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entitled 'Medicaid: State and Federal Actions Have Been Taken to 
Improve Children's Access to Dental Services, but Gaps Remain' which 
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Report to Congressional Requesters: 

United States Government Accountability Office: 
GAO: 

September 2009: 

Medicaid: 

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

GAO-09-723: 

GAO Highlights: 

Highlights of GAO-09-723, a report to congressional requesters. 

Why GAO Did This Study: 

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. 

What GAO Found: 

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. 

Figure: Number of States Reporting Barriers to Children Receiving 
Medicaid Dental Services and Barriers to Dental Providers Serving 
Medicaid Beneficiaries: 

[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] 

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. 

What GAO Recommends: 

GAO recommends that CMS develop a plan to review dental services in 
states with low utilization rates, ensure that states found to have 
inadequate managed care provider networks strengthen their networks, 
develop additional guidance, and identify ways to improve sharing of 
promising practices among states. CMS generally concurred with GAO’s 
recommendations. 

View [hyperlink, http://www.gao.gov/products/GAO-09-723] or key 
components. For more information, contact Alicia Puente Cackley, (202) 
512-7114, cackleya@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

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

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

Conclusions: 

Recommendations for Executive Action: 

Agency Comments: 

Appendix I: Methods Used by State Medicaid Programs to Monitor the 
Statewide Provision of Dental Care to Children: 

Appendix II: Statewide Utilization Goals for the Provision of Dental 
Care to Children in State Medicaid Programs: 

Appendix III: Access Standards Set by the 21 States That Provide Dental 
Services through Managed Care Organizations (MCOs): 

Appendix IV: Extent to Which Managed Care Organizations (MCO) Meet 
State Standards and State Verification of MCO Networks: 

Appendix V: CMS Promising Practices and State Reported Best Practices: 

Appendix VI: Comments from the Department of Health and Human Services: 

Appendix VII: GAO Contact and Staff Acknowledgments: 

Related GAO Products: 

Tables: 

Table 1: Number of State Medicaid Programs Employing Certain Methods to 
Monitor the Provision of Medicaid Dental Services to Children: 

Table 2: Number of State Medicaid Programs Employing Certain Measures 
to Monitor Children's Access to Dental Services, by Service Delivery 
Method: 

Table 3: Number of State Medicaid Programs That Reported Setting 
Statewide Utilization Goals for the Provision of Dental Services to 
Children: 

Table 4: MCO Access Standards Set by the 21 State Medicaid Programs 
That Provide Dental Services to Children under Managed Care: 

Table 5: Outreach Actions Taken to Educate Families on the Importance 
of Dental Care, as Reported by State Medicaid Programs: 

Table 6: Actions to Recruit Dental Providers since 2000, as Reported by 
State Medicaid Programs: 

Table 7: Barriers That Hinder State Initiatives to Improve Access to 
Medicaid Dental Services, as Reported by State Medicaid Programs: 

Table 8: Description of State-Reported Best Practices for Improving 
Dental Care for Children in Medicaid: 

Figure: 

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

Abbreviations: 

AAPD: American Academy of Pediatric Dentistry: 

CMS: Centers for Medicare & Medicaid Services: 

EPSDT: Early and Periodic Screening, Diagnostic, and Treatment: 

HHS: Department of Health and Human Services: 

MCO: managed care organization: 

NASMD: National Association of State Medicaid Directors: 

SCHIP: State Children's Health Insurance Program: 

[End of section] 

United States Government Accountability Office: 
Washington, DC 20548: 

September 30, 2009: 

The Honorable Dennis Kucinich: 
Chairman: 
Subcommittee on Domestic Policy: 
Committee on Oversight and Government Reform: 
House of Representatives: 

The Honorable Elijah Cummings: 
House of Representatives: 

Dental disease is a significant problem for children in Medicaid, a 
joint federal and state program that provides health care coverage, 
including dental care, for low-income children. 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. 
Attention to this subject became more acute after the widely publicized 
case of a 12-year-old boy who died in 2007 as a result of an untreated 
infected tooth, even though he was entitled to dental coverage under 
Medicaid. In testimony before the Subcommittee on Domestic Policy of 
the Committee on Oversight and Government Reform[Footnote 2] last year, 
we reported that children in Medicaid were almost twice as likely to 
have untreated cavities as children with private insurance.[Footnote 3] 
We also reported that the percentage of children in Medicaid ages 2 
through 18 who received any dental care--37 percent according to 
national survey data--was far below the Department of Health and Human 
Services' (HHS) target of having 66 percent of low-income children 
under age 19 receive a preventive dental service. 

Concerns about low-income children's poor oral health and 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. Our reports dating back to 2000 highlight 
the problem of chronic dental disease and the factors that contribute 
to low use of dental services by low-income populations, including 
children in Medicaid.[Footnote 4] A major concern has been the adequacy 
of the network of dental providers who serve low-income populations, 
particularly for children who receive Medicaid dental services under 
managed care. This concern stems in part from investigations by the 
Subcommittee that found that some managed care organizations (MCO) did 
not have adequate provider networks--that is, a sufficient number and 
mix of dental providers--to provide timely access to covered Medicaid 
dental services. In September 2000, we reported that while several 
factors contributed to the low use of dental services among low-income 
persons who had coverage, the major factor was difficulty finding 
dentists to treat them.[Footnote 5] During a Subcommittee hearing in 
May 2007, concerns were raised about federal oversight of state 
Medicaid dental services for children by the Centers for Medicare & 
Medicaid Services (CMS), the agency that oversees Medicaid at the 
federal level. 

You expressed concern about the state and federal actions taken to 
ensure children in Medicaid receive recommended dental services. This 
report examines (1) the strategies that state Medicaid programs employ 
to monitor and improve access to dental services for children in 
Medicaid and (2) CMS actions since 2007 to improve oversight of state 
Medicaid dental services for children. To identify state strategies to 
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.[Footnote 6] The survey included both closed-ended 
and open-ended questions regarding dental services for children, the 
methods states have used for promoting and monitoring dental 
utilization (the use of dental services), statewide goals for the 
delivery of dental services, and the federal support provided to states 
for the provision of dental services. To establish the reliability of 
our survey data, we consulted with knowledgeable state officials in 
developing the survey and pre-tested the survey questions with Medicaid 
officials from two states. The survey was conducted from December 8, 
2008, through January 30, 2009. We received responses from all 50 
states and the District of Columbia. We reviewed survey responses for 
internal consistency and in certain cases where responses were absent, 
unclear, or inconsistent, we contacted state officials for 
clarification. We did not independently verify specific aspects of 
responses or the effectiveness of programs reported through the survey. 
We determined that the data submitted by states were sufficiently 
reliable for the purposes of our engagement. In addition to the Web- 
based survey, we reviewed studies and reports on state Medicaid dental- 
related initiatives and conducted a review of current literature to 
obtain information on these initiatives and on barriers to providing 
dental care in Medicaid. To describe contractual provisions between 
states and MCOs concerning network adequacy and timely access standards 
related to dental services for children, we obtained and reviewed a non-
generalizable sample of contracts from the MCOs that covered dental 
services and that served the most Medicaid beneficiaries in 9 states, 
including 5 states whose dental programs had been reviewed by CMS in 
2008.[Footnote 7] 

To examine CMS's oversight of state Medicaid dental services for 
children, we interviewed CMS officials; reviewed federal laws, 
regulations, and guidance that CMS provides to states; and interviewed 
key stakeholders, including the Medicaid/SCHIP Dental 
Association,[Footnote 8] the National Association of State Medicaid 
Directors (NASMD), and experts involved with pediatric dental issues. 
We also reviewed data used by CMS to monitor provision of dental 
services to children in state Medicaid programs, including information 
in annual reports submitted by states on the provision of dental and 
other services provided under Medicaid's early and periodic screening, 
diagnostic, and treatment (EPSDT) benefit. We also examined CMS's 
reviews of Medicaid dental programs in 17 states. To obtain states' 
perspectives of CMS oversight, we included several questions about 
CMS's guidance and activities in our survey of state Medicaid programs. 
We conducted this performance audit from July 2008 through August 2009 
in accordance with generally accepted government auditing standards. 
Those standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe that 
the evidence obtained provides a reasonable basis for our findings and 
conclusions based on our audit objectives. 

Background: 

In 2000, the Surgeon General noted that tooth decay is the most common 
chronic disease among children.[Footnote 9] Left untreated, the pain 
and infections caused by tooth decay can lead to problems in eating, 
speaking, and learning. Proper dental care can prevent tooth decay and 
associated problems that can lead to dental disease and even death. 
Research has shown that preventive dental care is cost effective and 
can make a significant difference in health outcomes. For example, a 
2004 study found that, over a 5-year period, low-income children who 
had their first preventive dental visit by age 1 had average dental- 
related costs of $262, compared to $546 for children who received their 
first preventive visit at age 4 through 5.[Footnote 10] 

The American Academy of Pediatric Dentistry (AAPD) recommends that each 
child see a dentist when the child's first tooth erupts and no later 
than the child's first birthday, with subsequent visits occurring at 6- 
month intervals or more frequently if recommended by a dentist. The 
early initial visit establishes a "dental home" for the child, creating 
an opportunity to build an ongoing relationship with a dental provider 
who can ensure comprehensive, continuously accessible care. 
Comprehensive dental visits can include both clinical assessments, such 
as for tooth decay and the need for sealants,[Footnote 11] and 
appropriate discussion and counseling for oral hygiene, injury 
prevention, and speech and language development, among other topics. 
Because resistance to tooth decay is determined partly by genetics and 
partly by behavior, delaying the onset of tooth decay may also reduce 
long-term risk for decay. 

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.[Footnote 12] 

At the federal level, CMS oversees Medicaid, which provides health care 
coverage for low-income families and aged, blind, and disabled people. 
CMS oversight includes monitoring state Medicaid programs, issuing 
guidance to states, and facilitating communication and collaboration 
among stakeholders. Medicaid provided health coverage for over 30 
million children under 21 in fiscal year 2008.[Footnote 13] The states 
operate their Medicaid programs within broad federal requirements and 
may contract with MCOs to provide Medicaid benefits. CMS estimated that 
in 2006 about 65 percent of Medicaid beneficiaries received benefits 
through some form of managed care.[Footnote 14] State Medicaid programs 
are required to cover certain populations and services under federal 
law. For instance, under the Medicaid EPSDT benefit, state Medicaid 
programs generally must provide coverage of dental screening, 
diagnostic, and related treatment services for all eligible Medicaid 
beneficiaries under the age of 21. Other federal requirements for the 
EPSDT benefit that are related to dental services include the 
following: 

* Developing dental periodicity schedules. State Medicaid programs have 
some flexibility in determining the frequency and timing of dental 
screenings covered for children under the EPSDT benefit. Under federal 
law, however, state Medicaid programs must provide these dental 
services at intervals that meet reasonable standards of dental practice 
as determined by the state after consultation with recognized dental 
organizations involved in children's health care.[Footnote 15] 
According to CMS guidance, as an alternative to developing a state- 
specific periodicity schedule, a state may adopt a nationally 
recognized dental periodicity standard, such as the schedule 
recommended by AAPD. CMS considers AAPD's periodicity schedule a model 
for comparison and it is published in CMS's Guide to Children's Dental 
Care in Medicaid.[Footnote 16] 

* Reporting on delivery of EPSDT services. Federal law requires states 
to report annually on the provision of EPSDT services, including dental 
services.[Footnote 17] The annual EPSDT participation report, Form CMS- 
416 (hereafter called the CMS 416), is the agency's primary tool for 
gathering data on the provision of dental services to children in state 
Medicaid programs. It captures data on the number of children who 
received a preventive dental service, a dental treatment service, or 
any dental service each year. Information on the CMS 416 report is used 
to calculate a state's dental utilization rate--the percentage of 
children eligible for EPSDT that received any dental service in a given 
year. 

Inadequate access to dental services for low-income children has been a 
longstanding concern. In April 2000, we reported that Medicaid 
beneficiaries and other low-income people had low rates of dental 
visits and high rates of dental disease relative to the rest of the 
population.[Footnote 18] In a September 2000 report, we identified 
factors influencing the access that low-income groups have to dental 
care: a primary factor was limited dentist participation in 
Medicaid.[Footnote 19] As part of its oversight of state Medicaid 
dental services for children, in January 2001 CMS issued a letter to 
state Medicaid directors indicating that, through a series of state 
reviews, CMS would increase its oversight activities and assess state 
compliance with statutory requirements. CMS highlighted four areas for 
review: outreach and administrative case management, adequacy of 
Medicaid reimbursement rates, increasing provider participation, and 
claims reporting and processing. CMS did not complete this initiative. 
In September 2008, we reported that the extent of dental disease in 
Medicaid-enrolled children had not decreased between 1988 through 1994 
and 1999 through 2004.[Footnote 20] We also reported that millions of 
Medicaid-enrolled children were estimated to have untreated tooth 
decay, and that children in Medicaid were often not receiving dental 
services. 

The American Recovery and Reinvestment Act of 2009 (Recovery Act) 
authorized an estimated $87 billion in additional federal Medicaid 
funding for states in the form of a temporary increase in the funds 
that the federal government contributes toward state Medicaid programs, 
including the provision of Medicaid dental services for children. The 
Recovery Act provides this money to states through a temporary, 27- 
month increase in the federal medical assistance percentage formula-- 
the formula that determines the federal share of a state's Medicaid 
service expenditures.[Footnote 21] In July 2009, we reported that the 
receipt of an increased federal share may reduce the states' share of 
expenditures for their Medicaid program, and states have reported using 
these available funds for a variety of purposes, such as maintaining 
program eligibility, covering increased Medicaid caseloads, and 
maintaining local health care reform initiatives.[Footnote 22] 

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

In response to our survey, most states reported using multiple 
strategies to monitor and improve access to Medicaid dental services, 
but they also reported that persistent barriers hinder improvements. 
All 21 states that provided Medicaid dental services under managed care 
arrangements reported that they set measurable access standards for 
MCOs, however 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. Further, some states reported that they do not routinely 
verify the adequacy of MCO provider networks. Almost all states 
described initiatives to recruit dental providers and enhance outreach 
to beneficiaries' families, but barriers persist and access rates 
remain low. 

State Medicaid Programs Reported They Use a Variety of Methods to 
Monitor Dental Services: 

In response to our survey, all 51 states reported that they monitor the 
provision of dental care to Medicaid-enrolled children, but how they do 
so varies. The majority (39 states) reported that they use multiple 
methods--often three or more--to monitor the provision of dental care. 
These methods included surveys of oral health, monitoring dental 
claims, and collecting utilization data (see table 1). See appendix I 
for a list of the monitoring methods reported by each state. 

Table 1: Number of State Medicaid Programs Employing Certain Methods to 
Monitor the Provision of Medicaid Dental Services to Children: 

Monitoring method: Track utilization by collecting CMS 416 data; 
Number of states (51 states): 50. 

Monitoring method: Use claims data and/or encounter data provided by 
MCOs; 
Number of states (51 states): 23. 

Monitoring method: Collect and analyze data from phone calls to the 
state or MCOs regarding concerns with dental care; 
Number of states (51 states): 16. 

Monitoring method: Collect and analyze data from beneficiary 
satisfaction surveys; 
Number of states (51 states): 16. 

Monitoring method: Use survey data to monitor problems obtaining needed 
dental services; 
Number of states (51 states): 11. 

Monitoring method: Use survey data to monitor oral health of children; 
Number of states (51 states): 7. 

Monitoring method: Other monitoring methods[A]; 
Number of states (51 states): 19. 

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

Note: States could select more than one monitoring method and may be 
counted in more than one category. 

[A] States reported using other methods to monitor the provision of 
Medicaid dental services, including generating ad hoc reports on 
various dental procedures and analyzing monthly budget reports by 
procedure code to monitor utilization trends. 

[End of table] 

States also reported using various measures to monitor children's 
access to Medicaid dental services. The most common reported measure-- 
used by 40 (of 51) states for their fee-for-service programs and by 18 
(of 21) states that also used managed care[Footnote 23]--was the 
percentage of children who had a dental visit in the previous year (see 
table 2). In the 21 states where both fee-for-service and managed care 
programs are used to provide dental services to Medicaid-enrolled 
children, state monitoring can vary by service delivery method. For 
example, one state reported that it monitors the percentage of dentists 
who treat children through its managed care program, but does not 
monitor the percentage of dentists who treat children through its fee- 
for-service program. Conversely, another state reported the opposite-- 
that it monitors this percentage for its fee-for-service program, but 
not for managed care. 

Table 2: Number of State Medicaid Programs Employing Certain Measures 
to Monitor Children's Access to Dental Services, by Service Delivery 
Method: 

Measure: The percentage of children who had a dental visit in the 
previous year; 
Fee-for-service (51 states): 40; 
Managed care (21 states)[A]: 18. 

Measure: The percentage of dentists who treat children in Medicaid; 
Fee-for-service (51 states): 36; 
Managed care (21 states)[A]: 14. 

Measure: The extent to which provision of dental services is 
concentrated among a small number of providers; 
Fee-for-service (51 states): 27; 
Managed care (21 states)[A]: 7. 

Measure: The percentage of children who did not visit a dentist in the 
last three years; 
Fee-for-service (51 states): 12; 
Managed care (21 states)[A]: 5. 

Measure: Other analyses of claims data, utilization data, or both; 
Fee-for-service (51 states): 19; 
Managed care (21 states)[A]: 8. 

Measure: Other monitoring efforts; 
Fee-for-service (51 states): 6; 
Managed care (21 states)[A]: 4. 

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

Note: States could select more than one monitoring measure and may be 
counted in more than one category. 

[A] Twenty-one of the 51 state Medicaid programs reported using both 
managed care and fee-for-service to deliver dental services to Medicaid 
beneficiaries in their state. 

[End of table] 

States reported setting statewide dental utilization goals related to 
the provision of children's dental services. In response to our survey, 
42 states reported that they have set at least one statewide 
utilization goal related to the provision of children's dental care in 
Medicaid and about half of these 42 states (20 states) have set three 
or more statewide goals (see table 3). Nine states reported they had no 
goals related to children's dental care. See appendix II for a list of 
the utilization goals reported by each state. 

Table 3: Number of State Medicaid Programs That Reported Setting 
Statewide Utilization Goals for the Provision of Dental Services to 
Children: 

Statewide dental utilization goal: The percentage of children receiving 
any dental care in a given time period exceeds a certain threshold; 
Number of states (51 states): 31. 

Statewide dental utilization goal: The percentage of children receiving 
dental preventive services, such as sealants, exceeds a certain 
threshold; 
Number of states (51 states): 25. 

Statewide dental utilization goal: The ratio of participating dental 
providers to Medicaid children (provider to beneficiary ratio) exceeds 
a certain threshold; 
Number of states (51 states): 17. 

Statewide dental utilization goal: The percentage of children receiving 
restorative procedures for oral health problems, such as tooth decay, 
exceeds a certain threshold; Number of states (51 states): 14. 

Statewide dental utilization goal: The percentage of children who 
report difficulty finding dental care falls below a certain threshold; 
Number of states (51 states): 11. 

Statewide dental utilization goal: Other state goals[A]; 
Number of states (51 states): 16. 

Total number of states that set at least one statewide utilization 
goal: 
Number of states (51 states): 42. 

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

Note: States could select more than one statewide dental utilization 
goal and may be counted in more than one category. 

[A] States reported other goals, including a target percent of children 
who are continually enrolled in Medicaid and receive appropriate follow-
up care, and increasing levels of provider participation. 

[End of table] 

All States with Managed Care Programs Reported They Set Measurable MCO 
Access Standards and about Half Routinely Verified Provider Networks: 

All of the 21 states that reported using managed care programs to 
deliver Medicaid dental services reported that they had established one 
or more measurable MCO access standards specific to each MCO dental 
network, such as specifying maximum waiting times for scheduling 
appointments or a minimum ratio of available providers to Medicaid 
beneficiaries (see table 4). However, more than half--14 of the 21 
states--reported that the MCOs either did not meet any, or only met 
some, of their standards. Seventeen states reported that they used 
incentives or penalties to encourage the MCOs to meet or exceed state 
standards. However, 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 if MCOs did not meet all of the state's 
standards. 

Table 4: MCO Access Standards Set by the 21 State Medicaid Programs 
That Provide Dental Services to Children under Managed Care: 

Dental access standards specific to MCO provider networks: Maximum 
waiting times when scheduling dental appointments; States using MCOs 
(21 states): 17. 

Dental access standards specific to MCO provider networks: Maximum 
waiting times when scheduling emergency dental appointments; 
States using MCOs (21 states): 16. 

Dental access standards specific to MCO provider networks: Maximum 
travel distances from beneficiaries' residences to the dental 
provider's office; 
States using MCOs (21 states): 15. 

Dental access standards specific to MCO provider networks: Maximum 
travel times from beneficiaries' residences to the dental provider's 
office; 
States using MCOs (21 states): 11. 

Dental access standards specific to MCO provider networks: Minimum 
provider to patient ratios (minimum number of dental providers for a 
given enrollment); 
States using MCOs (21 states): 6. 

Dental access standards specific to MCO provider networks: Other state 
standards[A]; States using MCOs (21 states): 10. 

Dental access standards specific to MCO provider networks: Total number 
of states that established one or more MCO dental access standard; 
States using MCOs (21 states): 21. 

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

Note: States could select more than one MCO access standard and may be 
counted in more than one category. 

[A] States reported other standards, such as identifying and managing 
beneficiaries who use emergency room facilities to obtain dental 
services. 

[End of table] 

State oversight of MCO provider networks varied. Approximately half of 
the states using managed care--12 of 21 states--reported contacting a 
selection of providers in their MCO provider networks on a regular 
basis to determine if they accept new Medicaid patients. Eighteen 
states using managed care reported that they examined the adequacy of 
their dental networks in response to a complaint or concern.[Footnote 
24] Two of the 21 states using managed care did not report taking any 
action to verify MCO provider networks in their state. See appendix III 
for a list of MCO standards set by states and appendix IV for a 
description of the extent to which MCOs meet state standards and the 
methods states use to verify that MCO dental providers accept children 
in Medicaid. 

State Medicaid agencies also set expectations for MCOs related to 
provider networks and access to services through the contracts they 
establish with the MCOs. We reported in 2001 that specific and 
comprehensive contract language helps ensure that MCOs know their 
responsibilities and that they can be held accountable for delivering 
covered services.[Footnote 25] Our review of contracts between states 
and nine large MCOs that provide Medicaid dental services illustrate 
variations in the specificity of the standards that states established 
in their contracts concerning network adequacy and access measures. 
Regarding one measure of network adequacy--the maximum number of 
beneficiaries per dental provider--some, but not all, contracts 
specified a maximum allowed number of Medicaid enrollees per dental 
provider. One contract, for example, specified a county-level maximum 
of 486 enrollees per dental provider, while other contracts did not 
specify any maximum. Standards related to timely access also varied; 
for example, one contract required that routine dental appointments be 
scheduled within 30 calendar days, or sooner if possible, while another 
contract required that routine dental appointments be scheduled within 
90 days of a formal request. Finally, the specificity of the contracts 
with regard to standards for the proximity of dental providers to 
beneficiaries varied. One contract, for example, specified a maximum 
travel time of 30 minutes to a provider, while another contract had no 
proximity standards. 

State Medicaid Programs Reported Efforts to Improve Access, but Also 
Reported That Persistent Barriers Hinder Further Improvement in 
Children's Access to Dental Care: 

Many of the 51 states we surveyed reported efforts to improve 
children's access to dental care, including efforts to provide outreach 
to the families of children in Medicaid and recruit dental providers. 
Forty-eight states reported that they have taken one or more actions to 
facilitate or encourage parents to take their children to a dentist, 
including publishing literature about the importance of oral health and 
establishing a hotline that families can call for help in finding a 
dentist (see table 5). Studies in the published literature have 
reported some successes in outreach programs. One such study reported 
on a state program where dental hygienist services provided in three 
schools resulted in an increase in the percentage of children who had 
seen a dentist at least once a year from 59 percent to 78 percent in 
the first year of the program.[Footnote 26] 

Table 5: Outreach Actions Taken to Educate Families on the Importance 
of Dental Care, as Reported by State Medicaid Programs: 

State actions to provide outreach to families: Issued literature to 
Medicaid families discussing the importance of oral health; 
States responding (51 states): 39. 

State actions to provide outreach to families: Established a hotline 
that families in Medicaid can call for help in finding a dental 
provider; 
States responding (51 states): 35. 

State actions to provide outreach to families: Translated literature 
about the importance of oral health into other languages; 
States responding (51 states): 29. 

State actions to provide outreach to families: Distributed an up-to- 
date list of dental providers who accept children in Medicaid; 
States responding (51 states): 24. 

State actions to provide outreach to families: Required MCOs to assist 
families in finding a dental provider for their children; 
States responding (51 states): 20. 

State actions to provide outreach to families: Launched a Web site for 
Medicaid families providing information about oral health care; 
States responding (51 states): 18. 

State actions to provide outreach to families: Required MCOs to provide 
literature to their beneficiaries about the importance of oral health; 
States responding (51 states): 18. 

State actions to provide outreach to families: Provided incentives to 
Medicaid families to bring their children to dental providers; 
States responding (51 states): 5. 

State actions to provide outreach to families: Paid for advertisements 
aimed at Medicaid families that promote the importance of oral health; 
States responding (51 states): 5. 

State actions to provide outreach to families: Other state actions[A]; 
States responding (51 states): 17. 

Total number of states that have taken one or more outreach action: 
States responding (51 states): 48. 

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

Note: States could select more than one action to provide outreach to 
families and may be counted in more than one category. 

[A] States reported other actions, such as outreach to families with 
children who have not received a dental service in the past year and 
free dental screening programs. 

[End of table] 

All but one of the 51 state Medicaid programs reported they have taken 
at least one action since 2000 to recruit Medicaid dental providers 
(see table 6), and some states provided evidence that their initiatives 
have enhanced their Medicaid dental provider networks. For example, one 
state Medicaid program implemented an initiative that included 
simplifying claims processing, increasing reimbursement rates, 
educating and recruiting providers, and educating beneficiaries. 
According to a study of this program published in the Journal of Rural 
Health, from fiscal year 1999 to 2002, this state Medicaid program saw 
a 39 percent increase in the number of dentists accepting Medicaid and 
a 57 percent increase in the number of Medicaid-enrolled children 
receiving dental services after implementing this initiative.[Footnote 
27] 

Table 6: Actions to Recruit Dental Providers since 2000, as Reported by 
State Medicaid Programs: 

State actions to recruit dental providers: Met with dental provider 
groups to encourage them to see more children in Medicaid; 
States responding (51 states): 45. 

State actions to recruit dental providers: Increased dental fee-for- 
service reimbursement rates; 
States responding (51 states): 44. 

State actions to recruit dental providers: Streamlined fee-for-service 
claims processing; 
States responding (51 states): 36. 

State actions to recruit dental providers: Reduced or eliminated 
administrative burdens, such as prior authorization requirements; 
States responding (51 states): 35. 

State actions to recruit dental providers: Action by other state 
agencies, such as providing scholarships, loan repayment, or other 
funding to dental providers for serving low-income communities; 
States responding (51 states): 34. 

State actions to recruit dental providers: Encouraged non-dental 
providers, such as pediatricians, to provide basic oral health care; 
States responding (51 states): 31. 

State actions to recruit dental providers: Sent literature to dental 
providers to encourage them to see more children in Medicaid; 
States responding (51 states): 21. 

State actions to recruit dental providers: Increased funding to clinics 
serving Medicaid children for hiring more dental providers; 
States responding (51 states): 14. 

State actions to recruit dental providers: Increased dental managed 
care capitation payments to MCOs; 
States responding (51 states): 11. 

State actions to recruit dental providers: Paid for advertisements 
aimed at dental providers to encourage them to see more children in 
Medicaid; 
States responding (51 states): 5. 

State actions to recruit dental providers: Invested in health 
information technology that allows rural dental providers to consult 
with dentists in other areas on high risk cases; 
States responding (51 states): 2. 

State actions to recruit dental providers: Other actions taken by the 
state Medicaid agency[A]; 
States responding (51 states): 22. 

State actions to recruit dental providers: Total number of states that 
have taken one or more actions to recruit dental providers; 
States responding (51 states): 50. 

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

Note: States could select more than one action to recruit dental 
providers and may be counted in more than one category. 

[A] States reported other actions by the state Medicaid agency, 
including investing in telemedicine, producing a guide of program 
procedure codes with descriptions of services and prior authorization 
requirements, and introducing eligibility verification systems with 
free online access. 

[End of table] 

Although nearly all states reported that since 2000 they have 
undertaken initiatives to improve children's access to dental care, CMS 
416 data on children's access to dental care show that access rates 
remain low, and states report facing the same barriers they faced in 
2000. CMS 416 data show dental utilization rates have improved since 
2000, from a national average of 27 percent to 35 percent in 2007--but 
in 2007 only 1 state reported a dental utilization rate above 50 
percent and 12 states' utilization rates remained below 30 percent. 
Less than half of the states that reported undertaking initiatives to 
improve children's access to dental care (21 states) reported that all 
their initiatives met their expectations. Nearly all (48 of 51 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--continue to impede their current efforts. Apart from funding 
concerns, states most often reported that a lack of provider and 
beneficiary participation hindered their efforts to improve access to 
Medicaid dental services in their state (see table 7). Twenty-six 
states reported these and other barriers resulted in one or more of 
their improvement initiatives not being implemented or their 
expectations not being met. 

Table 7: Barriers That Hinder State Initiatives to Improve Access to 
Medicaid Dental Services, as Reported by State Medicaid Programs: 

Barriers to state initiatives: Lack of available funding; 
States responding (51 states): 44. 

Barriers to state initiatives: Lack of provider participation; 
States responding (51 states): 40. 

Barriers to state initiatives: Lack of beneficiary participation; 
States responding (51 states): 38. 

Barriers to state initiatives: Administrative burden on providers; 
States responding (51 states): 31. 

Barriers to state initiatives: Difficulty coordinating with other state 
agencies; 
States responding (51 states): 13. 

Barriers to state initiatives: Lack of CMS approval for state 
initiatives; 
States responding (51 states): 5. 

Barriers to state initiatives: Other barriers[A]; 
States responding (51 states): 6. 

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

Note: States could select more than one barrier and may be counted in 
more than one category. 

[A] States reported other barriers, including staffing shortages that 
limit the agencies' ability to take on additional projects and cultural 
competency barriers, such as translating oral health information into 
other languages. 

[End of table] 

When asked to describe the extent to which state goals were being met, 
some states reported that successes in increasing the numbers of 
providers enrolled in the Medicaid program have resulted in increasing 
rates of utilization by children, but that more needs to be done to 
increase the percentage of children receiving dental services beyond 
current levels. States also described other challenges to meeting their 
goals and improving children's access to dental care, such as 
fluctuations in eligibility for services, lack of beneficiary 
compliance, low oral health awareness among beneficiaries, and a lack 
of demand for routine dental care by beneficiaries. 

In addition to barriers that hinder state initiatives, states report 
that access rates could also be affected by two other types of 
barriers: those faced by children seeking dental services and those 
faced by providers serving Medicaid beneficiaries. For children seeking 
dental services, most states reported that finding a provider that 
accepts Medicaid is a moderate or major barrier. Comparatively fewer 
states reported that obtaining transportation to and from the 
provider's office or the ability of parents to take time off work are 
moderate or major barriers for children seeking dental care. For 
providers, most states also reported that beneficiaries not showing up 
for appointments and a limited capacity to accept new patients 
(reported by 45 and 30 states, respectively) are moderate to major 
barriers. One state noted that these issues are particularly 
significant when they are combined together, at which point they can 
become moderate to major barriers for dental providers. See figure 1 
for barriers faced by children and providers. 

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 congressional concern 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 Has Taken Steps toward Improving Oversight of State Medicaid Dental 
Services for Children: 

In February 2008 and September 2008 Subcommittee hearings, CMS 
officials described several initiatives under way by CMS to improve 
monitoring of state programs and to provide guidance and facilitate 
collaboration. At the time of our review, some of these initiatives had 
been completed, while others were still under way. CMS initiatives 
include the following: 

* Focused dental reviews in 17 states. Between October 2007 and May 
2008, CMS conducted a series of focused dental reviews in 17 states. 
[Footnote 28] The 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 
services. In January 2009, CMS published a summary report of its 
findings and recommendations in 16 states (in February 2008, CMS had 
published a separate report on Maryland).[Footnote 29] CMS had concerns 
that 11 of the 17 states were not adhering to federal law or 
regulation, including multiple findings in some states. For example, 
CMS found that 6 states had inadequate dental networks in MCOs that 
provided Medicaid dental services, 2 states had not ensured that all 
medically necessary dental services were provided, and 1 state had 
inappropriately limited reimbursement for out-of-state emergency dental 
services, leaving the remainder of the costs to the beneficiaries. 
[Footnote 30] CMS also made recommendations to all 17 states it 
reviewed and identified several promising practices, which it 
highlighted in its summary report.[Footnote 31] 

* Improved collection of CMS 416 reports. In June 2007, CMS began an 
initiative to improve reporting by states that had not submitted timely 
or reliable dental utilization data in their annual CMS 416 reports. 
CMS sent formal requests to 22 states that had failed to submit 
complete CMS 416 reports for one or more years. CMS also contacted the 
states and provided technical assistance on problems with data 
collection methodology. As of March 2009, all 51 states had submitted 
their 2007 CMS 416 reports to CMS. CMS 416 reports for 2008 were due to 
CMS in April 2009, however, as of early June 2009, only 42 states had 
submitted their 2008 reports. 

* Review of state periodicity schedules. In 2008, CMS examined dental- 
related periodicity schedules from all states. CMS found that all but 
three states reported having some type of periodicity schedule, but not 
all schedules were in compliance with CMS requirements. For example, 
some schedules indicated when a primary care provider should refer a 
child to a dentist, but the schedule did not specify how often dental 
services should occur. CMS also found that periodicity schedules in 
several states were not readily accessible by providers or 
beneficiaries. For states that had not submitted separate dental 
periodicity schedules as required by CMS, CMS recommended that the 
states adopt AAPD's periodicity schedule for children. 

* Publication of a dental policy document. 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 32] For example, 
one question asked if the state could allow providers to bill patients 
for missed appointments. CMS responded that Medicaid policy did not 
permit such billing, in part because no service was delivered. Further, 
missed appointments are not a distinct, reimbursable Medicaid service, 
but are instead considered part of a provider's overall cost of doing 
business. 

* Communications with states and stakeholders. 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. For 
example, CMS presented information on Medicaid dental issues at the 
April 2008 National Oral Health Conference sponsored by the American 
Association of Public Health Dentistry and the Association of State and 
Territorial Dental Directors. Other groups involved in CMS partnership 
activities included AAPD, the American Dental Association, and the 
Association of Community Affiliated Plans. 

* Establishment of an Oral Health Technical Advisory Group. In 
conjunction with NASMD, CMS established an Oral Health Technical 
Advisory Group to address issues related to oral health services, 
including access and quality. A NASMD member chairs the advisory group 
and, as of January 2009, other members included CMS representatives, 
state representatives from different regions of the country, and other 
NASMD staff. Advisory group projects include examining the effects on 
oral health programs of recent legislation, such as the Recovery Act 
and the Children's Health Insurance Program Reauthorization Act of 
2009, considering improvements to the CMS 416 annual reports, and 
improving materials used to inform beneficiaries of their Medicaid 
dental benefits. 

* Sharing of promising state practices related to dental services. CMS 
posted "promising practices"--described by CMS as successful state 
programs that reflect innovative approaches to meeting common problems--
on its Web site.[Footnote 33] As of May 2009, CMS had posted promising 
practices from 4 states related to Medicaid dental services: 

Delaware increased reimbursement, reduced administrative burden on 
providers, and increased provider outreach. 

South Carolina increased reimbursement rates, reduced administrative 
barriers, and began an outreach campaign to encourage dentists to 
participate in Medicaid. 

Tennessee increased reimbursement, separated (or "carved out") the 
dental benefit from Medicaid managed care contracts, and hired a 
contractor to administer the dental benefit. 

Virginia increased reimbursement, carved out the dental benefit from 
Medicaid managed care contracts, and adopted incentives to increase 
provider participation, such as establishment of a dedicated call 
center, new billing options and quicker payment, streamlined prior 
authorization for care, and simplified provider credentialing. 

Gaps Remain in CMS Efforts to Monitor Provision of Dental Services to 
Children in Medicaid, Provide Guidance, and Facilitate Collaboration 
among States: 

Although CMS has taken a number of important steps, gaps in CMS 
oversight point to opportunities for further action to improve access 
to dental services for children in Medicaid. Remaining gaps in CMS 
oversight include the following: 

* CMS does not have plans to conduct focused dental reviews in 
additional states. CMS's focused dental reviews targeted 15 states with 
the lowest dental utilization rates, but 2006 CMS 416 reports showed 
that in 24 additional states (including Georgia and Maryland) in that 
year, between 31 and 40 percent of eligible children received any 
dental service--well below HHS's Healthy People 2010 goal of having 66 
percent of low-income children under age 19 receive a preventive dental 
service. According to CMS officials, CMS, at the time or our review, 
did not plan to conduct focused dental reviews in these states, 
potentially missing an opportunity to identify important areas for 
improvement.[Footnote 34] When asked what additional assistance CMS 
could provide, 6 states responding to our survey reported that they 
believed that an independent review of dental services would be helpful 
to their Medicaid programs. 

* CMS did not require corrective action in states found to have 
inadequate MCO networks. CMS's focused dental reviews identified 8 
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. In 6 states, CMS presented its concerns as a 
"finding," that is, a concern that the state is not adhering to federal 
law or regulation. In the remaining 2 states, CMS cited deficiencies in 
MCO provider networks, but did not report its concerns as findings. CMS 
made recommendations to strengthen MCO provider networks in all 8 
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 416 reports provide limited information on dental service 
utilization. The CMS 416 report only gathers data on the number of 
children who received a preventive dental service, a dental treatment 
service, or any dental service. We have reported in the past that these 
data are limited in their usefulness for oversight of Medicaid dental 
services for children.[Footnote 35] For example, because dental 
services delivered to managed care enrollees are not reported 
separately from services to fee-for-service enrollees, the CMS 416 data 
does not provide information that could be used to flag problems with a 
specific service delivery method. Further, it is not possible to 
determine how many children in a state received all of the recommended 
dental services included in the state's periodicity schedule. According 
to the CMS Deputy Administrator, the Oral Health Technical Advisory 
Group has a project under way to consider improvements to the CMS 416. 

* States report that additional guidance from CMS is needed. In 
response to our survey, 2 states reported that CMS's September 2008 
policy paper on Medicaid dental issues was helpful, but nearly all 
states (49 of 51) reported that additional CMS guidance could help them 
improve delivery of Medicaid dental services. States cited a need for 
additional information in several areas: for example, guidance on 
standards for dental care, information on billing policies, better 
definitions for outreach and transportation services in Medicaid 
programs, establishing appropriate dental fee schedules, improving 
documentation and coding practices, and information on quality and 
preventive initiatives. 

* CMS has posted relatively few promising practices on its Web site. 
When asked what CMS assistance would be helpful to their state Medicaid 
program, the most common answer (other than increasing the federal 
medical assistance percentage), cited by 37 states, was information on 
other states' efforts to improve dental utilization. Although CMS 
maintains a Web site to publicize promising state Medicaid dental 
practices, 11 states reported that they were unaware of the promising 
practices posted on CMS's Web site. The 4 promising practices posted as 
of May 2009 are just a few of the practices that could be shared with 
other states. For example, during its focused dental reviews, CMS 
identified 17 additional promising and notable practices, none of which 
were included on the CMS promising practice Web site. Further, 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 (see appendix V for brief descriptions of these practices). 

Conclusions: 

CMS has begun several initiatives to strengthen its oversight of state 
Medicaid dental services for children, but information on the oral 
health of and receipt of dental services by Medicaid children show that 
much more needs to be done. Although many states have reported moderate 
increases in access to Medicaid dental services, we reported in 
September 2008 that the extent of dental disease in children had not 
decreased and that millions of children were estimated to have 
untreated tooth decay. States responding to our survey reported that a 
lack of available funding, low provider 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. Through a series of focused reviews of states' efforts to 
provide dental services to children in Medicaid, CMS has identified 
deficiencies in several state Medicaid programs. Although CMS made 
recommendations for improvement to the states, it required no 
corrective actions. Moreover, not all states with low rates of 
children's dental utilization have been reviewed, nor are such reviews 
planned. These reviews have not only identified problem areas, but have 
also helped identify information on promising state dental practices 
that could be useful to other states seeking to improve their own 
programs. Finally, for Medicaid-enrolled children who receive dental 
services through managed care programs, CMS has found that certain 
states have not ensured that MCOs have adequate provider networks to 
provide covered dental services to their enrollees. Although CMS and 
states have taken steps to address long-standing barriers, continued 
attention and action is needed to ensure children's access to Medicaid 
dental services. 

Recommendations for Executive Action: 

To strengthen monitoring of state Medicaid dental services for children 
and help states improve children's access to Medicaid dental services, 
we are recommending that the Administrator of CMS take the following 
four actions: 

* 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. 

* Ensure that states found to have inadequate MCO dental provider 
networks take action to strengthen these networks. 

* Work with stakeholders to develop needed guidance on topics of 
concern to states. 

* Identify ways to improve sharing of promising practices among states. 

Agency Comments: 

We provided a draft of this report for comment to HHS. Responding for 
HHS, CMS provided written comments. In summary, CMS concurred with 
three of our recommendations--specifically, to ensure that states found 
to have inadequate MCO provider networks take corrective action, to 
develop additional guidance on topics of concern to states, and to 
improve sharing of promising practices among states and other 
stakeholders. CMS described several initiatives planned or under way 
that would strengthen its oversight of state Medicaid dental services 
for children. CMS concurred in part with our fourth recommendation, to 
develop a plan to review Medicaid dental services in states with low 
utilization rates. In following up with CMS, an official clarified that 
CMS agreed with the need to review Medicaid dental services in these 
states but wanted this plan to be part of the agency's broader plan to 
review all EPSDT services. As part of this broader plan, CMS would 
consider additional focused dental reviews as well as comprehensive 
EPSDT service reviews.[Footnote 36] We believe that CMS's action will 
meet the intent of our recommendation. CMS also noted that the 
Children's Health Insurance Program Reauthorization Act of 2009 
included a number of provisions related to dental services that the 
agency was in the process of implementing, including requirements for 
states to post a listing of participating Medicaid and CHIP dental 
providers on HHS's [hyperlink, http://www.insurekidsnow.gov] Web site, 
to publish new quality measures for Medicaid and CHIP children, and to 
report additional information on children receiving dental care under 
Medicaid.[Footnote 37] Finally, CMS provided one technical comment, 
which we incorporated into the report. CMS's letter is reprinted in 
appendix VI. 

As agreed with your offices, unless you publicly announce the contents 
of this report earlier, we plan no further distribution until 30 days 
from the report date. At that time, we will send copies of this report 
to the Secretary of HHS and other interested parties. 

In addition, the report will be available at no charge on GAO's Web 
site at [hyperlink, http://www.gao.gov]. If you or your staffs have any 
questions about this report, please contact me at (202) 512-7114 or 
cackleya@gao.gov. Contact points for our Offices of Congressional 
Relations and Public Affairs may be found on the last page of this 
report. GAO staff that made major contributions to this report are 
listed in appendix VII. 

Signed by: 

Alicia Puente Cackley: 
Director, Health Care: 

[End of section] 

Appendix I: Methods Used by State Medicaid Programs to Monitor the 
Statewide Provision of Dental Care to Children: 

Yes: State did have this method of monitoring children's dental care. 

No: State did not have this method of monitoring children's dental 
care. 

State: Alaska; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: No; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: Yes. 

State: Alabama; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: No; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: Yes. 

State: Arkansas; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: No; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: Yes; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: Yes. 

State: Arizona; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: Yes; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: Yes; 
Survey for problems obtaining services: Yes; 
Survey to monitor oral health of children: No; 
Other methods[A]: Yes. 

State: California; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: Yes; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: No. 

State: Colorado; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: Yes; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: Yes. 

State: Connecticut; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: Yes; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: No. 

State: District of Columbia; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: Yes; 
Phone calls to state and/or MCOs on concerns: Yes; 
Beneficiary satisfaction surveys: Yes; 
Survey for problems obtaining services: Yes; 
Survey to monitor oral health of children: Yes; 
Other methods[A]: No. 

State: Delaware; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: No; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: Yes. 

State: Florida; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: No; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: No. 

State: Georgia; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: Yes; 
Phone calls to state and/or MCOs on concerns: Yes; 
Beneficiary satisfaction surveys: Yes; 
Survey for problems obtaining services: Yes; 
Survey to monitor oral health of children: No; 
Other methods[A]: No. 

State: Hawaii; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: No; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: No. 

State: Iowa; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: No; 
Phone calls to state and/or MCOs on concerns: Yes; 
Beneficiary satisfaction surveys: Yes; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: No. 

State: Idaho; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: No; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: No. 

State: Illinois; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: No; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: Yes; 
Survey for problems obtaining services: Yes; 
Survey to monitor oral health of children: No; 
Other methods[A]: Yes. 

State: Indiana; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: No; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: No. 

State: Kansas; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: No; 
Phone calls to state and/or MCOs on concerns: Yes; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: No. 

State: Kentucky; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: No; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: No. 

State: Louisiana; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: Yes; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: Yes. 

State: Massachusetts; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: Yes; 
Phone calls to state and/or MCOs on concerns: Yes; 
Beneficiary satisfaction surveys: Yes; 
Survey for problems obtaining services: Yes; 
Survey to monitor oral health of children: No; 
Other methods[A]: No. 

State: Maryland; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: Yes; 
Phone calls to state and/or MCOs on concerns: Yes; 
Beneficiary satisfaction surveys: Yes; 
Survey for problems obtaining services: Yes; 
Survey to monitor oral health of children: Yes; 
Other methods[A]: Yes. 

State: Maine; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: No; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: No. 

State: Michigan; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: Yes; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: No. 

State: Minnesota; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: No; 
Phone calls to state and/or MCOs on concerns: Yes; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: No. 

State: Missouri; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: No; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: No. 

State: Mississippi; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: No; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: Yes. 

State: Montana; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: Yes; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: No. 

State: North Carolina; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: Yes; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: Yes; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: No. 

State: North Dakota; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: No; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: Yes. 

State: Nebraska; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: No; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: No. 

State: New Hampshire; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: No; 
Phone calls to state and/or MCOs on concerns: Yes; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: Yes; 
Survey to monitor oral health of children: No; 
Other methods[A]: Yes. 

State: New Jersey; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: Yes; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: Yes; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: No. 

State: New Mexico; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: Yes; 
Phone calls to state and/or MCOs on concerns: Yes; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: No. 

State: Nevada; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: Yes; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: Yes; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: No. 

State: New York; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: Yes; 
Phone calls to state and/or MCOs on concerns: Yes; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: No. 

State: Ohio; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: Yes; 
Phone calls to state and/or MCOs on concerns: Yes; 
Beneficiary satisfaction surveys: Yes; 
Survey for problems obtaining services: Yes; 
Survey to monitor oral health of children: Yes; 
Other methods[A]: No. 

State: Oklahoma; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: No; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: No. 

State: Oregon; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: Yes; 
Phone calls to state and/or MCOs on concerns: Yes; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: Yes. 

State: Pennsylvania; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: Yes; 
Phone calls to state and/or MCOs on concerns: Yes; 
Beneficiary satisfaction surveys: Yes; 
Survey for problems obtaining services: Yes; 
Survey to monitor oral health of children: Yes; 
Other methods[A]: No. 

State: Rhode Island; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: Yes; 
Phone calls to state and/or MCOs on concerns: Yes; 
Beneficiary satisfaction surveys: Yes; 
Survey for problems obtaining services: Yes; 
Survey to monitor oral health of children: No; 
Other methods[A]: No. 

State: South Carolina; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: No; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: Yes; 
Survey to monitor oral health of children: Yes; 
Other methods[A]: Yes. 

State: South Dakota; 
CMS 416 data: No; 
Claims and/or encounter data from MCOs: No; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: Yes. 

State: Tennessee; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: Yes; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: Yes; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: No. 

State: Texas; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: No; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: Yes; 
Other methods[A]: No. 

State: Utah; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: Yes; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: No. 

State: Virginia; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: No; 
Phone calls to state and/or MCOs on concerns: Yes; 
Beneficiary satisfaction surveys: Yes; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: Yes. 

State: Vermont; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: No; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: No. 

State: Washington; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: No; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: Yes. 

State: Wisconsin; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: Yes; 
Phone calls to state and/or MCOs on concerns: Yes; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: Yes; 
Other methods[A]: Yes. 

State: West Virginia; 
CMS 416 data: Yes; 
Claims and/or encounter data from MCOs: No; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: No. 

State: Wyoming; 
CMS 416 data: v; 
Claims and/or encounter data from MCOs: No; 
Phone calls to state and/or MCOs on concerns: No; 
Beneficiary satisfaction surveys: No; 
Survey for problems obtaining services: No; 
Survey to monitor oral health of children: No; 
Other methods[A]: Yes. 

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

[A] States reported using other methods to monitor the provision of 
Medicaid dental services, including generating ad hoc reports on 
various dental procedures and analyzing monthly budget reports by 
procedure code to monitor utilization trends. 

[End of table] 

[End of section] 

Appendix II: Statewide Utilization Goals for the Provision of Dental 
Care to Children in State Medicaid Programs: 

Yes: State did have this access goal for children's dental care. 

No: State did not have this access goal for children's dental care. 

State: Alaska[B]; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: No; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: No; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: No; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: No. 

State: Alabama; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: Yes; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: Yes; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: No; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: No. 

State: Arkansas; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: Yes; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: No; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: Yes; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: Yes; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: No. 

State: Arizona; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: Yes; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: No; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: No; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: Yes. 

State: California; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: No; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: No; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: No; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: Yes. 

State: Colorado; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: Yes; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: Yes; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: No; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: Yes. 

State: Connecticut; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: Yes; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: Yes; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: Yes; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: Yes; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: Yes. 

State: District of Columbia; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: Yes; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: Yes; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: No; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: Yes; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: Yes; 
Other state goals[A]: No. 

State: Delaware; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: Yes; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: No; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: Yes; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: Yes; 
Other state goals[A]: No. 

State: Florida; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: No; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: Yes; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: Yes; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: Yes; 
Other state goals[A]: No. 

State: Georgia; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: Yes; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: Yes; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: Yes; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: Yes; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: Yes; 
Other state goals[A]: No. 

State: Hawaii; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: Yes; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: No; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: Yes; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: No. 

State: Iowa; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: Yes; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: Yes; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: No; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: Yes; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: No. 

State: Idaho; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: No; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: Yes; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: Yes; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: Yes; 
Other state goals[A]: No. 

State: Illinois; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: Yes; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: Yes; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: No; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: No. 

State: Indiana[B]; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: No; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: No; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: No; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: No. 

State: Kansas; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: No; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: No; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: No; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: Yes. 

State: Kentucky[B]; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: No; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: No; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: No; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: No. 

State: Louisiana; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: No; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: No; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: Yes; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: No. 

State: Massachusetts; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: Yes; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: Yes; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: Yes; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: Yes; 
Other state goals[A]: Yes. 

State: Maryland; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: Yes; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: Yes; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: Yes; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: Yes; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: Yes. 

State: Maine; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: Yes; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: Yes; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: No; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: No. 

State: Michigan; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: Yes; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: Yes; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: No; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: Yes; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: No. 

State: Minnesota[B]; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: No; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: No; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: No; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: No. 

State: Missouri[B]; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: No; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: No; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: No; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: No. 

State: Mississippi[B]; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: No; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: No; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: No; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: No. 

State: Montana; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: Yes; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: No; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: No; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: No. 

State: North Carolina; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: Yes; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: Yes; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: Yes; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: Yes. 

State: North Dakota; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: Yes; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: Yes; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: Yes; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: Yes; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: Yes; 
Other state goals[A]: No. 

State: Nebraska[B]; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: No; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: No; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: No; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: No. 

State: New Hampshire; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: Yes; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: Yes; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: No; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: Yes; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: Yes; 
Other state goals[A]: Yes. 

State: New Jersey; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: Yes; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: Yes; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: Yes; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: Yes; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: No. 

State: New Mexico; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: Yes; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: Yes; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: Yes; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: Yes; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: Yes; 
Other state goals[A]: No. 

State: Nevada; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: No; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: No; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: No; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: Yes. 

State: New York; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: Yes; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: No; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: No; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: No. 

State: Ohio; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: Yes; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: No; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: No; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: Yes. 

State: Oklahoma; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: Yes; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: Yes; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: Yes; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: Yes; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: Yes. 

State: Oregon; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: No; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: No; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: No; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: Yes. 

State: Pennsylvania; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: Yes; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: Yes; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: No; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: No. 

State: Rhode Island; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: No; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: No; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: No; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: Yes. 

State: South Carolina; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: Yes; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: No; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: No; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: Yes; 
Other state goals[A]: No. 

State: South Dakota; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: Yes; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: Yes; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: No; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: No. 

State: Tennessee; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: Yes; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: No; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: Yes; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: No. 

State: Texas; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: No; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: Yes; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: No; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: No. 

State: Utah; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: No; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: Yes; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: No; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: Yes; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: No. 

State: Virginia; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: Yes; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: No; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: No; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: Yes. 

State: Vermont[B]; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: No; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: No; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: No; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: No. 

State: Washington; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: No; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: No; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: No; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: Yes. 

State: Wisconsin; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: Yes; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: Yes; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: Yes; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: No. 

State: West Virginia[B]; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: No; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: No; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: No; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: No; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: No; 
Other state goals[A]: No. 

State: Wyoming; 
Percentage of children who receive any dental care in a given time 
period is to exceed a certain threshold: Yes; 
Percentage of children who received dental preventive services is to 
exceed a certain threshold: Yes; 
Ratio of participating dental providers in Medicaid exceeds a certain 
threshold: No; 
Percentage of children who received restorative procedures for oral 
health problems exceeds a certain threshold: Yes; 
Percentage of children who report difficulty finding dental care is to 
fall below a certain threshold: Yes; 
Other state goals[A]: No. 

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

[A] States reported other goals, including the percentage of children 
who are continually enrolled and receive appropriate follow-up or 
increasing levels of provider participation. 

[B] These states reported they do not have goals related to the 
provision of dental care for children in state Medicaid programs. 

[End of table] 

[End of section] 

Appendix III: Access Standards Set by the 21 States That Provide Dental 
Services through Managed Care Organizations (MCOs): 

Yes: State did have this standard for MCO networks in their state. 

No: State did not have this standard for MCO networks in their state. 

Access Standards States Set For MCOs: 

State: Arizona; 
Percentage of children who should receive a dental visit: Yes; 
Minimum payment rates for dental services: No; 
Beneficiary satisfaction scores or ratings: No; 
Minimum provider to patient ratios: No; 
Maximum travel times: No; 
Maximum travel distances: No; 
Maximum waiting times when scheduling dental appointments: Yes; 
Maximum waiting times when scheduling emergency dental appointments: 
Yes; 
Other standards[A]: Yes. 

State: California; 
Percentage of children who should receive a dental visit: No; 
Minimum payment rates for dental services: Yes; 
Beneficiary satisfaction scores or ratings: Yes; 
Minimum provider to patient ratios: Yes; 
Maximum travel times: Yes; 
Maximum travel distances: Yes; 
Maximum waiting times when scheduling dental appointments: Yes; 
Maximum waiting times when scheduling emergency dental appointments: 
Yes; 
Other standards[A]: Yes. 

State: District of Columbia; 
Percentage of children who should receive a dental visit: Yes; 
Minimum payment rates for dental services: Yes; 
Beneficiary satisfaction scores or ratings: No; 
Minimum provider to patient ratios: No; 
Maximum travel times: Yes; 
Maximum travel distances: Yes; 
Maximum waiting times when scheduling dental appointments: Yes; 
Maximum waiting times when scheduling emergency dental appointments: 
Yes; 
Other standards[A]: No. 

State: Florida; 
Percentage of children who should receive a dental visit: Yes; 
Minimum payment rates for dental services: No; 
Beneficiary satisfaction scores or ratings: No; 
Minimum provider to patient ratios: Yes; 
Maximum travel times: Yes; 
Maximum travel distances: Yes; 
Maximum waiting times when scheduling dental appointments: Yes; 
Maximum waiting times when scheduling emergency dental appointments: 
Yes; 
Other standards[A]: No. 

State: Georgia; 
Percentage of children who should receive a dental visit: Yes; 
Minimum payment rates for dental services: No; 
Beneficiary satisfaction scores or ratings: No; 
Minimum provider to patient ratios: No; 
Maximum travel times: Yes; 
Maximum travel distances: Yes; 
Maximum waiting times when scheduling dental appointments: Yes; 
Maximum waiting times when scheduling emergency dental appointments: 
No; 
Other standards[A]: Yes. 

State: Idaho; 
Percentage of children who should receive a dental visit: No; 
Minimum payment rates for dental services: Yes; 
Beneficiary satisfaction scores or ratings: No; 
Minimum provider to patient ratios: No; 
Maximum travel times: No; 
Maximum travel distances: Yes; 
Maximum waiting times when scheduling dental appointments: No; 
Maximum waiting times when scheduling emergency dental appointments: 
No; 
Other standards[A]: No. 

State: Kentucky; 
Percentage of children who should receive a dental visit: No; 
Minimum payment rates for dental services: Yes; 
Beneficiary satisfaction scores or ratings: Yes; 
Minimum provider to patient ratios: No; 
Maximum travel times: Yes; 
Maximum travel distances: Yes; 
Maximum waiting times when scheduling dental appointments: No; 
Maximum waiting times when scheduling emergency dental appointments: 
No; 
Other standards[A]: No. 

State: Maryland; 
Percentage of children who should receive a dental visit: Yes; 
Minimum payment rates for dental services: Yes; 
Beneficiary satisfaction scores or ratings: Yes; 
Minimum provider to patient ratios: Yes; 
Maximum travel times: Yes; 
Maximum travel distances: Yes; 
Maximum waiting times when scheduling dental appointments: Yes; 
Maximum waiting times when scheduling emergency dental appointments: 
Yes; 
Other standards[A]: No. 

State: Michigan; 
Percentage of children who should receive a dental visit: No; 
Minimum payment rates for dental services: No; 
Beneficiary satisfaction scores or ratings: No; 
Minimum provider to patient ratios: No; 
Maximum travel times: No; 
Maximum travel distances: No; 
Maximum waiting times when scheduling dental appointments: Yes; 
Maximum waiting times when scheduling emergency dental appointments: 
Yes; 
Other standards[A]: No. 

State: Minnesota; 
Percentage of children who should receive a dental visit: No; 
Minimum payment rates for dental services: No; 
Beneficiary satisfaction scores or ratings: No; 
Minimum provider to patient ratios: No; 
Maximum travel times: Yes; 
Maximum travel distances: Yes; 
Maximum waiting times when scheduling dental appointments: Yes; 
Maximum waiting times when scheduling emergency dental appointments: 
Yes; 
Other standards[A]: Yes. 

State: Missouri; 
Percentage of children who should receive a dental visit: No; 
Minimum payment rates for dental services: No; 
Beneficiary satisfaction scores or ratings: No; 
Minimum provider to patient ratios: No; 
Maximum travel times: No; 
Maximum travel distances: Yes; 
Maximum waiting times when scheduling dental appointments: Yes; 
Maximum waiting times when scheduling emergency dental appointments: 
Yes; 
Other standards[A]: Yes. 

State: New Jersey; 
Percentage of children who should receive a dental visit: Yes; 
Minimum payment rates for dental services: No; 
Beneficiary satisfaction scores or ratings: Yes; 
Minimum provider to patient ratios: Yes; 
Maximum travel times: Yes; 
Maximum travel distances: Yes; 
Maximum waiting times when scheduling dental appointments: Yes; 
Maximum waiting times when scheduling emergency dental appointments: 
Yes; 
Other standards[A]: Yes. 

State: New Mexico; 
Percentage of children who should receive a dental visit: No; 
Minimum payment rates for dental services: No; 
Beneficiary satisfaction scores or ratings: No; 
Minimum provider to patient ratios: No; 
Maximum travel times: No; 
Maximum travel distances: No; 
Maximum waiting times when scheduling dental appointments: Yes; 
Maximum waiting times when scheduling emergency dental appointments: 
Yes; 
Other standards[A]: No. 

State: Nevada; 
Percentage of children who should receive a dental visit: Yes; 
Minimum payment rates for dental services: No; 
Beneficiary satisfaction scores or ratings: No; 
Minimum provider to patient ratios: Yes; 
Maximum travel times: No; 
Maximum travel distances: No; 
Maximum waiting times when scheduling dental appointments: Yes; 
Maximum waiting times when scheduling emergency dental appointments: 
Yes; 
Other standards[A]: No. 

State: New York; 
Percentage of children who should receive a dental visit: Yes; 
Minimum payment rates for dental services: No; 
Beneficiary satisfaction scores or ratings: No; 
Minimum provider to patient ratios: Yes; 
Maximum travel times: Yes; 
Maximum travel distances: Yes; 
Maximum waiting times when scheduling dental appointments: Yes; 
Maximum waiting times when scheduling emergency dental appointments: 
Yes; 
Other standards[A]: No. 

State: Ohio; 
Percentage of children who should receive a dental visit: Yes; 
Minimum payment rates for dental services: No; 
Beneficiary satisfaction scores or ratings: Yes; 
Minimum provider to patient ratios: No; 
Maximum travel times: No; 
Maximum travel distances: Yes; 
Maximum waiting times when scheduling dental appointments: No; 
Maximum waiting times when scheduling emergency dental appointments: 
No; 
Other standards[A]: Yes. 

State: Oregon; 
Percentage of children who should receive a dental visit: No; 
Minimum payment rates for dental services: No; 
Beneficiary satisfaction scores or ratings: No; 
Minimum provider to patient ratios: No; 
Maximum travel times: Yes; 
Maximum travel distances: Yes; 
Maximum waiting times when scheduling dental appointments: No; 
Maximum waiting times when scheduling emergency dental appointments: 
No; 
Other standards[A]: Yes. 

State: Pennsylvania; 
Percentage of children who should receive a dental visit: Yes; 
Minimum payment rates for dental services: No; 
Beneficiary satisfaction scores or ratings: Yes; 
Minimum provider to patient ratios: No; 
Maximum travel times: Yes; 
Maximum travel distances: No; 
Maximum waiting times when scheduling dental appointments: Yes; 
Maximum waiting times when scheduling emergency dental appointments: 
Yes; 
Other standards[A]: No. 

State: Rhode Island; 
Percentage of children who should receive a dental visit: Yes; 
Minimum payment rates for dental services: Yes; 
Beneficiary satisfaction scores or ratings: No; 
Minimum provider to patient ratios: No; 
Maximum travel times: No; 
Maximum travel distances: Yes; 
Maximum waiting times when scheduling dental appointments: Yes; 
Maximum waiting times when scheduling emergency dental appointments: 
Yes; 
Other standards[A]: Yes. 

State: Texas; 
Percentage of children who should receive a dental visit: No; 
Minimum payment rates for dental services: No; 
Beneficiary satisfaction scores or ratings: No; 
Minimum provider to patient ratios: No; 
Maximum travel times: No; 
Maximum travel distances: Yes; 
Maximum waiting times when scheduling dental appointments: Yes; 
Maximum waiting times when scheduling emergency dental appointments: 
Yes; 
Other standards[A]: Yes. 

State: Wisconsin; 
Percentage of children who should receive a dental visit: Yes; 
Minimum payment rates for dental services: No; 
Beneficiary satisfaction scores or ratings: No; 
Minimum provider to patient ratios: No; 
Maximum travel times: No; 
Maximum travel distances: No; 
Maximum waiting times when scheduling dental appointments: Yes; 
Maximum waiting times when scheduling emergency dental appointments: 
Yes; 
Other standards[A]: No. 

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

[A] States reported other standards, such as identifying and managing 
beneficiaries who use emergency room facilities to obtain dental 
services. 

[End of table] 

[End of section] 

Appendix IV: Extent to Which Managed Care Organizations (MCO) Meet 
State Standards and State Verification of MCO Networks: 

Yes: State did report using this method to verify MCO provider 
networks. 

No: State did not report using this method to verify MCO provider 
networks. 

State: Arizona; 
Extent to which MCOs meet established standards: Meet some;
Method used to verify that dental providers are accepting children in 
Medicaid: 
Routinely contact a selection of providers to determine if they accept 
new Medicaid patients: No; 
Examine networks in responses to complaints or other concerns on an ad 
hoc basis: Yes; 
Other verification[A]: Yes. 

State: California; 
Extent to which MCOs meet established standards: Meet some;
Method used to verify that dental providers are accepting children in 
Medicaid: 
Routinely contact a selection of providers to determine if they accept 
new Medicaid patients: Yes; 
Examine networks in responses to complaints or other concerns on an ad 
hoc basis: Yes; 
Other verification[A]: Yes. 

State: District of Columbia; 
Extent to which MCOs meet established standards: Meet all; 
Method used to verify that dental providers are accepting children in 
Medicaid: 
Routinely contact a selection of providers to determine if they accept 
new Medicaid patients: Yes; 
Examine networks in responses to complaints or other concerns on an ad 
hoc basis: Yes; 
Other verification[A]: No. 

State: Florida; 
Extent to which MCOs meet established standards: Meet some;
Method used to verify that dental providers are accepting children in 
Medicaid: 
Routinely contact a selection of providers to determine if they accept 
new Medicaid patients: Yes; 
Examine networks in responses to complaints or other concerns on an ad 
hoc basis: No; 
Other verification[A]: No. 

State: Georgia; 
Extent to which MCOs meet established standards: Meet all; 
Method used to verify that dental providers are accepting children in 
Medicaid: 
Routinely contact a selection of providers to determine if they accept 
new Medicaid patients: Yes; 
Examine networks in responses to complaints or other concerns on an ad 
hoc basis: Yes; 
Other verification[A]: No. 

State: Idaho; 
Extent to which MCOs meet established standards: Meet all; 
Method used to verify that dental providers are accepting children in 
Medicaid: 
Routinely contact a selection of providers to determine if they accept 
new Medicaid patients: No; 
Examine networks in responses to complaints or other concerns on an ad 
hoc basis: Yes; 
Other verification[A]: No. 

State: Kentucky; 
Extent to which MCOs meet established standards: Meet all; 
Method used to verify that dental providers are accepting children in 
Medicaid: 
Routinely contact a selection of providers to determine if they accept 
new Medicaid patients: No; 
Examine networks in responses to complaints or other concerns on an ad 
hoc basis: No; 
Other verification[A]: No. 

State: Maryland; 
Extent to which MCOs meet established standards: Meet some;
Method used to verify that dental providers are accepting children in 
Medicaid: 
Routinely contact a selection of providers to determine if they accept 
new Medicaid patients: Yes; 
Examine networks in responses to complaints or other concerns on an ad 
hoc basis: Yes; 
Other verification[A]: No. 

State: Michigan; 
Extent to which MCOs meet established standards: Meet some;
Method used to verify that dental providers are accepting children in 
Medicaid: 
Routinely contact a selection of providers to determine if they accept 
new Medicaid patients: No; 
Examine networks in responses to complaints or other concerns on an ad 
hoc basis: No; 
Other verification[A]: No. 

State: Minnesota; 
Extent to which MCOs meet established standards: Meet some;
Method used to verify that dental providers are accepting children in 
Medicaid: 
Routinely contact a selection of providers to determine if they accept 
new Medicaid patients: No; 
Examine networks in responses to complaints or other concerns on an ad 
hoc basis: Yes; 
Other verification[A]: No. 

State: Missouri; 
Extent to which MCOs meet established standards: Meet some;
Method used to verify that dental providers are accepting children in 
Medicaid: 
Routinely contact a selection of providers to determine if they accept 
new Medicaid patients: No; 
Examine networks in responses to complaints or other concerns on an ad 
hoc basis: Yes; 
Other verification[A]: No. 

State: New Jersey; 
Extent to which MCOs meet established standards: Meet some;
Method used to verify that dental providers are accepting children in 
Medicaid: 
Routinely contact a selection of providers to determine if they accept 
new Medicaid patients: No; 
Examine networks in responses to complaints or other concerns on an ad 
hoc basis: Yes; 
Other verification[A]: Yes. 

State: New Mexico; 
Extent to which MCOs meet established standards: Meet some;
Method used to verify that dental providers are accepting children in 
Medicaid: 
Routinely contact a selection of providers to determine if they accept 
new Medicaid patients: Yes; 
Examine networks in responses to complaints or other concerns on an ad 
hoc basis: Yes; 
Other verification[A]: No. 

State: Nevada; 
Extent to which MCOs meet established standards: Meet all; 
Method used to verify that dental providers are accepting children in 
Medicaid: 
Routinely contact a selection of providers to determine if they accept 
new Medicaid patients: Yes; 
Examine networks in responses to complaints or other concerns on an ad 
hoc basis: Yes; 
Other verification[A]: No. 

State: New York; 
Extent to which MCOs meet established standards: Meet none; 
Method used to verify that dental providers are accepting children in 
Medicaid: 
Routinely contact a selection of providers to determine if they accept 
new Medicaid patients: Yes; 
Examine networks in responses to complaints or other concerns on an ad 
hoc basis: Yes; 
Other verification[A]: No. 

State: Ohio; 
Extent to which MCOs meet established standards: Meet some;
Method used to verify that dental providers are accepting children in 
Medicaid: 
Routinely contact a selection of providers to determine if they accept 
new Medicaid patients: Yes; 
Examine networks in responses to complaints or other concerns on an ad 
hoc basis: Yes; 
Other verification[A]: No. 

State: Oregon; 
Extent to which MCOs meet established standards: Meet some;
Method used to verify that dental providers are accepting children in 
Medicaid: 
Routinely contact a selection of providers to determine if they accept 
new Medicaid patients: No; 
Examine networks in responses to complaints or other concerns on an ad 
hoc basis: Yes; 
Other verification[A]: No. 

State: Pennsylvania; 
Extent to which MCOs meet established standards: Meet all; 
Method used to verify that dental providers are accepting children in 
Medicaid: 
Routinely contact a selection of providers to determine if they accept 
new Medicaid patients: Yes; 
Examine networks in responses to complaints or other concerns on an ad 
hoc basis: Yes; 
Other verification[A]: No. 

State: Rhode Island; 
Extent to which MCOs meet established standards: Meet all; 
Method used to verify that dental providers are accepting children in 
Medicaid: 
Routinely contact a selection of providers to determine if they accept 
new Medicaid patients: Yes; 
Examine networks in responses to complaints or other concerns on an ad 
hoc basis: Yes; 
Other verification[A]: No. 

State: Texas; 
Extent to which MCOs meet established standards: Meet some;
Method used to verify that dental providers are accepting children in 
Medicaid: 
Routinely contact a selection of providers to determine if they accept 
new Medicaid patients: Yes; 
Examine networks in responses to complaints or other concerns on an ad 
hoc basis: Yes; 
Other verification[A]: No. 

State: Wisconsin; 
Extent to which MCOs meet established standards: Meet none; 
Method used to verify that dental providers are accepting children in 
Medicaid: 
Routinely contact a selection of providers to determine if they accept 
new Medicaid patients: No; 
Examine networks in responses to complaints or other concerns on an ad 
hoc basis: Yes; 
Other verification[A]: No. 

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

[A] States reported using other methods to verify MCO networks, 
including monthly spot checks, monitoring provider registration, and 
requiring annual network development plans. 

[End of table] 

[End of section] 

Appendix V: CMS Promising Practices and State Reported Best Practices: 

To promote information sharing and collaboration among states, the 
Centers for Medicare & Medicaid Services (CMS) has created a Web site 
in which it publishes notable "Promising Practices" related to Medicaid 
and the State Children's Health Insurance Program (SCHIP). Dental care 
is one of the subject areas covered on this Web site. To nominate a 
promising practice, a state must complete an application describing the 
underlying problem, the approach taken, and the results obtained. A 
promising practice is defined by CMS as an approach to meeting a 
challenge related to Medicaid/SCHIP program operations, clinical 
practice, or functional level that serves to enhance quality of care 
and/or life and may be of interest to other states. Specifically, the 
practice must: 

* Be related to the improvement of quality of care and/or life for 
Medicaid and/or SCHIP beneficiaries. 

* Address a significant problem in health status or functioning based 
on trends in mortality, morbidity, quality of life, utilization, and/or 
costs. 

* Reflect an innovative approach to meeting a common problem. 

* Have been in operation for a sufficient period of time to demonstrate 
effectiveness (e.g., minimum 12 months). 

* Have demonstrated success through tangible results (e.g., 
improvements in beneficiary physical or mental well-being, savings). 

* Comply with federal Medicaid statute and regulations and CMS policy 
direction. 

As of May 2009, there were five dental practices listed on CMS's 
"Promising Practices" Web site, four of which pertained to Medicaid. 
[Footnote 38] Each of the 4 states cited as having promising practices 
also indicated on our survey of state Medicaid programs that they 
consider their state to have a dental best practice. 

In addition to these 4 states, 22 states responding to our survey 
reported that they had best practices that could be shared with other 
states. See table 12 for brief descriptions of all 26 state-reported 
best practices. 

Table 8: Description of State-Reported Best Practices for Improving 
Dental Care for Children in Medicaid: 

State: Alabama; 
State-reported best practice: The "Smile Alabama!" initiative 
encompassed administrative reforms, implemented a case management 
system, increased outreach to patients and dentists, and set 
reimbursement rates equal to rates paid by commercial insurers. 

State: Arkansas; 
State-reported best practice: The state contracted with an organization 
to assist with outreach, scheduling, reminders, and transportation for 
Medicaid beneficiaries needing dental care. 

State: Arizona; 
State-reported best practice: The Oral Health Performance Improvement 
Project assists health plans identify gaps in quality-improvement 
strategies and address those areas. Examples include collaboration with 
programs such as Head Start and using health plan staff or dental 
providers to make presentations in schools or at community health 
fairs. 

State: Connecticut; 
State-reported best practice: The state established dental health care 
specialists who interact with the community to stress the importance of 
a dental home and regular dental care. Specialists interact with 
dentists to ensure families and children make their 6-month checkups, 
and act as a point of contact for the dentists. Specialists also 
provide oral health counseling and assistance, such as obtaining 
transportation and addressing language barriers. The state also created 
a member outreach handbook, including information on office etiquette 
and making appointments. 

State: Delaware[A]; 
State-reported best practice: The state reimburses providers at 85 
percent of usual and customary rates, which has encouraged dentists to 
participate in the state Medicaid program. 

State: Florida; 
State-reported best practice: The state provides coverage of fluoride 
varnish applications by non-dentists. 

State: Georgia; 
State-reported best practice: A managed care organization implemented a 
program that transferred a significant percentage of patients receiving 
intravenous sedation from outpatient hospital settings to dental 
offices. 

State: Iowa; 
State-reported best practice: As part of the I Smile Dental Home Plan, 
Oral Health Care Coordinators, who are dental hygienists employed by 
the Department of Public Health, work with counties to strengthen the 
public health dental system, link with local boards of health, provide 
training and oversight of health agency staff, and coordinate services 
for children ages 12 and under. 

State: Illinois; 
State-reported best practice: The state implemented several 
initiatives; (1) the Dental Champions Program, a peer-to-peer provider 
recruitment/retention effort to enroll providers, particularly in 
underserved areas, and to encourage increased participation among 
enrolled providers; (2) dental administrators and Early and Periodic 
Screening, Diagnostic, and Treatment (EPSDT) program outreach; (3) 
dental grants to build infrastructure in the public delivery system; 
and (4) fluoride varnish application in pediatric practices to promote 
a focus on oral health and appropriate referrals. 

State: Michigan; 
State-reported best practice: In its Healthy Kids Dental Program, the 
state contracted with one dental insurer so that all beneficiaries have 
access to the insurer's dental network. Beneficiaries carry the 
insurer's card, so they are treated the same as other employer-
sponsored subscribers. 

State: North Carolina; 
State-reported best practice: The state described two initiatives: (1) 
The Physician Fluoride Varnish Program, known as Into the Mouth of 
Babes, in which Medicaid recipients ages 6-42 months receive oral 
health services from participating primary care physicians; and (2) 
Carolina Dental Home Program, which is a pilot project that seeks to 
identify high-risk preschool Medicaid recipients and facilitates care 
coordination and referrals to general and pediatric dentists. 

State: New Hampshire; 
State-reported best practice: The Statewide Sealant Project is a school 
based program in which volunteer dentists and dental hygienists provide 
examinations and sealant applications. Other initiatives include 
raising dental rates, promoting access through partnership building, 
reducing administrative burdens, hiring a dental director, educating 
primary care physicians and caregivers, working to reduce broken 
appointments, and establishing a liaison between the state Medicaid 
program and Medicaid providers. 

State: New Jersey; 
State-reported best practice: The state reported three dental 
initiatives: (1) the Pediatric Oral Health Forum and Committee, which 
developed and is implementing the Pediatric Oral Health Action Plan; 
(2) a Collaborative to Improve Birth Outcomes and Health Status of 
Children, which facilitates coordination of care between medical 
providers and dentists; and (3) the New Jersey Smiles initiative, which 
aims to increase the percentage of children up to age 6 who have a 
dental home and who receive annual dental visits. 

State: New Mexico; 
State-reported best practice: The state created a special needs code, a 
reimbursement strategy that allows for dental practitioners to be 
eligible for an encounter fee of $90 (in addition to other billable 
services) when providing dental care to a person with developmental 
disabilities, if the practitioner has been through the program training 
and has become certified. 

State: Nevada; 
State-reported best practice: The Pay for Performance Program provides 
bonuses to health plans based on high performance and plan improvement, 
and has been incorporated into managed care contracts. 

State: Ohio; 
State-reported best practice: The state reported two initiatives; (1) 
reimbursement of physicians for application of fluoride varnish for 
children from first tooth eruption to age 3; and (2) use of mobile 
dental vans to improve access in underserved areas. 

State: Oklahoma; 
State-reported best practice: The state has implemented a student loan 
repayment program for dentists who agree to practice in identified 
areas and have at least 30 percent of their practice composed of 
Medicaid beneficiaries. 

State: Oregon; 
State-reported best practice: The Early Childhood Cavities Prevention 
Program trains general medical practitioners to perform oral screenings 
and apply fluoride. 

State: Pennsylvania; 
State-reported best practice: The state described two initiatives: (1) 
the Dental Disease Management Program, which encourages dental 
practices to provide comprehensive preventive, routine, and follow-up 
dental care; and (2) a requirement that providers notify the 
Department's Intensive Care Management Unit or Access Plus contractor 
when a child is referred to a dentist in order to be reimbursed. Follow 
up is made to confirm that the recommended visit has occurred. For 
children in MCOs, the provider must notify the MCO that the child is 
due for a dental referral as part of a complete EPSDT screen. 

State: Rhode Island; 
State-reported best practice: The Dental Benefits Manager Program is 
charged (among other things) with increasing reimbursement rates, 
ensuring there are sufficient dentists participating in the network, 
and assisting beneficiaries with finding dentists, securing 
transportation, and providing interpretation services. 

State: South Carolina[A]; 
State-reported best practice: The state increased fees to the 75th 
percentile of private-sector reimbursement rates and reduced 
administrative barriers for providers. The South Carolina Dental 
Association began an outreach campaign to encourage dentists to 
participate in Medicaid. 

State: South Dakota; 
State-reported best practice: The Accessing Better Children's Dentistry 
is an initiative in which certified dentists receive an enhanced 
reimbursement for certain procedures. 

State: Tennessee[A]; 
State-reported best practice: The state carved out the dental benefit 
in a Medicaid managed care environment and selected a benefit manager 
to administer dental benefits and establish reasonable provider 
reimbursement rates. Other activities include gathering input through a 
dental advisory committee, recruiting community-based dentists, and 
additional education and outreach. 

State: Texas; 
State-reported best practice: The First Dental Home initiative expands 
preventive dental services to children 6 through 35 months of age by 
providing risk assessments, anticipatory guidance, and more frequent 
dental checkup visits, based on the child's risk of developing caries. 

State: Virginia[A]; 
State-reported best practice: The Smiles for Children Program includes 
an increase in dental fees, streamlined administration, and the 
reduction of prior authorization requirements. The program also 
includes a Broken Appointment initiative, which tracks broken 
appointments and provides assistance, such as transportation, to help 
families keep their appointments. 

State: Washington; 
State-reported best practice: The Access to Baby and Child Dentistry 
program focuses on providing dental benefits to children up to age 5 by 
conducting outreach to organizations in which Medicaid-eligible 
children receive services, identifying and enrolling children in the 
program, educating families and caregivers, and matching each child 
with a program-certified dentist. 

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

[A] Posted on CMS's Web site as a promising practice as of May 2009. 

[End of table] 

[End of section] 

Appendix VI: Comments from the Department of Health and Human Services: 

Department Of Health & Human Services: 
Office Of The Secretary: 
Assistant Secretary for Legislation: 
Washington, DC 20201: 

August 19, 2009: 

Alicia Puente Cackley: 
Director, Health Care: 
U.S. Government Accountability Office: 
441 G Street, NW: 
Washington, DC 20548: 

Dear Ms. Cackley: 

Enclosed are the Department's comments on the U.S. Government 
Accountability Office's draft report entitled, "Medicaid: State and 
Federal Actions Have Been Taken to Improve Children's Access to Dental 
Services but Gaps Remain" (GAO-09-723). 

The Department appreciates the opportunity to review and comment on 
this draft report before its publication. 

Sincerely, 

Signed by: 

Barbara Pisaro Clark: 
Acting Assistant Secretary for Legislation: 

Enclosure: 

[End of letter] 

DEPARTMENT OF HEALTH & HUMAN SERVICES: 
Centers for Medicare & Medicaid Services: 
Administrator: 
Washington, DC 20201: 

Date: August 14, 2009: 

To: Alicia Puente Cackley: 
Director, Health Care: 
Government Accountability Office: 

From: [Signed by] Charlene Frizzera: 
Acting Administrator: 

Subject: Government Accountability Office (GAO) Draft Report: 
"Medicaid: State and Federal Actions Have Been Taken to Improve 
Children's Access to Dental Services but Gaps Remain" (GAO-09-723): 

Thank you for the opportunity to review and comment on the GAO Draft 
Report entitled, "Medicaid: State and Federal Actions Have Been Taken 
to Improve Children's Access to Dental Services but Gaps Remain" (GAO-
09-723). The report was prepared at the request of Congressman Dennis 
Kucinich, Chairman of the Subcommittee on Domestic Policy, and 
Congressman Elijah Cummings The purpose of the report was to examine: 

1) State strategies to monitor and improve access to dental care for 
children in Medicaid; and; 

2) The Centers for Medicare & Medicaid Services (CMS) actions since 
2007 to improve oversight of Medicaid dental services for children. 

The GAO Draft Report includes the following four recommendations for 
CMS: 

1. 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; 

2. Ensure that States found to have inadequate managed care 
organization (MCO) dental provider networks take action to strengthen 
those networks; 

3. Work with stakeholders to develop needed guidance on topics of 
concerns to States; and; 

4. Identify ways to improve sharing of promising practices among 
States. 

CMS Response to Recommendation 1: 

The CMS agrees in part with the GAO recommendation to develop a plan to 
review Medicaid dental services. CMS recognizes the need to continue 
and increase our focus on improving access to dental services for 
Medicaid-eligible children and to ensure that children receive the full 
scope of services available under the Early and Periodic Screening, 
Diagnostic and Treatment (EPSDT) benefit. As noted in the draft report, 
CMS has undertaken a number of activities related to improving access 
to dental services, such as focused dental reviews in 16 States, the 
release of the National Dental Summary in January 2009, and the 
National Medicaid Dental Town Hall Forum held on April 6, 2009. The 
purpose of the Town Hall Forum was to begin a dialogue between the 
interested stakeholders to discuss what steps can be taken to address 
issues related to and improve the delivery of dental services to 
Medicaid-eligible children. The National Association of State Medicaid 
Directors and the American Dental Association partnered with CMS for 
this event. A portion of the forum was devoted to presentations by 
States that provided examples of different approaches States have used 
to solve issues confronted by State Medicaid dental programs. CMS is in 
the process of preparing a summary of the Town Hall Forum that will be 
available to the public. The summary, including several best practices 
that have been identified, will be posted on the CMS Website when it 
has been completed. 

In the larger context of the provision of EPSDT services, CMS has 
convened an internal workgroup to review the policies and procedures 
related to EPSDT, including the provision of dental services. Based on 
this review, we are developing a workplan in which we will solicit
input and obtain recommendations from various stakeholders to provide 
updated, comprehensive guidance for State Medicaid programs. CMS is 
committed to releasing this guidance to States through State Medicaid 
Director letters by the end of this calendar year. As part of this 
review, the workgroup will consider additional focused reviews of State 
Dental programs, as well as comprehensive EPSDT service reviews. 

The CMS is also in the process of implementing the Children's Health 
Insurance Program Reauthorization Act of 2009 (CHIPRA) legislation, 
which includes a number of provisions related to dental services for 
both Medicaid and the Children's Health Insurance Program (CHIP). In 
regards to the Medicaid program, CHIPRA requires additional reporting 
information and requires that the Secretary work with States and others 
to provide a current list of all dentists and providers that provide 
dental services to children under Medicaid or CHIP State plans or
waivers. The Secretary is also required to work with States to provide 
a description of the dental services that each State provides under its 
Medicaid or CHIP State plan or waiver. CI IIPRA requires that this 
information be reported on the Insure Kids Now (IKN) website. CMS is 
currently working with the Health Resources and Services Administration 
(HRSA) on these provisions to include this information on the website. 
CMS will also ensure that dental quality measures are built into the 
quality measures program as required under CHIPRA. 

In terms of CHIP, CHIPRA requires the development of a dental education 
program for new parents of targeted low-income children. It also 
requires that targeted low-income children receive dental coverage; 
allows States to provide dental services through benchmark plans; and 
allows States with separate CHIP programs to provide dental-only 
supplemental coverage. 

CMS Response to Recommendation 2: 

The CMS agrees that States found to have inadequate MCO dental networks 
should be required to address this problem. Implementing regulations 
found at 42 CFR 438.206(6)(1) requires States to ensure through their 
contracts with managed care entities that the entity "maintains and 
monitors a network of appropriate providers that is supported by 
written agreements and is sufficient to provide adequate access to all 
services covered under the contract." Section 438207(a) of Federal 
regulations further requires States to obtain supporting documentation 
of the adequacy of a managed care entity's provider networks. CMS 
cannot approve contracts without these requirements being met. As GAO 
indicates, each of the 21 States reviewed applies measurable access 
standards to their MCO's dental networks. 

However, once a network is verified for purposes of contract approval, 
previously open panels may become filled or providers may drop out of a 
network which could create an issue with ongoing provider availability. 
In order to address this issue CMS is working with States to implement 
the requirement that was included in CHIPRA that all States post a 
listing of participating Medicaid and CHIP dental providers on the 
Insure Kids Now (IKN) Website at [hyperlink, 
http://www.insurekidsnow.gov]. States' MCO dental networks will also be 
included on the Website as appropriate. This information became 
available on the IKN website beginning August 4, 2009, as required by 
CHIPRA. 

Although making the lists of dental providers more publicly available 
will not necessarily address the problem of network inadequacy, it will 
give beneficiaries more accurate and updated information for the 
purpose of finding available providers. It will also give CMS the 
opportunity to assess where network adequacy problems may be occurring. 
In cases where an inadequate network is identified, CMS requires the 
State to impose a corrective action plan on the managed care entity to 
require an expansion of its dental network. If the problem is not 
corrected within a reasonable time frame, CMS could require the State 
to permit enrollees to access dental services outside of the managed 
care network. 

With respect to the 16 State dental reviews in the CMS National Dental 
Summary, GAO notes that 6 States found that they were not ensuring that 
MCO provider networks were adequate to afford access to covered dental 
services. As noted in the Summary, CMS is following up with each State 
to address issues noted during the reviews and to ensure that the State 
is in compliance with Federal laws. 

CMS Response to Recommendation 3: 

The CMS agrees with the recommendation to work with stakeholders to 
develop needed guidance on topics of concerns to States. As noted in 
our response to Recommendation 1, CMS is forming a workgroup on EPSDT 
services. The workgroup will provide an opportunity for CMS to involve 
interested stakeholders such as State Medicaid Agencies and 
organizations that work on child health care issues to assist us in 
this endeavor. We believe that input from these entities will be 
helpful in focusing the workgroup in areas of the most importance. 
While EPSDT will be the focus of the workgroup, access to dental 
services will continue to remain a high priority. As previously 
mentioned, guidance will be shared with the States as a result of the 
activities of this workgroup. We anticipate the workgroup will also 
focus on data reporting including dental reporting, as well as quality 
measurement. We will also issue guidance on the dental provisions of 
CHIPRA as we move forward with CHIPRA implementation. 

CMS Response to Recommendation 4: 

The CMS agrees with, and is committed to, the recommendation to improve 
sharing of promising practices among States and other stakeholders. The 
CMS Promising Practice. Webpage contains information on the process for 
submitting a promising practice for consideration, as well as a list of 
promising practices that have been vetted for publication. 

The CMS routinely requests that States submit information on promising 
practices through various avenues, such as our Technical Advisory 
Groups (TAGs) and calls our regional offices have with State EPSDT 
coordinators. CMS held a National Quality Call on Pediatric Oral Health 
on April 3, 2008, highlighting several State oral health initiatives. 
At that time we requested that the presenters and others in the 
audience submit any oral health promising practices to be shared with 
other States via our Webpage. In addition, in the National Medicaid 
Dental Summary of the 16 state dental reviews, CMS noted various 
promising or notable practices; some of these efforts were statewide 
and others were performed on the local level. We also used that 
opportunity to request those practices be submitted to us formally.
We will continue to highlight Promising Practices on our website and 
solicit additional input whenever opportunities arise. The Webpage is 
located at: [hyperlink, 
http://www.cms.hhs.gov/MedicaidCHIPQualPrac/MCPPDL/list.asp#Top0fPage]. 

In addition, as required under title IV of the CHIPRA legislation on 
Quality of Care, CMS is responsible for identifying and disseminating 
information to States regarding best practices with respect to 
"measuring and reporting on the quality of health care for children." 
CMS is also responsible for facilitating the adoption of such best 
practices. CMS is currently developing a work plan for identification, 
dissemination, and technical assistance related to Medicaid promising 
practices. 

Summary: 

In response to the ongoing problems related to access to dental care 
identified in this report, CMS is in the process of developing 
additional guidance and technical assistance to States on the provision 
of EPSDT services, with a particular focus on access to dental 
services. As part of our larger EPSDT initiative, CMS has undertaken a 
review of our policy guidance, policies and procedures and has convened 
an internal workgroup tasked with evaluating opportunities for working 
with States to improve access to and the consistent provision of EPSDT 
services. 

The CMS expects to increase our efforts to reach out to States and 
other interested parties and stakeholders through a variety of 
mechanisms such as Websites, TAG (including the Oral Health TAG), 
public meetings, and focused reviews. 

The CMS is working to implement the CHIPRA legislation, which includes 
a number of activities related to dental services. Dental measures will 
be included in the new quality measures program, and there will also be 
new reporting requirements. In addition, a list of dental providers 
will be available on the IKN Website. Finally, CMS will continue to 
focus our efforts on collecting and disseminating promising practices 
related to child health issues including oral health services. We will 
continue to use every opportunity to solicit input from States 
including a reminder in our guidance to States in State Medicaid 
Director letters on EPSDT services. 

[End of section] 

Appendix VII: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Alicia Puente Cackley, (202) 512-7114 or cackleya@gao.gov: 

Staff Acknowledgments: 

In addition to the contact named above, Katherine Iritani, Acting 
Director; Susannah Bloch; Sarah Burton; Martha Kelly; Ba Lin; Sarah 
Marshall; Terry Saiki; Jessica Cobert Smith; Teresa Tam; and Hemi 
Tewarson made key contributions to this report. 

[End of section] 

Related GAO Products: 

Medicaid: Extent of Dental Disease in Children Has Not Decreased, and 
Millions Are Estimated to Have Untreated Tooth Decay. [hyperlink, 
http://www.gao.gov/products/GAO-08-1121]. Washington, D.C.: September 
23, 2008. 

Medicaid: Extent of Dental Disease in Children Has Not Decreased. 
[hyperlink, http://www.gao.gov/products/GAO-08-1176T]. Washington, 
D.C.: September 23, 2008. 

Medicaid: Concerns Remain about Sufficiency of Data for Oversight of 
Children's Dental Services. [hyperlink, 
http://www.gao.gov/products/GAO-07-826T]. Washington, D.C.: May 2, 
2007. 

Medicaid Managed Care: Access and Quality Requirements Specific to Low- 
Income and Other Special Needs Enrollees. [hyperlink, 
http://www.gao.gov/products/GAO-05-44R]. Washington, D.C.: December 8, 
2004. 

Medicaid and SCHIP: States Use Varying Approaches to Monitor Children's 
Access to Care. [hyperlink, http://www.gao.gov/products/GAO-03-222]. 
Washington, D.C.: January 14, 2003. 

Medicaid: Stronger Efforts Needed to Ensure Children's Access to Health 
Screening Services. [hyperlink, 
http://www.gao.gov/products/GAO-01-749]. Washington, D.C.: July 13, 
2001. 

Oral Health: Factors Contributing to Low Use of Dental Services by Low- 
Income Populations. [hyperlink, 
http://www.gao.gov/products/GAO/HEHS-00-149]. Washington, D.C.: 
September 11, 2000. 

Oral Health: Dental Disease Is a Chronic Problem Among Low-Income 
Populations. [hyperlink, http://www.gao.gov/products/GAO/HEHS-00-72]. 
Washington, D.C.: April 12, 2000. 

Medicaid Managed Care: Challenge of Holding Plans Accountable Requires 
Greater State Effort. [hyperlink, 
http://www.gao.gov/products/GAO/HEHS-97-86]. Washington, D.C.: May 16, 
1997. 

[End of section] 

Footnotes: 

[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] We refer to the Subcommittee on Domestic Policy, Committee on 
Oversight and Government Reform, House of Representatives, as the 
Subcommittee throughout this report. 

[3] GAO, Medicaid: Extent of Dental Disease in Children Has Not 
Decreased, [hyperlink, http://www.gao.gov/products/GAO-08-1176T] 
(Washington, D.C.: Sept. 23, 2008). 

[4] A list of related GAO products can be found at the end of this 
report. 

[5] GAO, Oral Health: Factors Contributing to Low Use of Dental 
Services by Low-Income Populations, [hyperlink, 
http://www.gao.gov/products/GAO/HEHS-00-149] (Washington, D.C.: Sept. 
11, 2000). 

[6] We refer to the District of Columbia as a state and refer to the 
Medicaid director's survey response as the state Medicaid program's 
response or as the state's response throughout this report. 

[7] We reviewed only those dental provisions that were specified in the 
contracts under sections titled network adequacy, covered services, 
access standards, or similar. We also searched each contract using key 
terms, such as network and access, to identify additional related 
provisions. 

[8] The State Children's Health Insurance Program (SCHIP) provides 
health care coverage to children in low-income families who are not 
eligible for traditional Medicaid programs. CMS now refers to SCHIP as 
the Children's Health Insurance Program (CHIP). 

[9] U.S. Department of Health and Human Services, National Institute of 
Dental and Craniofacial Research, National Institutes of Health, Oral 
Health in America: A Report of the Surgeon General (Rockville, Md.: 
2000). 

[10] Matthew F. Savage, Jessica Y. Lee, Jonathan B. Kotch, and William 
F. Vann Jr., "Early Preventive Dental Visits: Effects on Subsequent 
Utilization and Costs," Pediatrics, 114 (2004). 

[11] Dental sealants, a plastic material put on the chewing surfaces of 
back teeth, have been shown to prevent decay on tooth surfaces where 
food and bacteria can build up. AAPD recommends sealants for 6-year and 
12-year molars as soon as possible after eruption. 

[12] The Healthy People 2010 goal was increased from 57 percent when it 
was first established in 2000 to 66 percent during a mid-course review 
in the mid-2000s. The goal defines preventive dental care to include 
examination, x-ray, fluoride treatment, cleaning, or sealant 
application. See U.S. Department of Health and Human Services, Public 
Health Service, Progress Review: Oral Health (Feb. 7, 2008). 

[13] The 30 million children represent the 2008 unduplicated annual 
enrollment (the total number of children, each child counted once, who 
were enrolled in Medicaid at any point in federal fiscal year 2008) 
reported by CMS. See [hyperlink, 
http://www.cms.hhs.gov/CapMarketUpdates/02_CMSStatistics.asp#TopOfPage] 
(accessed May 18, 2009). 

[14] CMS's statistics include the Medicaid population enrolled in 
capitated plans (typically defined as plans that contract with states 
to receive a prepaid payment per enrollee for coverage of Medicaid 
services) and primary care case management models. 

[15] Dental services must also be provided as medically necessary to 
identify a suspected illness or condition and must include, at a 
minimum, relief of pain and infections, restoration of teeth, and 
maintenance of dental health. 42 U.S.C. § 1396d(r)(3). 

[16] CMS, Guide to Children's Dental Care in Medicaid (Washington, 
D.C.: October 2004). Under contract with CMS, AAPD developed the guide 
as a resource for states on clinical practice, evolving technologies, 
and recommendations in dental care. 

[17] State Medicaid programs must annually report to the Secretary of 
HHS information on EPSDT services, including the number of children 
provided EPSDT screenings, the number of children referred for 
corrective treatment as a result of the screenings, the number of 
children receiving dental services, and the states' results in meeting 
annual goals for children's receipt of EPSDT services established by 
HHS. 42 U.S.C. § 1396a(a)(43). 

[18] GAO, Oral Health: Dental Disease Is a Chronic Problem among Low- 
Income Populations, [hyperlink, 
http://www.gao.gov/products/GAO/HEHS-00-72] (Washington, D.C.: Apr. 12, 
2000). 

[19] [hyperlink, http://www.gao.gov/products/GAO/HEHS-00-149]. 

[20] Although dental disease in the overall Medicaid population aged 2 
through 18 did not decrease, the trends vary somewhat among different 
age groups. Younger children--those aged 2 through 5--had statistically 
significant higher rates of dental disease in the more recent time 
period examined as compared to earlier surveys. By contrast, data for 
adolescents--children in Medicaid aged 16 through 18--show declining 
rates of tooth decay, although the change was not statistically 
significant. GAO, Medicaid: Extent of Dental Disease in Children Has 
Not Decreased, and Millions Are Estimated to Have Untreated Tooth 
Decay, [hyperlink, http://www.gao.gov/products/GAO-08-1121] 
(Washington, D.C.: Sept. 23, 2008). 

[21] See Pub. L. No. 111-5, div. B, tit. V § 5001, 123 Stat. 115, 496 
(Feb. 17, 2009) (codified at 42 U.S.C. § 1396d note). 

[22] GAO, Recovery Act: States' and Localities' Current and Planned 
Uses of Funds While Facing Fiscal Stresses, [hyperlink, 
http://www.gao.gov/products/GAO-09-829] (Washington, D.C.: July 8, 
2009). 

[23] Twenty-one of the 51 state Medicaid programs reported using both 
managed care and fee-for-service to deliver dental services to Medicaid 
beneficiaries in their state. For our survey, we defined managed care 
as arrangements where the state pays an MCO a capitated (per member per 
month) payment and the MCO uses this payment to provide care. We 
defined dental care organizations as managed care organizations that 
provide only dental benefits. 

[24] Five of the 18 states reported that examining MCO networks in 
response to a complaint or concern was their only method to verify MCO 
networks, 13 states do so in combination with other verification 
methods. 

[25] GAO, Medicaid: Stronger Efforts Needed to Ensure Children's Access 
to Health Screening Services, [hyperlink, 
http://www.gao.gov/products/GAO-01-749] (Washington, D.C.: July 13, 
2001). 

[26] Christina Melvin, "A Collaborative Community-based Oral Care 
Program for School-age Children," Clinical Nurse Specialist, vol. 20, 
no. 1 (2006): 18-22. 

[27] Mary Greene-McIntyre, Mary Hayes Finch, and John Searcy, "Smile 
Alabama! Initiative: Interim Results from a Program To Increase 
Children's Access to Dental Care," Journal of Rural Health, vol. 19 
suppl. (2003): 407-15. 

[28] 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. 

[29] 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, 
2008). 

[30] CMS regional offices noted deficiencies for some states with 
respect to certain Medicaid requirements such as: (i) states must 
ensure, through their contracts, that MCOs maintain and monitor a 
network of appropriate providers that is supported by written 
agreements and is sufficient to provide adequate access to covered 
services (see 42 C.F.R. 438.206(b)(1)); (ii) states must ensure that 
all covered services are available and accessible to MCO enrollees (see 
42 C.F.R. § 438.206(a)); and (iii) Medicaid beneficiaries cannot be 
charged cost-sharing for EPSDT or emergency services (see 42 C.F.R. 
447.53(b)). 

[31] Provider reimbursement rates were not a specific part of CMS's 
focused dental reviews, even though some providers and others 
interviewed by CMS noted that low payment rates contributed to low 
provider participation in Medicaid. A CMS official indicated that the 
issue of low reimbursement rates would likely be part of ongoing 
discussions involving Medicaid dental topics such as delivery systems 
and administrative issues, but would not be the focus of its oversight 
efforts. The official reported that the agency plans to continue 
working with states and the American Dental Association on 
reimbursement issues. 

[32] HHS, Centers for Medicare & Medicaid Services, Policy Issues in 
the Delivery of Dental Services to Medicaid Children and Their Families 
(Sept. 22, 2008); [hyperlink, 
http://www.cms.hhs.gov/medicaiddentalcoverage/] (accessed Oct. 6, 
2008). 

[33] See [hyperlink, 
http://www.cms.hhs.gov/MedicaidCHIPQualPrac/MCPPDL/list.asp] (accessed 
May 20, 2009). 

[34] In commenting on a draft of this report, CMS indicated that it 
would consider additional focused dental reviews as part of a broader 
planning effort to review all EPSDT services. 

[35] GAO, Medicaid: Concerns Remain about Sufficiency of Data for 
Oversight of Children's Dental Services, [hyperlink, 
http://www.gao.gov/products/GAO-07-826T] (Washington, D.C.: May 2, 
2007). 

[36] In July 2009, CMS reported that it was developing a comprehensive 
workplan that included establishing a regular schedule for reviewing 
state EPSDT policy and implementation efforts. See Medicaid Preventive 
Services: Concerted Efforts Needed to Ensure Beneficiaries Receive 
Services, [hyperlink, http://www.gao.gov/products/GAO-09-578] 
(Washington, D.C.: August 14, 2009). 

[37] The Children's Health Insurance Program Reauthorization Act of 
2009 also mandates that GAO conduct a study on certain dental workforce 
and other Medicaid and CHIP dental issues and submit a report to 
Congress by August 2010. See Pub. L. No. 111-3, § 501(h), 123 Stat. 8, 
88 (Feb. 4, 2009). 

[38] The additional promising practice was related to dental benefits 
under the SCHIP program. 

[End of section] 

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Washington, D.C. 20548: 

Public Affairs: 

Chuck Young, Managing Director, youngc1@gao.gov: 
(202) 512-4800: 
U.S. Government Accountability Office: 
441 G Street NW, Room 7149: 
Washington, D.C. 20548: