Medicaid:

State and Federal Actions Have Been Taken to Improve Children's Access to Dental Services, but Gaps Remain

GAO-09-723: Published: Sep 30, 2009. Publicly Released: Oct 7, 2009.

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Children's access to Medicaid dental services is a long-standing concern. The tragic case of a 12-year-old boy who died from an untreated infected tooth that led to a fatal brain infection renewed attention to this issue. He was enrolled in Medicaid--a joint federal and state program that provides health care coverage, including dental care, for 30 million low-income children--but, like many children in Medicaid, he experienced difficulty finding a dentist who would treat him. At the federal level, the Centers for Medicare & Medicaid Services (CMS), an agency within the Department of Health and Human Services (HHS), oversees Medicaid. In this report, GAO examined (1) state strategies to monitor and improve access to dental care for children in Medicaid and (2) CMS actions since 2007 to improve oversight of Medicaid dental services for children. GAO surveyed all state Medicaid programs and interviewed state and federal officials, and dental researchers and associations

State Medicaid programs reported that they use multiple strategies to monitor and improve access to dental services for children, but problems persist. Most states responding to our survey use a variety of tools, such as examining claims and utilization data, to monitor the provision of dental services to children in Medicaid. Although all 21 states that provide Medicaid dental services through managed care organizations (MCO) reported that they set measurable access standards for MCOs, 14 states reported that MCOs do not meet all of the state's dental access standards. Almost all states described initiatives to improve access to dental services, including simplifying claims processing, increasing reimbursement rates, recruiting providers, and educating beneficiaries. Nonetheless, access rates remain low and states reported that long-standing barriers hinder further improvement. Since May 2007, CMS has taken steps to strengthen its oversight of Medicaid dental services for children, but gaps remain. For example, CMS reviews of Medicaid dental services in 17 states identified a number of concerns and made recommendations for improvement. Nonetheless, at the time of our review CMS did not plan to perform more reviews, even though other states had utilization rates well below HHS's 2010 target for low-income children receiving a preventive dental service. CMS also provided guidance to states and facilitated collaboration among stakeholders, but states reported needing more CMS support, including guidance on setting dental payment rates, on quality initiatives, and on promoting outreach. States also reported wanting more information on other states' efforts to improve dental utilization.

Status Legend:

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  • Review Pending-GAO has not yet assessed implementation status.
  • Open-Actions to satisfy the intent of the recommendation have not been taken or are being planned, or actions that partially satisfy the intent of the recommendation have been taken.
  • Closed-implemented-Actions that satisfy the intent of the recommendation have been taken.
  • Closed-not implemented-While the intent of the recommendation has not been satisfied, time or circumstances have rendered the recommendation invalid.
    • Review Pending
    • Open
    • Closed - implemented
    • Closed - not implemented

    Recommendations for Executive Action

    Recommendation: To strengthen monitoring of state Medicaid dental services for children and help states improve children's access to Medicaid dental services, the Administrator of CMS should develop a plan to review dental services for Medicaid children in all states with low utilization rates, such as those not meeting HHS's Healthy People 2010 targets.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

    Status: Closed - Implemented

    Comments: In October 2009, the Director of CMS's Center for Medicaid and State Operations testified that CMS concurred with GAO's recommendation, recognized the need to continue the state review process, and had undertaken a number of activities taken action to improve access to Medicaid dental services for children. Subsequent to the hearing, CMS described plans to review states with low dental utilization through (1) setting oral health goals for states, (2) requiring states to report dental utilization, and (3) measuring progress and identifying gaps in state Medicaid dental programs. Specifically CMS's April 2011 Oral Health Strategy indicated that two national oral health goals for children, increasing children's utilization of preventive dental services by at least ten percentage points nationwide and increasing the rate of children ages 6-9 who receive a dental sealant, would be applied at the state level with the intent that corresponding state goals would drive the achievement of national goals. CMS also issued a technical brief in February 2012 to assist states in the collection and reporting of the two initial core set dental measures that affect the oral health of children. Finally, based on data provided by states, CMS has calculated baseline and goal percentages for each state and monitored key indicators of children's access to Medicaid dental services in each state. CMS also reported plans to identify barriers to access and provide technical assistance to states to help improve access to Medicaid dental services.

    Recommendation: To strengthen monitoring of state Medicaid dental services for children and help states improve children's access to Medicaid dental services, the Administrator of CMS should ensure that states found to have inadequate MCO dental provider networks take action to strengthen these networks.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

    Status: Open

    Comments: In commenting on a draft of our report, CMS agreed that states found to have inadequate MCO dental networks should be required to address this problem. CMS stated that in cases where an inadequate network is identified, CMS requires state to impose a corrective action plan on the managed care entity to require an expansion of its dental network, and that if the problem is not corrected within a reasonable timeframe, CMS could require the State to permit enrollees to access dental services outside of the managed care network.

    Recommendation: To strengthen monitoring of state Medicaid dental services for children and help states improve children's access to Medicaid dental services, the Administrator of CMS should work with stakeholders to develop needed guidance on topics of concern to states.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

    Status: Closed - Implemented

    Comments: In an October 7, 2009 hearing, the Director of CMS's Center for Medicaid and State Operations cited our recommendation and testified that, in response, CMS was actively engaged with a range partners by way of CMS's Oral Health Technical Assistance Group, meetings with stakeholders, and ongoing workgroups. Since then, CMS has developed and shared additional guidance to help states improve access to Medicaid dental services for children, including a February 2012 technical brief to assist states in the collection and reporting of the two initial core set dental measures that affect the oral health of children. According to the brief, it was the first of a series of documents designed to help states collect, report, and use quality measures to improve access to oral health services in the Medicaid and CHIP programs. In addition, CMS' April 2011 Oral Health Strategy described developing state-specific action plans and identified potential strategies for state to implement. For example, one specific proposal included actions to reduce the administrative burden on dental providers, such as to: simplify and expedite the provider enrollment process; streamline or remove the prior authorization requirement for most procedures; make information about covered services easily available online; create opportunities for dialogue among managed care organizations, providers, state and local dental societies, about opportunities for administrative simplification; inform dentists and managed care organizations promptly of changes to patient contact information to ensure continuity of care; and create a dental director position in the Medicaid or public health agency. Finally, in a series of informational seminars called learning labs in 2013, CMS dental officials provided guidance to improve the delivery of Medicaid dental services. For example, in a January 2013 learning lab, CMS provided step-by-step guidance on establishing a quality improvement process for Medicaid and CHIP oral health programs, and provided references to a number of oral health quality resources.

    Recommendation: To strengthen monitoring of state Medicaid dental services for children and help states improve children's access to Medicaid dental services, the Administrator of CMS should identify ways to improve sharing of promising practices among states.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

    Status: Closed - Implemented

    Comments: CMS has taken a number of actions to share promising practices among states and other stakeholders. On June 15, 2012 CMS issued an informational bulletin, indicating that it would be providing technical assistance to states in an effort to identify and share promising practices states had used to increase children?s access to oral health care. CMS also launched a series of informational seminars, called learning labs, that provided states an opportunity to share promising practices they had implemented. For example, CMS's learning labs in 2012 and 2013 covered topics such as developing a state action plan using state data, successful beneficiary outreach strategies, engaging more general dentists to care for young children that CMS highlighted promising practices in several states. In addition, the Executive Director of the Medicaid-CHIP State Dental Association presented information on best practices and quality of care. Finally, CMS also provides links to dental resources, including promising practices, on its website.

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