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A. Conan Davis National Dental Summary

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  • 1. National Medicaid Dental Review Summary November 14, 2008
  • 2. Background
    • Despite improvement in the dental status of children over the past several decades in the US, poor children suffer twice as much dental caries as more affluent children and their decay is more likely to remain untreated (2000 Surgeon General’s Report)
    • 25% of US children are living below the federal poverty level (annual income for a family of four at $17,050 in 2000 – now $21,200 in 2008)
  • 3. Background Continued:
    • The GAO noted in 2000 that “analysis of key dental health indicators…showed large disparities between low-income groups and their higher-income counterparts”.
    • A review of the 416 EPSDT reports from 2003 revealed that the national average for providing dental services was 30% of eligible Medicaid children.
    • The average for 2006 was 33%.
  • 4. Factors to Consider
    • Low number of participating providers
    • Low reimbursement rates for providers
    • Problems with broken appointments
    • Administrative barriers for providers
    • Lack of beneficiary education regarding the importance of dental health care services.
  • 5. US Dental Expenditures 2006
    • Total US dental spending = $90 Billion
    • Total spent by Private Insurance = $42.7 Billion
    • Total out of pocket dental spending = $40.1 Billion
    • Total dental spending by Medicare = $100 million
    • Total dental spending by Medicaid = $6.2 Billion.
    • (CMS Health Accounts Data)
  • 6. February 2007- November 2008
    • Two Children Died as a Result of Dental Infections
    • Three Congressional Oversight Hearings Held
    • GAO Medicaid Dental Studies Conducted
    • CMS Medicaid Dental EPSDT State Reviews Conducted
  • 7. = no Medicaid dental review = Medicaid dental review conducted Date 11/14/2008
  • 8. 31 31% 507,946 155804 Maryland 32 30% 1,085,180 325592 Michigan 33 29% 85,669 24973 Delaware 34 28% 4,562,231 1286493 California 35 28% 777,212 214399 Louisiana 36 27% 2,079,460 568963 New York 37 27% 1,111,384 301965 Pennsylvania 38 27% 405,965 108684 Arkansas 39 26% 96,063 25125 DC 40 26% 582,257 151026 New Jersey 41 25% 61,369 15066 Montana 42 24% 664,330 157869 Missouri 43 21% 498,162 105394 Wisconsin 44 21% 1,691,146 352741 Florida 45 20% 155,354 30647 Nevada 46 19% 44,868 8478 North Dakota Rank Percent Receiving a Dental Service Total Eligibles (line 1) Total Number of Dental Services (line 12a) State
  • 9. State Review Preparation
    • Developed Review Protocol for Consistent Results
    • Established Review Teams
    • Teams Consisted of CMS Regional Office and Central Office staff
    • Training Held for Review Teams
  • 10. Scope of Reviews
    • Teams interviewed the State Medicaid Agency in all States as well as a non-representative sample of Dental providers.
    • Also interviewed (varied by State):
    • State EPSDT Coordinators
    • State or County Public Health Officials
    • State Dental Staff
    • State Dental Associations
    • MCO Officials
  • 11. “A Finding”
    • A “finding” was noted when an identified issue rose to the level of the State potentially being out of compliance with federal law or regulations.
  • 12. Examples of Findings
    • 42 CFR 438.206 – requirement not met for timely dental access standards or lack of monitoring provider networks for adequacy.
    • 1905(r)(3) – States out of compliance with dental periodicity schedule requirement.
    • 1905(r)(5) – A State was limiting medically necessary EPSDT services.
  • 13. Overarching Issues Observed
    • Lack of informing recipients about EPSDT and Dental Services.
    • No clear document outlining Dental Services in many States.
    • Providers characterized Medicaid administrative processes as “burdensome” in many States.
    • Lack of monitoring provider distribution and/or recruitment.
  • 14. Overarching Issues Continued:
    • Provider lists not regularly updated in many States.
    • Many States not informing recipients about Dental Periodicity Schedule.
    • Many States lacked utilization data on Dental Services.
    • Lack of transportation assistance in some States.
  • 15. Some Examples of Recommendations Made by CMS
    • States should track which children have not received services and take steps to ensure access to Dental Care.
    • States should consider innovative approaches to delivering Dental Services.
    • States should consider working with State Leaders to develop incentives and encouragement for expanding provider enrollment in Medicaid.
    • States should ensure recipients receive reminders for periodic Dental Services.
  • 16. Some Concerns and Issues Observed
    • Dental care does not appear to be a priority for many Medicaid-Eligible families – revealing a need for education.
    • Many States do not make dental specific information available to beneficiaries.
    • Many dentists interviewed indicated their Medicaid patients needed more preventive dental education than routinely provided.
    • Missed appointments was a continual theme observed. Most providers made several attempts to improve this problem, but it continues.
    • Below market dental fees was mentioned by most providers as a concern and an issue.
  • 17. Promising Practices Observed
    • Selected counties in one State were observed to have increased access to Dental Services through use of mobile dental vans.
    • An FQHC in one State cultivated an atmosphere of mutual respect to encourage compliance with dental appointments to increase access.
    • One State had a 90% compliance rate for their Head Start population.
    • Several States reduced administrative burdens for providers by reducing prior authorization requirements and using Administrative Services Organization (ASO) contracts to administer the dental program.
  • 18. Notable Practices Observed
    • One State posts their provider manual and updates online.
    • “ Shared medical (and dental) appointments” was found in one practice.
    • One provider teaches children to co-teach others through a program called “Dental Detectives”.
    • One State’s Medical Director was a Dentist and this had a positive effect on communications between the dental program and other areas in the Agency.
  • 19. Closing Remarks
    • Most States knew they needed improvement and many were taking steps to improve dental care access.
    • There are some innovative programs and pilot projects making improvement in dental access, but many of these are not state-wide.
    • All States expressed concern for their Medicaid-eligible children’s dental care and plan to continue working to improve access.
  • 20.
    • For more information please contact:
    • A. Conan Davis, DMD MPH
    • Chief Dental Officer
    • CMS
    • [email_address]