for a different method of determining eligibility,
based on actual medical expenses incurred by an individual.
Medically needy persons are individuals who fall within
one of the mandatory or optional eligibility groups,
but have income and resources that would make them
ineligible, except when the cost of their medical
care is taken into account. When they incur medical
expenses they "spend down" their income,
and become eligible for the balance of the eligibility
period from the point in time they spend down their
income to the eligibility level. The process begins
again at the beginning of the next state-defined eligibility
period.
Income Eligibility Levels: States have considerable
flexibility in setting permissible income levels.
Income eligibility levels can be set separately for
specific groups, such as children, families, pregnant
women, the disabled and the elderly.
States can increase effective eligibility levels
for pregnant women, children, families with children,
elderly and disabled persons by "disregarding"
a certain amount of income. In this way, eligibility
for children could be extended above 185% of the FPL
(technically the upper limit for pregnant women and
infants), by setting the disregarded amount to a level
that would bring countable income down to 185% of
the FPL. To extend the eligibility level to 285% of
the FPL, for example, a State would set the disregarded
amount at 100% of the FPL.
The income disregard provisions can also be used
to effectively increase the income limits for Qualified
Medicare Beneficiaries (who receive Medicaid assistance
with their Medicare premiums, deductibles, and coinsurance),
and some aged, blind and disabled Medicaid groups.
This flexibility over countable income is found in
Section 1902 (r)(2) and Section 1931 of the Social
Security Act.
State Children's Health Insurance Program (SCHIP):
A State can implement its SCHIP program as a Medicaid
expansion, or as a separate health insurance program.
Another option is for a State to have both a Medicaid
expansion and a separate program operating at the
same time with each one targeted at health coverage
for different groups of children. SCHIP has an enhanced
Federal matching rate, ranging from 65 percent to
about 85 percent. Because the matching rate is higher,
a State can extend coverage to children at a lower
State cost through SCHIP than through regular Medicaid.
A key feature of SCHIP is its focus on finding children
who are eligible, but not yet enrolled in either Medicaid
or a separate SCHIP program. Matching funds are available
specifically for the purpose of marketing, outreach
and determining eligibility.
Increase Services Covered by Medicaid:
Each State determines what medical services will be
covered under Medicaid. By defining services appropriately,
a State can be sure services provided by other State
agencies qualify for Medicaid reimbursement. Typically,
medical services provided through public health, mental
health, disability, substance abuse treatment, aging,
or education agencies can qualify for Federal Medicaid
matching funds. Federal Medicaid matching funds can
help finance capacity expansion in these programs
or reduce the net cost to the State for these services,
if they are specifically covered in the State Plan.
Mandatory coverage includes the following services:
- Hospital services, inpatient and outpatient
- Physician services
- Lab and X-ray
- Immunizations and other well-child services listed
under the Early and Periodic Screening, Diagnostic
and Treatment requirements, including any medically
necessary diagnostic and treatment services, plus
vision, dental and hearing services for children.
- Family planning services
- Nurse midwife, pediatric and family nurse practitioner
serves
- Federally-qualified health center (FQHC) and rural
health clinic (RHC) services
- Home health care services
- Nursing home services
- Transportation for medical services
The number of optional services
covered by states
range from 13 to 33. The median is 24. |
Optional coverages include 34 specific services,
including the following:
- Prescription drugs
- Clinic series
- Rehabilitation and physical therapy services
- Prosthetic and orthotic devices
- Optometrist services and eyeglasses
- Hearing services
- Dental Services
- Home and community based care for persons with
certain impairments
Set Medicaid Reimbursement Rates at Appropriate
Levels: State Medicaid programs are required
by Federal law to set their payment rates at a levels
sufficient to achieve access to needed care. Medicaid
may want to set rates to achieve specific public policy
objectives, such as access to primary care, well-child
care, prenatal care or deliveries.
Rates for safety net providers, including FQHCs and
RHCs, can be set to assure their financial viability.
Federal law specifies cost-related reimbursement methods
for FQHCs, but meeting the minimum legal requirement
may not assure full reimbursement of costs for Medicaid
patients. Medicaid has the option under the law to
provide full-cost reimbursement for these providers.
The maximum amount that the State Medicaid Programs
are allowed to pay is defined by the Upper Payment
Limit, which is generally the amount Medicare would
have paid for the same services and patients. If a
Medicaid program were to pay an amount greater than
the upper payment limit, the amount above the limit
would not qualify for Federal Medicaid matching funds.
Special "Disproportionate Share Hospital"
(DSH) payments can be made to hospitals that qualify
on the basis of their service to Medicaid and the
uninsured. Each State is able to define the specific
criteria these hospitals must meet to qualify. Funds
are distributed based on a state-defined formula.
DSH payments are limited to inpatient and outpatient
hospital providers.
Find and Enroll Potential Eligibles:
Medicaid, Title V Maternal and Child Health Program
or Temporary Assistance to Needy Families (TANF) funding
can support administrative activities that are directed
at case-finding, education and outreach initiatives
that help locate and enroll persons who are eligible
for Medicaid. Medicaid funding also is available to
create the systems needed to determine eligibility
and to enroll individuals into Medicaid. Federal Medicaid
funds can be used to support outstationed enrollment
services of FQHCs, DSH payment hospitals, health departments
and other community sites.
Medicaid can also reimburse for case management as
an administrative activity. Case management may apply
in situations where enrolled persons have complex
medical conditions; and it is beneficial to set up
a process to systematically manage their medical care.
5. Sources of Information About Medicaid
Excellent information on Medicaid is available from
several sources. These sources may provide more detailed
information on specific areas of interest. Medicaid
is constantly changing and responding to new issues.
The following sources may be useful in obtaining up
to date information.
Centers for Medicare and Medicaid Services (CMS)
Web site: www.cms.gov
-- on the CMS web, see:
- Medicaid, Medicare, and State Children's Health
Insurance Program (SCHIP) descriptions and data
sections
- State Medicaid Director Letters
(specific direction to Medicaid agencies on
a range of issues)
- Federal Medical Assistance Percentages for each
state
Bureau of Primary Health Care
Health Resources and Services Administration
Web site: www.bphc.hrsa.gov
Center for Health Services Financing and Managed
Care
Health Resources and Services Administration
Web site: www.hrsa.gov/financeMC
Kaiser Commission on Medicaid and the Uninsured
Web site: www.kff.org
National Academy for State Health Policy
Web site: www.nashp.org
National Health Law Program
Web site: www.healthlaw.org/medicaid.shtml
Center on Budget and Policy Priorities
Web site: www.cbpp.org
Urban Institute New Federalism Project
Web site: newfederalism.urban.org
Rural Policy Research Institute
Web site: www.rupri.org
Footnotes:
[1] DHHS Office of Inspector
General, Children's Dental Services under Medicaid,
Access and Utilization, OEI-09-93-00240, San Francisco:
Office of Evaluation and Inspections, April 1996.
[2] Edelstein B, Manski
RJ, Moeller JF. Pediatric Dental Visits During 1996:
An Analysis of Federal Medical Expenditure Survey.
Pediatric Dentistry, 22:17-20, 2000.
[3] U.S. Department of Health
and Human Services. Oral Health in America: A Report
of the Surgeon General. Rockville, MD: USDHHS, National
Institute of Dental and Craniofacial Research, National
Institutes of Health, 2000.
[4] P. Newachek, et.al.,
The Unmet Health Needs of America's Children, Pediatrics
105(4): 989-997, April 2000.
[5] Erin Nagy, 1999 Survey
on Access to Dental Care for Medicaid-Enrolled Children,
American Public Human Services Association, under
contract with the Centers for Medicare and Medicaid Services,
July 2000 and Camm A. Epstein, States' Approaches
to Increasing Medicaid Beneficiaries' Access to Dental
Services, Center for Health Care Strategies, November
2000.
[6] Centers for Medicare and Medicaid Services, Division of Intergovernmental Affairs.
Medicaid Services State by State, October 1, 1996.
CMS Publication 02155-97.
[7] Centers for Medicare and Medicaid Services, Division of Intergovernmental Affairs.
Medicaid Services State by State, October 1, 1996.
CMS Publication 02155-97.
[8] The Academy of Pediatric
Dentistry, the American Dental Association, the American
Public Health Association and the Bright Futures Project
all have adopted periodicity schedules by age. Currently,
each one recommends the first dental visit be scheduled
at the time of the child's first birthday.
[9] CMS, "Medicaid
and School Health: A Technical Assistance Guide,"
August 1997. Available at www.cms.gov/medicaid/scbintro.htm.
[10] Section 1902(a)(30)(A)
of the Social Security Act codified as 42 U.S.C.A.ยง1396a(a)(30)(A)
[11] These strategies are
listed in "1999 Survey on Access to Dental Care
for Medicaid-Enrolled Children," by Erin Nagy,
American Public Human Services Association. July 2000.
[12] Medicaid Survey on
Barriers to Medicaid Enrollment, Kaiser Commission
on Medicaid and the Uninsured, 1999.
[13] "CHIP Program
Enrollment: December 1998 to December 1999,"
Kaiser Commission on Medicaid and the Uninsured. Publication
2195 (July 2000).
[14] CMS, Letter to State
Medicaid Directors, "Guidance on Proposed Demonstration
Projects under Section 1115 Authority," July
31, 2000. Available at: cms.hhs.gov/schip/ch73100.asp
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