Earlier this month, the Centers for Medicare and Medicaid Services (CMS) issued an informational bulletin underscoring the link between oral and overall health and the importance of dental care for children with Medicaid coverage. This bulletin recognizes the pitfalls of a one-size-fits-all approach and underscores existing policy that states that children should be covered for the full range of dental services they need to maintain their oral and overall health. Following this guidance will help states ensure that children receive the full range of dental health services they need and that providers are reimbursed for them. This guidance puts much needed emphasis on the importance of oral health for general health and children’s overall wellbeing. Specifically, the bulletin recommends that states ensure they are conforming to existing policy in the following ways:
States should ensure that necessary oral health services and payment policies are aligned
“Periodicity schedules” (chosen by each state) outline the minimum oral health services children should receive and the recommended frequency with which they should get them. Payment policies, such as fee schedules, lay out which dental services Medicaid/CHIP will reimburse providers for. To ensure that children receive the oral health services they need to stay healthy and perform well in school, CMS is directing states to ensure that periodicity and fee schedules are in alignment. For example, if a state’s periodicity schedule states that children should receive fluoride varnish every three months, starting at six months old, that state’s Medicaid fee schedule should allow providers to be reimbursed for applying fluoride varnish every three months. If the fee schedule only allows reimbursement for fluoride varnish every 12 months, children will likely not get all the dental services they need, putting their oral health at risk.
States should treat dental periodicity schedules as a floor, not a ceiling
While a state’s dental periodicity schedule provides recommendations, CMS notes that states should cover additional oral health services based on individual children’s risk factors and health needs, underscoring the importance of Medicaid’s Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. CMS also encourages the creation of individualized care plans to ensure that each child gets appropriate care. For example, if a state’s periodicity schedule indicates children should get two fluoride treatments per year, but a child with a special health care need or history of cavities requires recall visits every three months to maintain their health, that child should be covered for four yearly visits and fluoride treatments, even though this is beyond what is indicated in the state’s dental periodicity schedule.
States should conduct necessary oversight of managed care plans
Even when a state Medicaid program is providing dental benefits through a managed care entity (MCO), the state is ultimately responsible for ensuring that children receive appropriate care in accordance with EPSDT. CMS instructs states to confirm that the fee schedules and payment policies of contracted plans are aligned with the state’s periodicity schedule. States should also make clear that the standards of EPSDT apply to dental care, regardless of how benefits are administered.
Advocates can support their states
This new bulletin underscores what health advocates and the oral health community already know: Ensuring children’s oral and overall health requires intentional investment on the part of Medicaid and CHIP programs and other state entities. Because oral health and general health are so closely related, supporting this guidance, advocating for periodicity schedules that provide needed preventive services for children and for fee schedules that are aligned with them should be a priority for children’s health advocates.
Advocates play an important role in fostering accountability within their states and may consider the following activities to maximize the positive impact of EPSDT and the CMS guidance:
1) Find out what dental services are included in your state’s periodicity schedule and consider advocating for more robust standards, if necessary. The American Academy of Pediatrics Bright Futures pediatric periodicity schedule recommends all children receive an oral health risk assessment and appropriate follow-up care based on their individual risk factors for tooth decay and other guidelines for preventive oral health services. The American Academy of Pediatric Dentistry includes similar recommendations. States can choose to use Bright Futures as the basis for their periodicity schedule.
2) Contact your state’s Medicaid program to check that the periodicity schedule matches the fee schedule and advocate for alignment if it does not. If your state uses managed care, contact the MCOs to ensure they are paying providers for services included in your state’s dental periodicity schedule.
3) Find out if your state and its MCOs have a formalized process for approving and paying for additional dental services, above what is laid out in the periodicity schedule. You may consider advocating for this process if one does not exist or educating families about the details of the process if it exists.
4) Monitor any changes your state makes to the dental periodicity schedule and ensure the fee schedule is updated accordingly; monitor any changes to payment policies and ensure they remain in line with recommended care in the periodicity schedule.
5) Make sure you know about the oral health needs of children with Medicaid coverage in your state, so that your advocacy reflects the needs of communities. Consider creating a grassroots organizing plan, if you don’t already have one.
Community Catalyst supports this guidance and the policies it underscores that ensure children get access to the oral and general health services they need to support their growth, development and wellbeing.
Kasey Wilson and guest blogger Deborah Vishnevsky, Policy Analyst, Children’s Dental Health Project