Oral Health Services
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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. 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.
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. 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
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
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
The issues in improving oral health and access to dental
services are complex and challenging to address. Barriers
1) Low or declining participation of dentists in State
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
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
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
(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.
(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
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. 
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
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.
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
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
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
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
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
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
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:
* 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
* 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
* 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
* 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
D. Ensuring that Eligible Persons are Enrolled
- Adults and children eligible for Medicaid
- Children eligible for the State Children's Health
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
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
- 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);
- 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
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.
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
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.
This would allow States to provide "family coverage"
as an extension of SCHIP coverage for children.
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
U.S. Department of Health and Human Services
Health Resources and Services Administration
Health Systems and Financing Group
5600 Fishers Lane, Room 10-29
Rockville, Maryland 20857
For copies of this document, contact:
HRSA Information Center
P.O. Box 2910
Merrifield, VA 22116
Se Habla Espanol
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.
 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.
 Edelstein B, Manski RJ,
Moeller JF. Pediatric Dental Visits During 1996: An
Analysis of Federal Medical Expenditure Survey. Pediatric
Dentistry, 22:17-20, 2000.
 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.
 P. Newachek, et.al., The
Unmet Health Needs of America's Children, Pediatrics
105(4): 989-997, April 2000.
 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
 Centers for Medicare and
Medicaid Services, Division of Intergovernmental Affairs.
Medicaid Services State by State, October 1, 1996. CMS
 Centers for Medicare and
Medicaid Services, Division of Intergovernmental Affairs.
Medicaid Services State by State, October 1, 1996. CMS
 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.
 CMS, "Medicaid and
School Health: A Technical Assistance Guide," August
1997. Available at www.cms.gov/medicaid/scbintro.htm.
 Section 1902(a)(30)(A)
of the Social Security Act codified as 42 U.S.C.A.§1396a(a)(30)(A)
 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.
 Medicaid Survey on Barriers
to Medicaid Enrollment, Kaiser Commission on Medicaid
and the Uninsured, 1999.
 "CHIP Program Enrollment:
December 1998 to December 1999," Kaiser Commission
on Medicaid and the Uninsured. Publication 2195 (July
 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