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Most Children With Medicaid in Four States Are Not Receiving Required Dental Services

WHY WE DID THIS STUDY

Medicaid is the primary source of dental coverage for children in low-income families and provides access to dental care for approximately 37 million children. However, access to dental care for children with Medicaid has been a longstanding concern. When children lack dental care, untreated decay and infection in their mouths can result in preventable emergency room visits or more complicated and expensive dental and medical interventions later in life. Medicaid provides dental services to children through the Early and Periodic Screening, Diagnostic, and Treatment program. Under this program, States are required to cover all medically necessary dental services and these services must be provided at the intervals specified in States' pediatric dental periodicity schedules.

HOW WE DID THIS STUDY

This study focuses on four States: California, Indiana, Louisiana, and Maryland. We analyzed Medicaid dental claims with service dates in 2011 and 2012, analyzed Medicaid beneficiary enrollment files, and conducted structured interviews with State officials. We focused our analysis on three required dental services-biannual oral exams, dental cleanings, and fluoride treatments-for children continuously enrolled in Medicaid for 2 years.

WHAT WE FOUND

We found that three out of four children did not receive all required dental services, with one in four children failing to see a dentist at all. All four States reported that they do not routinely track whether children are receiving all the required services. In addition, two of the four States had policies that do not allow payment for particular services in accordance with their periodicity schedules. The States we reviewed reported facing shortages of participating dental providers and challenges in educating families about the importance of regular dental care. While the States reported that they employ a variety of strategies to address these problems and CMS has taken some positive steps in this area, we continue to have concerns that children are not receiving required dental services.

WHAT WE RECOMMEND

We provided CMS with eight recommendations designed to monitor and ensure that children with Medicaid receive all of their EPSDT required dental services. Specifically, CMS should (1) develop a comprehensive plan to increase the number of children who receive required services; (2) develop benchmarks for dental services and require States to create mandatory action plans to meet them; (3) work with States to identify areas with limited providers and the barriers preventing providers from participating in Medicaid; (4) work with States to analyze the effects of Medicaid payments on access to dental providers; (5) work with States to educate families about the importance of dental care and to encourage ongoing relationships between children and their dentists; (6) work with States to track children's utilization of required dental services; (7) identify and share effective strategies with States; and (8) ensure that States pay for services in accordance with their periodicity schedules.

CMS concurred either fully or partially with all but one of our recommendations. With regard to our sixth recommendation-with which CMS did not concur-CMS does not agree that it is necessary to require additional data on dental services beyond the data collected on Form CMS 416. With regard to our second recommendation-with which CMS partially concurred-CMS does not agree that it is necessary to require mandatory action plans for meeting benchmarks for dental services. Also, in response to the first recommendation, CMS argued that children's dental services are not "one size fits all" and that a child who receives an exam may not need a second one during the year. While we agree that services should be customized, we do not agree that children with Medicaid should receive services less frequently than at the minimum frequency set by States in their periodicity schedules, which for the four States we reviewed is twice per year.

Copies can also be obtained by contacting the Office of Public Affairs at Public.Affairs@oig.hhs.gov.

Download the complete report.

Office of Inspector General, U.S. Department of Health and Human Services | 330 Independence Avenue, SW, Washington, DC 20201