Advancing Access to Oral Health Care Amidst COVID-19 Recovery

Teledentistry

Participating state officials expressed their interest in increasing access to oral health care by sustaining or building on new teledentistry flexibilities introduced during the pandemic. According to the ADA, teledentistry, like other telehealth services, involves “the use of telehealth systems and methodologies” in dentistry, such as live video interaction, asynchronous or “store and forward” communication, and remote patient monitoring. Adoption of these methods and reimbursement for teledentistry approaches varies by state. Teledentistry can greatly increase access to oral health care, particularly for underserved populations such as communities of color and those living in rural areas.

During the pandemic, 17 states updated their Medicaid teledentistry guidance to allow new provider types to deliver virtual services, expand the scope of services that can be reimbursed through Medicaid, and ease consent restrictions that limited access to teledentistry, among other policy modifications. Considering telehealth policy revisions made during the COVID-19 pandemic, twenty-three states currently have policies in place to allow for delivery and reimbursement of teledentistry, however, challenges remain. For example, state leaders shared concerns about reimbursement for teledental services and limited guidance for providers about scheduling teledentistry visits in tandem with in-person visits. Some states, such as Pennsylvania and Rhode Island, seek to maintain or enhance teledentristry policies enacted during the pandemic to increase access to care for low-income children and adults.

In March 2020, Pennsylvania established guidance defining teledentistry as “two-way, real-time interactive communication” between a patient and dental provider. Accordingly, the Pennsylvania Medicaid program dental fee schedule was updated with billing codes D9995 (“teledentistry – synchronous”) and D0140 (“limited oral evaluation – problem focused”). (The D9995 code is not reimbursable, rather it is used to document teledental visits and must be used in conjunction with D0140 to provide services to patients experiencing dental emergencies). This policy lasted for the duration of the state of emergency in Pennsylvania, ending June 10, 2021.  Now, officials seek to make permanent these Medicaid policies for preventive teledentistry through developing guidance on:

• virtual supervision of fluoride varnish application,
• tobacco cessation counseling,
• oral hygiene instructions and nutritional counseling,
• limited problem-focused evaluations,
• integration of different settings of care delivery, and
• care coordination for follow up to in-person visits as needed.

Rhode Island is in the process of establishing Medicaid guidance for teledentistry to expand dental services, particularly for children. At the beginning of the COVID-19 pandemic, the Rhode Island Department of Health released guidance allowing providers to bill telehealth services to Medicaid. This allowed dental providers to bill for a care coordination phone call (D9992) and schedule emergency video consultations with patients (D9310). This guidance expired on July 6, 2021, but the Rhode Island legislature recently passed an update to the Telemedicine Coverage Act, which expands telemedicine coverage requirements for Medicaid and private insurers, requires reimbursement rates for telemedicine services to match in-person rates, and ensures that dentists providing teledentistry services be held to the same standards of care that would apply in an in-person setting. Work to communicate reimbursable services to dental providers is in progress.

As states identify approaches to expand the use of teledentistry, many are creating pathways for patients and their caregivers to administer certain preventive procedures under virtual supervision from dental practitioners. As part of a pilot project, Nevada allows parents to apply fluoride varnish for their children under virtual supervision from a licensed dental provider. The Nevada Board of Dental Examiners approved virtual provision of fluoride varnish for individuals under the age of 21 in October 2020. A forthcoming fact sheet will provide more information on Nevada’s fluoride varnish program.

School-linked and School-based Programs

States also are considering how to leverage schools to fill dental care gaps among children. School-based dental sealant programs (SBSPs) provide critical primary and preventive dental care and disproportionately serve low-income students and those living in rural areas. However, according to a 2015 survey, 39 states and the District of Columbia do not have sealant programs in most of their high need schools, and only 5 states have sealant programs in at least 75 percent of high need schools. The Centers for Disease Control and Prevention (CDC) published considerations for SBSPs during the COVID-19 pandemic that includes information on restarting SBSPs. Still, state leaders cited concerns that reestablishing school-based programs will be challenging due to safety concerns, changing guidance, and workforce shortages, and they are searching for other strategies to increase access to dental care for students from low-income households.

To encourage children to visit dental providers in advance of the 2021-2022 school year, Smile, California, the California Medi-Cal Dental Program’s campaign, is partnering with the Office of Oral Health and Local Oral Health Programs to carry out a Back Tooth School Activation. Campaign partners can access Back Tooth School resources on the Oral Health and School Readiness website. Additionally, although the pandemic has limited students’ ability to receive oral care at school, California is pursuing strategies to screen children at school and refer them to dental providers using an electronic referral system. California’s Dental Transformation Initiative created a pilot program to improve dental health for Medicaid-eligible children. More LA Smiles, run through UCLA, is the largest of these pilot projects and created the LA Dental Registry and Referral System (LADRRS) to connect medical providers in clinical settings with dental providers. To implement a school-linked program, a platform like LADRRS can be modified to include referrals from schools. This system will enable state leaders to target low-income schools and gather data on students’ health.

Acknowledgement: The authors thank state officials from California, Rhode Island, Colorado, Pennsylvania, Minnesota, and North Carolina who reviewed a draft of this publication. Additionally, we thank the Health Resources and Services Administration (HRSA) officials who provided thoughtful input. This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services under grant number U2MOA394670100, National Organizations of State and Local Officials. This information, content, or conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the US government.