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entitled 'Medicaid: State and Federal Actions Have Been Taken to 
Improve Children's Access to Dental Services, but More Can Be Done' 
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Before the Subcommittee on Domestic Policy, Committee on Oversight and 
Government Reform, House of Representatives: 

United States Government Accountability Office: 

For Release on Delivery: 
Expected at 2:00 p.m. EDT:
Wednesday, October 7, 2009: 


State and Federal Actions Have Been Taken to Improve Children's Access 
to Dental Services, but More Can Be Done: 

Statement of Katherine M. Iritani: 

Acting Director, Health Care: 


[End of section] 

Mr. Chairman and Members of the Subcommittee, 

I am pleased to be here today as you examine federal and state efforts 
to improve access to dental services by children in Medicaid (a joint 
federal and state program that provides health care coverage, including 
dental care, for low-income children). Dental disease remains a 
significant problem for children in Medicaid. Although dental services 
are a mandatory benefit for the 30 million children served by Medicaid, 
[Footnote 1] these children often experience elevated levels of dental 
problems and have difficulty finding dentists to treat them. In 
testimony before your Subcommittee last September, we reported that 
children in Medicaid were almost twice as likely to have untreated 
cavities as children with private insurance and that the percentage of 
children in Medicaid who received any dental care was far below the 
Department of Health and Human Service's (HHS) target for low-income 
children.[Footnote 2] Concerns about low-income children's poor oral 
health, inadequate access to dental services, low payment rates for 
dental services, and insufficient federal and state efforts to address 
oral health access problems are long-standing. During subcommittee 
hearings in May 2007 and February 2008, you raised concerns about the 
effectiveness of federal oversight of state Medicaid dental services by 
the Centers for Medicare & Medicaid Services (CMS), the agency that 
oversees Medicaid at the federal level. 

My remarks today are based on our report, released at this hearing, 
Medicaid: State and Federal Actions Have Been Taken to Improve 
Children's Access to Dental Services, but Gaps Remain.[Footnote 3] This 
report was prepared at the request of the subcommittee and 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. To identify state 
strategies to monitor and improve children's access to Medicaid dental 
services, we conducted a Web-based survey of state Medicaid directors 
in all 50 states and the District of Columbia (we refer to the District 
of Columbia as a state in this report)--all 51 responded to our survey. 
The survey included questions on the methods states have used for 
promoting and monitoring dental utilization, statewide goals for the 
delivery of dental services, and the federal support provided to states 
for the provision of Medicaid dental services. We also reviewed 
contracts between state Medicaid programs and nine large managed care 
organizations (MCO) to identify certain dental provisions concerning 
network adequacy and access standards.[Footnote 4] To examine CMS's 
oversight of state Medicaid dental services for children, we 
interviewed CMS officials, dental associations, and key stakeholders; 
reviewed federal laws, regulations, and CMS guidance; and analyzed data 
used by CMS to monitor provision of Medicaid dental services. Our work 
was performed in accordance with generally accepted government auditing 

State Medicaid Programs Reported They Employ Multiple Strategies to 
Monitor and Improve Access to Medicaid Dental Services, but Problems 

All 51 states responding to our survey reported that they monitor the 
provision of dental care to Medicaid-enrolled children--often using 
three or more methods. Common methods included collecting utilization 
data, conducting surveys of oral health, and monitoring dental 
claims.[Footnote 5] States also reported using various measures to 
assess children's access to Medicaid dental services, including the 
percentage of children who had a dental visit in the previous year, the 
percentage of children who had not visited a dentist in the last 3 
years, and the percentage of dentists in the state who treat children 
in Medicaid. Forty-two states also reported that they have set at least 
one statewide dental utilization goal related to the provision of 
children's dental care in Medicaid. Commonly reported goals include the 
percentage of children receiving any dental care in a given period 
exceeding a certain threshold, the ratio of participating dental 
providers to Medicaid children exceeding a certain threshold, and the 
percentage of children who report difficulty finding dental care fall 
below a certain threshold. 

States' oversight of MCO provider networks varied. All 21 states that 
provide Medicaid dental services through MCOs reported that they set 
measurable access standards for MCOs, but more than half also reported 
that MCOs in their state do not meet any, or only meet some, of the 
state's dental access standards. Common MCO access standards include 
maximum waiting times for appointments, maximum travel time or distance 
to the dentist's office, and minimum provider-to-patient ratios. Twelve 
of the 21 states reported that they routinely verify that MCO providers 
accept new Medicaid patients. Two states did not report taking any 
action to verify MCO provider networks. Although 17 states reported 
that they used incentives or penalties to encourage the MCOs to meet or 
exceed state standards, potential incentives or penalties did not 
always produce the desired result. For example, one state reported MCOs 
had not met any of the established standards even though MCOs could be 
paid a bonus if they met some or all of the standards. Similarly, other 
states reported that only some standards were being met, despite 
potential financial penalties for MCOs that did not meet all of the 
state's standards. Our review of nine MCO contracts illustrates 
variations in the standards that states established for MCOs concerning 
network adequacy and access measures. For example, some, but not all, 
contracts specified a maximum number of Medicaid enrollees per dental 
provider--one contract specified a county-level maximum of 486 
enrollees per dental provider, while other contracts did not specify 
such a maximum. 

Nearly all states reported that they had undertaken initiatives to 
improve children's access to Medicaid dental services, but persistent 
barriers remain. For example, states reported simplifying claims 
processing, increasing reimbursement rates, recruiting providers, and 
educating beneficiaries. Although some states reported limited success, 
Medicaid dental utilization rates remain low. CMS data show that the 
national average Medicaid dental utilization rate for children had 
improved from 27 percent in 2000 to 35 percent in 2007--but in 2007, 
only 1 state reported a dental utilization rate above 50 percent and 12 
states remained below 30 percent. Forty-eight states reported that the 
principal barriers that contributed to the low use of dental services 
by Medicaid beneficiaries in 2000--including low provider participation 
rates, administrative burdens, and insufficient funding--were impeding 
their current efforts. States also reported that access rates could be 
affected by barriers faced by children seeking dental services, such as 
finding a provider that accepts Medicaid, and barriers faced by 
providers serving Medicaid beneficiaries, such as beneficiaries not 
showing up for appointments (see figure 1). 

Figure 1: Barriers to Children Seeking Medicaid Dental Services and 
Barriers to Dental Providers Serving Medicaid Beneficiaries, as 
Reported by State Medicaid Programs: 

[Refer to PDF for image: illustration] 

To what extent do you believe the following are barriers to children 
receiving Medicaid dental services in your state? 

Finding a dental provider that accepts Medicaid: 
Major/moderate barrier: 43; 
Minor barrier: 6; 
Nor a barrier: 2. 

Transportation to and from the dental provider's office: 
Major/moderate barrier: 25; 
Minor barrier: 16; 
Nor a barrier: 10. 

Distance between the dental provider's office and the family's home: 
Major/moderate barrier: 34; 
Minor barrier: 14; 
Nor a barrier: 3. 

Parents are unable to take time off work: 
Major/moderate barrier: 27; 
Minor barrier: 22; 
Nor a barrier: 2. 

Other barriers: 
Major/moderate barrier: 23; 
Minor barrier: 1; 
Nor a barrier: 7. 

To what extent do you believe the following are barriers to dental 
providers beginning to serve or serving more Medicaid beneficiaries? 

Low reimbursement rates: 36; 
Major/moderate barrier: 9; 
Minor barrier: 6. 
Nor a barrier: 

Administrative requirements: 
Major/moderate barrier: 28; 
Minor barrier: 17; 
Nor a barrier: 6. 

Limited capacity to accept new patients: 
Major/moderate barrier: 30; 
Minor barrier: 13; 
Nor a barrier: 8. 

Beneficiary does not show up for appointments: 
Major/moderate barrier: 45; 
Minor barrier: 6; 
Nor a barrier: 0. 

Beneficiary does not follow treatment plan as advised by the provider: 
Major/moderate barrier: 30; 
Minor barrier: 20; 
Nor a barrier: 1. 

Other barriers: 
Major/moderate barrier: 14; 
Minor barrier: 2; 
Nor a barrier: 8. 

Source: GAO (Survey of state Medicaid directors conducted between 
December 2008 and January 2009). 

[End of figure] 

CMS Has Taken Action to Improve Federal Oversight of State Medicaid 
Dental Services for Children, but Gaps Remain: 

Responding to concerns expressed by your subcommittee about CMS 
oversight of state Medicaid dental services, CMS has taken a number of 
actions since May 2007 to strengthen its oversight of Medicaid dental 
services for children, but gaps remain in the agency's efforts. CMS 
actions include the following:[Footnote 6] 

* Focused dental reviews in 17 states identified significant concerns, 
but CMS did not plan additional reviews.[Footnote 7] Between October 
2007 and May 2008, CMS conducted a series of focused dental reviews in 
17 states.[Footnote 8] CMS identified concerns in all 17 states it 
reviewed, including multiple findings in some states, and made 
recommendations to all states. In 11 states, CMS reported concerns that 
the states were not adhering to federal law or regulations. CMS also 
identified several promising practices to improve the delivery of oral 
health services, which it highlighted in its summary report.[Footnote 
9] Although CMS reviews identified shortcomings in state practices and 
identified needed improvements, CMS did not have plans at the time of 
our review to conduct focused dental reviews in additional states. CMS 
416 data from 2006 showed that 24 of the 34 states that CMS did not 
review reported dental utilization rates between 31 and 40 percent of 
eligible children having received any dental service in the prior year--
well below HHS's Healthy People 2010 goal of having 66 percent of low- 
income children under age 19 receive a preventive dental service. 
[Footnote 10] In addition, CMS did not require corrective action in 
states found to have inadequate MCO networks. CMS's focused dental 
reviews identified eight states that provided dental services through 
managed care that did not ensure that MCO provider networks were 
adequate to afford access to covered dental services. CMS made 
recommendations to strengthen MCO provider networks in all eight 
states; however, CMS did not require these states to take corrective 
action--rather, agency officials indicated they would follow up with 
states on the status of CMS's recommendations. 

* CMS established an Oral Health Technical Advisory Group and published 
a dental policy document, but states reported additional guidance was 
needed. In conjunction with the National Association of State Medicaid 
Directors, CMS established an Oral Health Technical Advisory Group to 
address issues related to oral health services. Advisory group projects 
include examining the effects of recent legislation on oral health 
programs, considering improvements to the CMS 416 annual reports, and 
improving materials used to inform beneficiaries of their Medicaid 
dental benefits. In addition, CMS posted a 16-page document on Medicaid 
dental policy issues on its Web site in September 2008. This document 
covered a variety of questions from states on topics including 
periodicity schedules, dental referral requirements, covered services, 
and patient cost sharing.[Footnote 11] Although CMS has taken action to 
provide some guidance to states, states report that additional guidance 
from CMS is needed. In response to our survey, nearly all states 
reported that additional CMS guidance could help them improve delivery 
of Medicaid dental services. States cited a need for additional 
information in several areas, including information on billing 
policies, establishing appropriate dental fee schedules, improving 
documentation and coding practices, and information on quality and 
preventive initiatives. 

* CMS has taken steps to improve communications with states and 
stakeholders, including sharing promising state dental practices, but 
states reported further collaboration was needed. From 2007 through 
2009, CMS held several meetings and conference calls with state dental 
representatives, provider associations, and other stakeholders to 
discuss issues concerning Medicaid dental services for children. Groups 
involved in CMS partnership activities included American Academy of 
Pediatric Dentistry, the American Association of Public Health 
Dentistry, the Association of State and Territorial Dental Directors, 
and the American Dental Association. CMS also posted "promising 
practices"--described by CMS as successful state programs that reflect 
innovative approaches to meeting common problems--on its Web site. As 
of May 2009, CMS had posted promising dental practices from Delaware, 
South Carolina, Tennessee, and Virginia. Although CMS has taken action 
to involve stakeholders and share promising dental practices, 37 states 
responding to our survey indicated a need for more information on other 
states' efforts to improve dental utilization. Eleven states reported 
that they were unaware of the promising practices posted on CMS's Web 
site and 26 states responding to our survey reported that their states 
had best practices that could be shared with other states, such as 
providing mobile dental vans, training and reimbursing physicians to do 
oral screens and apply fluoride varnish, and establishing a dental home 
for children. 

In conclusion, states and CMS have made concerted efforts to improve 
access to dental services for children in Medicaid. However, 
information on the oral health of and receipt of dental services by 
Medicaid children show that more needs to be done. Although many states 
have reported moderate increases in access to Medicaid dental services, 
states responding to our survey reported that low provider and 
beneficiary participation, and administrative burdens--many of the same 
factors that contributed to the low use of dental services in 2000-- 
still present barriers to access today. CMS's reviews of states' 
efforts have identified deficiencies in several state Medicaid 
programs, but CMS has not required corrective actions by states or 
planned additional dental reviews. In our report, we are making four 
recommendations to CMS to strengthen the agency's monitoring of state 
Medicaid dental services for children and help states improve 
children's access to Medicaid dental services. Our recommendations 
include developing a plan to review dental services for Medicaid 
children in all states with low utilization rates, ensuring that states 
found to have inadequate MCO dental provider networks take action to 
strengthen these networks, working with stakeholders to develop needed 
guidance on topics of concern to states, and identifying ways to 
improve sharing of promising practices among states. 

In commenting on a draft of our report being released today, CMS 
generally concurred with all four recommendations and described several 
initiatives planned or under way that would strengthen its oversight of 
state Medicaid dental services for children. CMS indicated that the 
agency was developing additional guidance and technical assistance to 
states on the provision of EPSDT services, with a particular focus on 
access to dental services. CMS also reported that its efforts to 
implement the Children's Health Insurance Program Reauthorization Act 
of 2009 would include a number of activities related to dental 
services, such as a new quality measure program and new reporting 

Mr. Chairman, this concludes my prepared remarks. I would be pleased to 
answer any questions you or other members of the subcommittee may have. 

For further information regarding this statement, please contact 
Katherine Iritani at (202) 512-7114 or at Contact 
points for our Offices of Congressional Relations and Public Affairs 
may be found on the last page of this statement. Kim Yamane, Assistant 
Director; Sarah Burton; Mollie Hertel; Sarah Marshall; Terry Saiki; and 
Teresa Tam also make key contributions to this statement. 

[End of section] 

Related GAO Products: 

Medicaid: State and Federal Actions Have Been Taken to Improve 
Children's Access to Dental Services, but Gaps Remain. [hyperlink,]. Washington, D.C.: September 
30, 2009. 

Medicaid: Extent of Dental Disease in Children Has Not Decreased, and 
Millions Are Estimated to Have Untreated Tooth Decay. [hyperlink,]. Washington, D.C.: September 
23, 2008. 

Medicaid: Extent of Dental Disease in Children Has Not Decreased. 
[hyperlink,]. Washington, 
D.C.: September 23, 2008. 

Medicaid: Concerns Remain about Sufficiency of Data for Oversight of 
Children's Dental Services. [hyperlink,]. Washington, D.C.: May 2, 

Medicaid Managed Care: Access and Quality Requirements Specific to Low- 
Income and Other Special Needs Enrollees. [hyperlink,]. Washington, D.C.: December 8, 

Medicaid and SCHIP: States Use Varying Approaches to Monitor Children's 
Access to Care. [hyperlink,]. 
Washington, D.C.: January 14, 2003. 

Medicaid: Stronger Efforts Needed to Ensure Children's Access to Health 
Screening Services. [hyperlink,
749]. Washington, D.C.: July 13, 2001. 

Oral Health: Factors Contributing to Low Use of Dental Services by Low- 
Income Populations. [hyperlink,]. Washington, D.C.: 
September 11, 2000. 

Oral Health: Dental Disease Is a Chronic Problem Among Low-Income 
Populations. [hyperlink,]. 
Washington, D.C.: April 12, 2000. 

Medicaid Managed Care: Challenge of Holding Plans Accountable Requires 
Greater State Effort. [hyperlink,]. Washington, D.C.: May 16, 

[End of section] 


[1] Low-income children eligible under a state Medicaid plan generally 
are entitled to coverage of screening, diagnostic, and treatment 
services--including dental services--under Medicaid's early and 
periodic screening, diagnostic, and treatment (EPSDT) benefit. 

[2] GAO, Medicaid: Extent of Dental Disease in Children Has Not 
Decreased, [hyperlink,] 
(Washington, D.C.: Sept. 23, 2008). 

[3] GAO, Medicaid: State and Federal Actions Have Been Taken to Improve 
Children's Access to Dental Services, but Gaps Remain, [hyperlink,] (Washington, D.C.: Sept. 30, 

[4] We obtained a non-generalizable sample of contracts from MCOs that 
covered dental services and that served the most Medicaid beneficiaries 
in nine states, including five states whose dental programs had been 
reviewed by CMS in 2008. 

[5] States are required to report annually to CMS on the provision of 
EPSDT services, including dental services. The annual EPSDT 
participation report, Form CMS-416, is the agency's primary tool for 
gathering data on the provision of dental services to children in state 
Medicaid programs. 

[6] See [hyperlink,] for 
additional information on the actions taken by CMS to improve its 
oversight of Medicaid dental services. 

[7] CMS focused reviews were designed to examine state efforts to 
improve children's dental utilization rates, assess state compliance 
with federal Medicaid statutes and regulations, and identify promising 
or notable state practices to improve the delivery of oral health 

[8] Fifteen of the 17 states reviewed had reported dental utilization 
rates below 30 percent in fiscal year 2006: Arkansas, California, 
Delaware, District of Columbia, Florida, Louisiana, Michigan, Missouri, 
Montana, Nevada, New Jersey, New York, North Dakota, Pennsylvania, and 
Wisconsin. In addition, Maryland was reviewed in October 2007 and 
Georgia was reviewed in May 2008 at the request of the subcommittee. 

[9] CMS, 2008 National Dental Summary, (January 2009) and Final Report 
on Maryland's Early and Periodic Screening, Diagnostic and Treatment 
(EPSDT) Program With a Focus on Dental Services for Children (Feb. 5, 

[10] Recognizing the importance of good oral health, HHS in 1990 
established oral health goals as part of its Healthy People 2000 
initiative; and in 2000 updated these oral health goals for 2010. These 
include goals related to oral health in children, for example, reducing 
the proportion of children with untreated tooth decay. Another goal 
relates to the Medicaid population: to increase the proportion of low- 
income children and adolescents under the age of 19 who receive any 
preventive dental service each year to 66 percent in 2010. See U.S. 
Department of Health and Human Services, Public Health Service, 
Progress Review: Oral Health (Feb. 7, 2008). 

[11] HHS, Centers for Medicare & Medicaid Services, Policy Issues in 
the Delivery of Dental Services to Medicaid Children and Their Families 
(Sept. 22, 2008); [hyperlink,] (accessed Oct. 6, 

[End of section] 

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