On Oct. 7, 2009, the House Committee on Oversight and Government Reform’s Subcommittee on Domestic Policy held a hearing entitled, “Medicaid’s Efforts to Reform since the Preventable Death of Deamonte Driver; a Progress Report.” This marks the fourth hearing on this topic since Rep. Dennis Kucinich (D-OH-10) took over as Chairman in 2007. 

The hearing reviewed recent state and federal actions taken to improve children’s access to dental services, with the highlight being the release of a report on the subject matter by the Government Accountability Office (GAO), the investigative arm of Congress. The GAO found that almost all states report implementing initiatives to improve access to dental services, such as simplifying dental claims processing, increasing reimbursement rates, recruiting providers, and educating beneficiaries, but that access rates remain low due to long-standing barriers, such as low payment rates for dental services and insufficient federal and state efforts to address oral health access problems. According to the GAO, children served by Medicaid have difficulty finding dentists to treat them due to limited dentist participation in Medicaid. 

The GAO reported that all 50 states have reported taking at least one action to recruit Medicaid providers. The GAO highlighted Alabama’s efforts (the “Smile Alabama” initiative), which has simplified claims processing, increased reimbursement rates to equal those paid by commercial insurers, educated and recruited providers, and educated beneficiaries. These efforts led to 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.

The GAO also reported that the Centers for Medicare and Medicaid Services (CMS) have taken several actions in recent years to increase children’s access to dental care. These actions include conducting a focused dental review of 17 states between October 2007 and May 2008 that found many of the states’ efforts lacking, publishing a 16-page Medicaid dental policy document on its Web site, hosting several meetings and conference calls with state dental representatives and other stakeholders from 2007 to 2009, establishing an Oral Health Technical Advisory Group, and describing successful state programs by posting “promising practices” on its Web site —currently, Delaware, South Carolina, Tennessee, and Virginia are highlighted.

Each of the four states currently highlighted on the CMS Web site for increasing access to care has increased reimbursement rates to better reflect the true cost of providing care:

• Delaware now reimburses providers at 85 percent of usual and customary rates.
• South Carolina increased fees to the 75th percentile of private-sector reimbursement rates and reduced administrative barriers.
• Tennessee 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.
• Virginia increased dental fees, streamlined administration, and reduced prior authorization requirements. It also began a Broken Appointment Initiative, which tracks broken appointments and provides assistance, such as transportation, to help families keep their appointments.

Impact on General Dentistry: The GAO’s report, released at the Domestic Policy Subcommittee hearing, demonstrates that when states increase their Medicaid reimbursement rates for dental providers, participation in the program goes up and access to care improves. 

The GAO also recognized in its report that missed appointments by Medicaid beneficiaries are a problem. The GAO reported that 45 states indicated in surveys that providers find missed appointments to be a moderate-to-major impediment to increased children’s access to dental care. 

Few solutions were offered to this issue. In fact, the GAO reported that the CMS has determined that a state may not permit providers to bill patients for missed appointments. The CMS indicated that Medicaid policy does not permit such billing, in part because no services were delivered and in part because missed appointments are not a reimbursable Medicaid service but rather are considered to be a part of a provider’s overall cost of doing business.