Promoting Maternal and Child Health: Virginia’s Dental Benefit for Pregnant Women
The maternal mortality crisis has driven state and federal leaders to address access to high quality care during the perinatal period. With proposals to extend Medicaid coverage to twelve months postpartum, states are also considering what services are offered to pregnant women through Medicaid. Currently, 29 states and Washington DC offer extensive dental services to pregnant and postpartum women.
Dental care during the perinatal period influences health outcomes for both the parent and child, and can reduce expensive medical care that results from lack of care. With this in mind, Virginia added a pregnancy dental benefit in 2015. With nearly half of pregnancies in the United States financed by Medicaid, Virginia shows how states can play an important role in providing access to dental care for pregnant women through their Medicaid programs.
Access to Perinatal Dental Care and Health Outcomes
Inability to access dental care while pregnant can result in adverse health outcomes. Research indicates that all dental care, including procedures that require dental anesthesia during pregnancy, is safe. Poor oral health is associated with low birthweight, preeclampsia, other pregnancy complications and a lower quality of life. Nationally, 73 percent of women had dental insurance during pregnancy, but only 48 percent received a dental cleaning during pregnancy.
Evidence suggests that prenatal oral health care can improve children’s oral health by reducing the incidence of Early Childhood Caries (ECC). ECC is the presence of decayed, missing or filled tooth surfaces in primary (baby) teeth in a child under the age of 6. ECC can lead to emergency room visits and negatively impact school performance. Dental caries (tooth decay) is the most common chronic disease in US children ages 6 to 19 years. Additionally, children are at a higher risk for tooth decay if their birth parent has untreated tooth decay. Parents’ oral health behaviors and dental care utilization can influence children’s risk of dental caries.
Despite overall oral health improvement in the United States over the past several decades, racial and economic disparities persist. Access to dental clinics, insurance status, financial resources and underrepresentation of people of color in the dental workforce are cited as structural barriers for accessing dental care for people of color. These disparities are evident in children, pregnant women and adult populations:
- Latino children, regardless of insurance type, visit the dentist less frequently than white children and are more likely from age two to five have cavities.
- Black and Hispanic pregnant women are less likely to receive dental care, including teeth cleanings before or during pregnancy, than white women.
- Over 40 percent of low-income and non-Hispanic Black adults experience tooth decay, and low-income adults are three times as likely to have four or more untreated cavities as adults with higher incomes.
Dental Care for Pregnant Women in Medicaid
While state Medicaid programs are required to cover dental services for children under 21 as a part of the Early and Periodic, Screening, Diagnostic and Treatment (EPSDT) benefit, dental services for adults are optional in Medicaid. However, 36 states and Washington, DC provide services beyond emergency dental situations; 22 states and Washington, DC provide extensive services for adults, and 29 states and Washington, DC offer an extensive benefit to pregnant women. State benefit packages vary from state to state and generally fall into the following categories:
- Emergency services only;
- Limited services: a cap of $1,000 annually and fewer than 100 American Dental Association (ADA) identified services; or
- Extensive coverage: a cap greater than $1,000 dollars annually and more than 100 ADA identified services including major restorative procedures.
The American Academy of Pediatric Dentistry and the American College of Obstetricians and Gynecologists recommend diagnostic, preventative, restorative, emergency and periodontal care for pregnant women.
When states face revenue shortfalls, they tend to cut optional services, including dental services for pregnant women. For example, 19 states restricted their dental programs during the great recession and only 8 states restored their dental benefit between state fiscal years 2013 and 2016. Despite these fiscal constraints, Virginia expanded health benefits to pregnant women, citing the importance of good oral health for overall health and impact on child oral health.
Virginia’s Dental Benefit for Pregnant Women
Recognizing the importance of oral health in overall health and its key role in healthy birth outcomes, Virginia added a dental benefit in 2015. It was introduced as part of Gov. McAuliffe’s A Healthy Virginia Plan, which proposed expanding services to over 200,000 Virginians, including dental benefits to 45,000 pregnant women in Virginia. The initial cost for the program was 1.9 million over the 2014-2016 biennium budget.
In Virginia, pregnant women over age 21 with incomes less than 148 percent of the Federal Poverty Line (FPL) are covered by Medicaid, and pregnant women with incomes between 148 and 205 percent FPL are covered by the Family Access to Medical Insurance Security (FAMIS) program, which is Virginia’s Children’s Health Insurance Program (CHIP). Dental services are delivered either by the individual’s selected medical managed care organization (MCO) or through fee-for-service. All pregnant women receive dental services through the state’s Smiles For Children program, provided by a dental benefits manager (DBM). The dental benefit ends at the end of the month following an individual’s 60th day postpartum.
Virginia requires coordination between the Medicaid MCOs and the DBM. The Medicaid managed care request for proposals (RFP) outlines the MCO’s role for coordination with the DBM on outreach for dental service utilization. According to state officials, the Commonwealth has also established relationships between MCOs and the DBM to assist pregnant members in locating dentists and securing appointments.
State officials noted that there is still skepticism about going to the dentist while pregnant. This presents the state with an opportunity to collaborate with MCOs and the DBM to educate enrollees about the safety of services and the new benefit.
A staff member with the DBM is responsible for collaboration efforts including education and training. Virginia Medicaid MCOs work to promote dental services with pedicitricians, family practices and OB/GYNS through the Smiling Stork Program. The Smiling Stork program educates women about the importance of being screened for periodontal disease during pregnancy, the value of establishing good oral health habits for their babies, and how to access covered dental services during pregnancy.
The addition of dental services for pregnant women in Medicaid has yielded positive results for Virginia. Pregnancy Risk Assessment Monitoring System (PRAMS) data show that the number of pregnant women receiving dental services doubled from 2014 to 2019. The Virginia Department of Health created practice guidance for prenatal and dental providers, and it conducts outreach to maternity clinics to promote dental care access.
The expanded dental benefit was initially funded for three years. The Department of Medical Asssistance Services (DMAS), Virginia’s Medicaid program, engaged the Dental Advisory Committee and other stakeholders to maintain the expanded benefit. State officials cite strong internal collaboration among IT staff, health care services, maternal and child health, training and transportation, and executive leadership as key for successful implementation of the benefit.
Implications
Recent state Medicaid coverage expansions and a concerted focus on improving maternal health provide opportunities for states to ensure dental services for pregnant women. The expansion of dental services for pregnant women in Virginia was a part of broader coverage expansion introduced by Gov. McAuliffe, with the 2015 dental benefit for pregnant women predating Medicaid expansion in 2019 and an adult Medicaid dental benefit in 2020.
Virginia also recently submitted an amendment to its 1115 demonstration waiver to extend postpartum Medicaid coverage to 12 months. This expansion would include dental benefits, as “full benefit coverage is essential to meeting the needs of the state’s postpartum women.” The demonstration waiver amendment includes an evaluation plan to determine the impact of postpartum coverage on reducing the rate of maternal mortality, morbidity and racial disparities among postpartum women and infants.
As Virginia expands services for pregnant and postpartum women, there is an increased focus on quality care during the perinatal period at the state and federal level. The Mothers and Offspring Mortality and Morbidity Awareness (MOMMA’s) Act introduced in the House of Representatives and Senate would extend Medicaid coverage to 12 months postpartum and require states to cover preventative, diagnostic, periodontal and restorative care during pregnancy and the postpartum period. Additionally, the recently passed American Rescue Plan gives states the option to extend Medicaid coverage to 12 months postpartum through a state plan amendment (SPA). States seeking to expand postpartum coverage through a waiver may select the SPA option.
Another introduced bill, S. 560, the Oral Health for Moms Act, aims to expand dental services for pregnant women. This bill would require Medicaid and CHIP to cover dental services for pregnant and postpartum women and make dental services an essential health benefit for pregnant women who receive health insurance through the federal marketplace or small group markets. The bill would also:
- Provide grants to federally qualified health centers (FQHCs) for dental services;
- Create an oral health initiative through the Indian Health Service to address barriers to oral health for American Indian and Alaskan Native populations;
- Require the Medicaid and CHIP Payment and Access Commission to issue a maternal oral health care report;
- Establish a perinatal oral health outreach and education program to provide information on best oral health practices and connect pregnant and postpartum individuals and children to oral health care; and
- Integrate oral health care into maternal health care settings through grants to state health departments and agencies to develop trainings on oral health for maternal health providers.
With national attention on Medicaid coverage for the postpartum period, states can consider including dental services as a component of perinatal health care. New federal options including the MOMMA’s Act, ARPA, and Senate Bill 560 may allow states to expand dental services to pregnant women and lengthen the duration of services; recently introduced federal legislation might further increase opportunities for states. Experience from Virginia can serve as a case study for states looking to expand access to dental services during the perinatal period and improve maternal health outcomes.
Acknowledgement: This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under grant number U2MOA394670100, National Organizations of State and Local Officials. This information or content and conclusions are those of the author 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. The author would like to thank the Virginia state officials, including Dr. Hairston who helped review and provide feedback on this blog.
Medicaid Strategies for Addressing Social Determinants of Health: Considerations from State Leaders for Improving Oral and Overall Health
Upstream factors such as access to nutritious food, education, and transportation drive inequities in oral health and health outcomes. States are working to improve the oral and physical health of Medicaid enrollees and to reduce costs by addressing social determinants of health (SDOH) in their managed care medical and dental contracts. The National Academy for State Health Policy (NASHP) recently convened state leaders to discuss emerging opportunities for addressing SDOH related to oral health and ways to leverage existing SDOH efforts in medical delivery systems for dental delivery systems. Three key themes emerged from the discussion: integrating medical and dental systems to more effectively coordinate care and address patients’ social needs; working with and educating different provider types – including community health workers and dental staff – to address social determinants of oral health; and investing in communities to support programs that promote health equity.
Medical/Dental Integration
Experts agree that dental care is essential health care, and therefore oral health is an important part of overall health. State Medicaid programs deliver dental services through different models, including fee-for-service, carved-in managed care programs where states contract with managed care organizations (MCOs), carved-out managed care programs where states contract with a dental MCO or a third-party administrator, or a combination of these models. States shared that regardless of their dental delivery system, there is ample opportunity to better integrate their medical and dental systems. Closed loop referral systems, state managed care contracting requirements, and shared data/metrics are examples of tools for integration to better address SDOH.
- A closed loop referral system is an important care coordination tool that uses technology to track cross-sector referrals and services a patient receives. Data is shared with multiple providers, lends accountability for community-clinical referrals, and can be used to identify gaps in available services. Arizona Medicaid recently launched its Whole Person Care Initiative to address enrollees’ SDOH and will implement a closed loop referral system for providers, health plans, community-based organizations (CBOs), and community stakeholders. In February 2021, the state’s Health Information Exchange (Health Current) contracted with a technology provider to work with Arizona Medicaid, Health Current, and 2-1-1 Arizona on the referral system. Through the closed loop system, enrollees will be screened for social risk factors and referred to highly matched community resources.
- States can use managed care contracting requirements to integrate medical and dental services. In Oklahoma, the state’s request for proposals includes language requiring the medical MCO to share an enrollee’s health risk screening information with the dental plan to prevent duplication and coordinate care. Kansas’ managed care contract includes a service coordinator to connect enrollees to CBOs for social needs based on a health risk assessment.
- State officials also identified data sharing as a key tool for medical and dental integration. In Michigan, officials are using lessons learned from the state’s physical and behavioral health integration, specifically the use of shared metrics, to inform their medical and dental integration. Michigan is also exploring data sharing with health plans around emergency dental data, for a shared metric between MCOs in the future. Pennsylvania is working with its MCOs to collect quality data for various dental services and discussing the specifics of their initiatives during quarterly meetings to highlight which demographics are impacted the most. The next step is to then investigate the specific barriers for each defined population within different areas, acknowledging different SDOH. Other state officials also mentioned the need for a shared diagnostic language between medical and dental providers such as ICD-10 Z codes used to document SDOH data.
Oral Health Workforce
State leaders agree that a strong oral health workforce is necessary to address SDOH. The oral health workforce includes dentists, dental hygienists, community health workers (CHWs), and other providers that deliver oral health services or provide important referrals to dental services. The Institute of Medicine’s Advancing Oral Health in America report recommends the use of all professionals in oral health care and training for collaborative efforts between dental and medical staff, including the use of referrals. During the roundtable, state officials stressed the importance of dental staff who reflect the community and therefore understand the resources available for care coordination and referrals.
- State officials identified the need for staff trained in SDOH and community resources to best address enrollees’ social needs. For example, Nebraska’s dental contract requires staff to be trained on how SDOH affect members’ health and wellness. A NASHP 50-state scan of medical and dental contracts revealed that more medical MCOs require training for SDOH than dental MCOs. Therefore, integrating medical and dental care can also leverage medical MCO staff training in SDOH.
- CHWs, community members with public health training, promote health equity and can address SDOH, along with oral and overall health needs. CHWs have served communities in Michigan since 1960. Since 2016, Michigan has required Medicaid MCOs to have CHWs based on an enrollee ratio. The current contract requires at least 1 full time CHW for every 5,000 enrollees. CHWs are an integral part of the MI Care Team Health Home program for Medicaid enrollees with chronic conditions to identify community resources, coordinate and track referrals, and provide health education. CHW programs also illustrate connections between public health programs that generally oversee CHW training and regulation and Medicaid programs that can finance CHWs.
- Rhode Island Medicaid piloted a dental case management program with CHWs, social workers, and dental staff. The goal of the program was to increase utilization in dental services and remove barriers to service delivery. Dental case managers provided motivational interviewing, health literacy activities, care coordination, community outreach, education, and appointment reminders. These services were tracked using Current Dental Terminology (CDT) codes to monitor care and patient needs. In one Federally Qualified Health Center, a CHW worked part time on case management and was successful in reducing the dental clinic’s no-show rate. In 2021, the dental case management program was included in the state’s approved 1115 Comprehensive Demonstration Waiver.
Community Partnerships and Investment
State leaders also discussed the importance of community partnerships and shared examples of how their states incentivize health plans to invest in the community. State governments can support system-level changes to address SDOH, and managed care plans also can play a valuable role given their extensive reach, existing relationships with members, and larger budgets. However, CBOs and community members also play an important role in improving health equity; according to state leaders, it is critical to ensure that community members are actively engaged in addressing SDOH and that the relationship between the plan and the community is bidirectional. Through their Medicaid medical and dental contracts, some states have started requiring MCOs to support the work of CBOs to improve residents’ social and economic needs. States might consider encouraging dental plans and providers to make similar investments in SDOH and community partnerships to address health equity:
- Arizona’s Medicaid MCO contracts require the plans to spend at least 6 percent of their annual profits on community reinvestment, with a special focus on SDOH. In 2020, the MCOs pooled a portion of their community reinvestment dollars to invest in Home Matters to Arizona, a statewide initiative to improve access to affordable housing. The MCOs’ grants helped create the $100 million Home Matters Arizona Fund to finance affordable housing projects and development. These new funds will prioritize investment in CBO development of affordable housing to serve Medicaid-eligible and other low-income households throughout Arizona. Especially in a state like Arizona, where the dental benefit is carved into the medical managed care program, the dental program and dental subcontractors could work with medical plans or with each other to pool profits and reinvest in the community to maximize impact.
- Similarly, Rhode Island’s Accountable Entities (AEs) must allocate 10 percent of the incentive funds they earn to CBOs that support behavioral health care, substance abuse treatment and/or SDOH. The state encourages AEs to use these funds to build CBO capacity – including supporting their technological, analytical, and care coordination needs –to integrate health and social services and help the CBOs enter into financial arrangements with health systems. By requiring the health plans to invest in community partners, Rhode Island aims to strengthen the link between clinical and community settings.
In addition to the medical system efforts, some states also require dental plans to partner with CBOs:
- Nevada requires its dental vendor to use annual community-based needs assessments to evaluate the health education, cultural, and linguistic needs of the plan’s members. The vendor must then implement culturally appropriate health promotion and education activities to address any identified needs.
- In Nebraska, the dental contractor employs Member Advocate and Outreach Specialists, who partner with CBOs to help educate members about their dental benefits and connect individuals to community resources.
Strong partnerships between health systems and CBOs are necessary to address SDOH and make lasting change. It can be challenging, though, to bring together stakeholders with different resources, budgets, and terminologies. State officials identified multiple keys to success for these relationships, including establishing clear responsibilities through an MOU, acknowledging the different organizations’ operating budgets, compensating CBOs for their work, and making sure that representatives from the medical and dental systems and from CBOs use a shared language and are familiar with each other’s terminology.
Conclusion
Evidence suggests that addressing SDOH improves physical and oral health outcomes. In both medical and dental delivery systems, states are finding innovative ways to address individuals’ and communities’ social and economic needs to improve health. Many of these initiatives are currently driven by the medical system, but they can also serve as examples of programs and contract language that states might consider adopting for dental plans.
Though conversations about health equity often focus on Medicaid’s role in driving SDOH-related initiatives, public health agencies and providers are key players and may have best practices for improving population health from which Medicaid can learn. Contractual requirements and incentive payments may motivate medical and dental plans to address SDOH, but Medicaid MCOs tend to focus their initiatives on their own membership. Encouraging Medicaid to address population-wide concerns remains a challenge, likely in part due to how Medicaid is funded and federal limits on how dollars may be used. Arizona’s Medicaid MCOs’ joint investment in housing is one example of how Medicaid can support community-level initiatives statewide. NASHP will continue to bring together state Medicaid and public health medical and dental leaders to discuss best practices and strategies for addressing SDOH as they relate to oral and overall health.
This blog and the related activities were made possible by support from the CareQuest Institute for Oral Health. The authors would like to thank the CareQuest Institute and the state officials who helped review and provide feedback on this blog.
Texas Improves Access to Routine Oral Health Services for Very Young Children
Though largely preventable, tooth decay (caries) is the most common chronic disease in US children, affecting approximately 23 percent of children ages 2 to 5.[1],[2] Texas’s First Dental Home and its enhanced bundled payment has increased access to preventive dental service and improved the oral health of Medicaid-enrolled children ages 6 to 35 months.
Providing children with access to routine oral health services has the potential to prevent dental caries, reduce emergency dental visits, and promote overall health, resulting in significant cost savings for states. States are required to provide dental services to Medicaid-enrolled children under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. While it is recommended that all children receive an initial dental visit in their first year of life, less than 10 percent of Medicaid-enrolled children under age 3 receive preventive dental services.[3] This case study explores how Texas is improving oral health access for these very young children.
Importance of Oral Health in Very Young Children
Early childhood caries (ECC) is characterized by the presence of at least one decayed, missing, or filled primary tooth surface in a child younger than age 6.[4] Among children in this age group, nearly one-quarter have ECC,[5] with 10 percent untreated.[6]
In addition to causing pain and discomfort, dental caries, including ECC, can affect young children’s quality of life and overall development, including reduced intake of food, lower weight, and increased school absences.[7] High incidences of untreated dental caries are also associated with increased risk of hospitalizations and emergency dental visits, resulting in significant costs to state Medicaid programs.[8],[9] One report examining Medicaid-enrolled children under age 6 in Iowa found that children treated for ECC in a hospital or ambulatory setting accounted for 25 to 45 percent of total dental costs.[10]
Children who have their first preventive dental visit by age 1 are more likely to have subsequent preventive visits and lower dental-related costs.[11] Given the importance of early access to routine, preventive oral health services among young children, several leading national pediatric medical and dental organizations recommend that all children receive an initial dental visit during the first year of life.[12],[13],[14] Yet, only 9 percent of Medicaid-enrolled children under age 3 received a preventive dental service over a one-year period, compared to 84 percent of children in the same age group who received a well-child visit.[15],[16]
As states explore opportunities to improve access to oral health services, there is growing interest in strengthening routine access to oral health services among young children.
Texas First Dental Home
Implemented in 2008 by the Texas Health and Human Services Commission (HHSC) – the state’s Medicaid program – to increase children’s access to preventive services under the EPSDT benefit, the First Dental Home (FDH) is a legislatively supported, Medicaid dental initiative designed to improve the oral health of Medicaid-enrolled children, ages 6-35 month, through the following actions:
- Initiate early preventive dental services (including for those children without erupted teeth);
- Provide communication and education to parents and caregivers promoting the importance of children’s oral health; and
- Establish dental homes for children beginning at 6 months of age or as early as possible upon enrollment in Medicaid. [17]
Children participating in FDHs are eligible for a maximum of 10 visits between 6 to 35 months of age, with at least 60 days between visits. This requirement allows for a child to begin FDH visits at six months of age with a recall schedule of every three months (for those children at moderate-to-high risk for developing severe ECC) until their third birthday.[18] In addition to completing an oral health questionnaire, a dental risk assessment questionnaire, and a comprehensive oral evaluation during the initial visit, FDH visits include:
- Texas Health Steps Caries Risk Assessment Tool;
- Dental prophylaxis;
- Oral hygiene instructions for the child’s primary caregiver;
- Application of topical fluoride varnish;
- Dental anticipatory guidance, including nutritional counseling and oral developmental milestones; and
- Establishment of a dental recall schedule.[19]
Due to the importance of caregiver participation and understanding of their children’s oral health, HHSC requires at least one parent or caregiver to be present with the child during the entire FDH visit.[20] An evaluation of FDH found that participation in the program increased caregivers’ oral health knowledge and some of their oral health practices to improve their children’s oral health.[21]
First Dental Home Bundled Reimbursement and Provider Enrollment
The Current Dental Terminology (CDT) code D0145 is used at an enhanced reimbursement rate of $142.07 for all FDH visits. For the purposes of FDH billing, D0145 is considered an all-inclusive (or bundled) code required for all diagnostic and preventive services rendered under FDH, including those not traditionally reimbursed for routine preventive services, such as oral hygiene instruction and nutritional counseling.[22],[23] Dentists cannot bill for any other exam, prophy, or fluoride codes for a FDH visit.[24]
Eligible providers (e.g., pediatric and general dentists) must become FDH providers to claim reimbursement using the enhanced bundled CDT code. In addition to being trained and certified by the Texas Health Steps Program, the state’s EPSDT program, dentists must have a National Provider Indicator number (NPI) and an individual Texas Provider Indicator (TPI) number of each practice location.[25] Within the first 12 months of the program’s implementation, 815 dentists became FDH providers, 674 of whom billed for services.[26]
Texas is a state with dental benefits carved-out of its medical managed care program to three dental maintenance organizations (DMOs). Collectively, these DMOs help to manage the dental care needs of the state’s Medicaid members, including participation in FDH. Under this arrangement, HHSC outlines FDH-specific contract requirements, which stipulate that each DMO must:
- Implement a process to detect under-utilization of FDH services;
- Verify a providers’ qualifications to submit claims for FDH services; and
- Publish provider directories and note which providers are FDH providers.
In addition to these contract requirements, HHSC has a dental Pay-for-Quality (P4Q) program to further strengthen oral health utilization. Under Texas’s dental P4Q program, 1.5 percent of each DMO’s capitation is at risk of recoupment for specific performance measures (e.g., the percentage of enrolled children who receive a comprehensive or periodic oral evaluation in a reporting year) if a DMO’s performance declines beyond a defined threshold. Conversely, if a DMO’s performance improves beyond the threshold, the DMO can earn incentive payments.[27] To help bolster its performance, at least one DMO implemented value-added services for members participating in FDH, including a free dental care kit and gift card upon completion of a FDH visit.[28] As a result of limited data due to COVID-19 from which to assess quality measures, HHSC has temporarily suspended its dental P4Q program, including performance measures under FDH.[29]
Texas’s multipronged efforts to increase access to preventive oral health services for Medicaid enrolled children 6 to 35 months of age under the EPSDT benefit have resulted in increased utilization, even exceeding the rate of dental care use among commercially insured children in some years.[30],[31] Based on available dental performance measures collected by HHSC, participation in FDH has steadily increased with approximately 71 percent of children 6 to 35 months of age receiving at least one FDH visit in FY 19.[32] Based on claims data collected from 2005-2011, there was an estimated cost savings of $12.9 million (or $269.01 per member per year) among children 3 to 6 years of age receiving routine preventive dental services. The savings per member is driven, in part, by reductions in oral health utilization and treatment expenditures.[33] The goal of FDH services is to aid in the additional reduction of treatment expenditures.[34]
Due to the impact of COVID-19 on access to preventive services,[35] utilization of FDH was down 90 percent at the start of the public health emergency. By summer 2020, use of FDH services was at 80 percent compared to the previous year, with access rates slowly returning to normal.
Conclusion
To improve the oral health of Medicaid-enrolled children ages 6 to 35 months, Texas’s First Dental Home successfully implemented an enhanced bundled payment, caregiver engagement strategies, and provider-specific requirements to increase access to preventive oral health services for very young children under the EPSDT benefit. Texas’s approach is one that other state Medicaid programs can adapt as they explore strategies to improve the oral health of very young children and promote access to an initial dental visit during the first year of life.
Acknowledgements: This case study is a publication of the National Academy for State Health Policy (NASHP). This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under the Supporting Maternal and Child Health Innovation in States Grant No. U1XMC31658; $398,953. The information, content, and 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.
Notes
[1] “Hygiene-related Diseases, Dental Caries,” U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, September 2016. https://www.cdc.gov/healthywater/hygiene/disease/dental_caries.html [2] “Dental Caries in Primary Teeth,” U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, September 2019. https://www.cdc.gov/oralhealth/publications/OHSR-2019-dental-caries-primary-teeth.html – :~:text=The prevalence of untreated tooth,-poor, and poor children. [3] “Utilization of Dental Services Among Medicaid Enrolled Children,” U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, October 2012. https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MedicaidDataSourcesGenInfo/Downloads/MAX_IB9_DentalCare.pdf [4] “Statement on Early Childhood Caries,” American Dental Association, 2000. https://www.ada.org/en/about-the-ada/ada-positions-policies-and-statements/statement-on-early-childhood-caries [5] U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, “Dental Caries in Primary Teeth,” [6] “Dental Caries and Sealant Prevalence in Adolescents in the United States, 2011-2011, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, March 2015. https://www.cdc.gov/nchs/products/databriefs/db191.htm#:~:text=Dental%20caries%20among%20children%20aged,31%25)%20aged%202%E2%80%938 [7]Sheiham, A., “Dental caries affects body weight, growth, and quality of life in pre-school children,” British Dental Journal, November 2006. https://www.nature.com/articles/4814259 – :~:text=First, untreated caries and associated,foods because eating is painful.&text=Second, severe caries can affect,irritability and disturbed sleeping habits [8] “The Importance of the Age One Dental Visit,” Pediatric Oral Health Research & Policy Center, 2019. https://www.aapd.org/globalassets/media/policy-center/year1visit.pdf [9] “Allareddy, V., et al., “Hospital-based emergency department visits involving dental conditions: profile and predictors of poor outcomes and resource utilization,” Journal of the American Dental Association, April 2014. https://pubmed.ncbi.nlm.nih.gov/24686965/ [10] “Kanellis, M., et al., “ Medicaid Costs Associated with the Hospitalization of Young Children for Restorative Dental Treatment under General Anesthesia,” Journal of Public Health Dentistry, May 2007. https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1752-7325.2000.tb03288.x?sid=nlm%3Apubmed [11] Savage, M., et al., “Early Preventive Dental Visits: Effects of Subsequent Utilization and Costs,” Journal of the American Academy of Pediatrics, October 2004. https://pediatrics.aappublications.org/content/114/4/e418.long [12] “Recommendations for preventive pediatric health care,” Journal of the American Academy of Pediatrics, March 2000. https://pediatrics.aappublications.org/content/105/3/645 [13] American Dental Association, “Statement on Early Childhood Caries.” [14] “First Oral Health Assessment Policy,” American Association of Public Health Dentistry, May 4, 2004. https://www.aaphd.org/oral-health-assessment-policy [15] Centers for Medicare and Medicaid Services, “Utilization of Dental Services Among Medicaid Enrolled Children.” [16] “Utilization of Well-Child Care Among Medicaid Enrolled Children,” U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, October 2012. https://www.cms.gov/research-statistics-data-and-systems/computer-data-and-systems/medicaiddatasourcesgeninfo/downloads/max_ib10_wellchild.pdf [17] “First Dental Home: Section 1: Overview of the First Dental Home Initiative,” Texas Health and Human Services, Texas Health Steps. https://www.txhealthsteps.com/static/warehouse/1076-2010-Jun-8-7c06br1a1rkyar7csn96/section_1.html [18] “First Dental Home: Section 3: Scheduling, Treatment Planning, Documentation, and Billing,” Texas Health and Human Services, Texas Health Steps. https://www.txhealthsteps.com/static/warehouse/1076-2010-Jun-8-7c06br1a1rkyar7csn96/section_3.html [19] “First Dental Home,” Texas Health and Human Services. https://hhs.texas.gov/doing-business-hhs/provider-portals/health-services-providers/texas-health-steps/dental-providers/first-dental-home [20] Texas Health and Human Services, Texas Health Steps, “First Dental Home: Section 1: Overview of the First Dental Home Initiative.” [21] Mccann, Ann., & Schneiderman, E., “Does the Texas First Dental Home Program Improve Parental Oral Care Knowledge and Practices,” Journal of Pediatric Dentistry, March 2017. https://www.researchgate.net/profile/Ann_Mccann/publication/319040790_Does_the_Texas_First_Dental_Home_Program_Improve_Parental_Oral_Care_Knowledge_and_Practices/links/5e496c8f299bf1cdb930f08e/Does-the-Texas-First-Dental-Home-Program-Improve-Parental-Oral-Care-Knowledge-and-Practices.pdf [22] Texas Health and Human Services, Texas Health Steps, “First Dental Home: Section 3: Scheduling, Treatment Planning, Documentation, and Billing.” [23] Use of CDT code D0145 in other state Medicaid programs is typically limited to an oral evaluation and counseling with the primary caregiver. [24] Texas Health and Human Services, “First Dental Home.” [25] Ibid. [26] “State of Texas Medicaid Dental Review,” U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, October 2010. https://www.mchoralhealth.org/PDFs/CMSReview_TX.pdf [27] “Pay-for-Quality Program,” Texas Health and Human Services. https://hhs.texas.gov/about-hhs/process-improvement/improving-services-texans/medicaid-chip-quality-efficiency-improvement/pay-quality-p4q-program – :~:text=Medical Pay-for-Quality Program,performance on certain quality measures.&text=The redesigned medic. [28] “DentaQuest Provider Office Reference Manual: TX HHSC Dental Services,” DentaQuest, October 2020. https://dentaquest.com/getattachment/State-Plans/Regions/texas/Dentists-Page/Provider-Resources/TX_ORM.pdf/ [29] National Academy for State Health Policy, Early and Periodic Screening, Diagnostic and Treatment Network Call, “How States Can Promote Children’s Oral Health.” [30] Nasseh, K., et al., “ Dental Care Use among Children Varies Widely across States and between Medicaid and Commercial Plans with States,” Health Policy Institute Research Brief, 2014. https://www.semanticscholar.org/paper/Dental-Care-Use-among-Children-Varies-Widely-across-Nasseh-Aravamudhan/763bbe86700c42c0f4b8a5cec50772dc20cda1a7#references [31] Gupta, N., et al., “Medicaid Fee-for-Service Reimbursement Rates for Child and Adult Dental Care Services for all States, 2016,” American Dental Association, Health Policy Institute, 2017. https://www.ada.org/~/media/ADA/Science and Research/HPI/Files/HPIBrief_0417_1.pdf [32] “How States Can Promote Children’s Oral Health,” National Academy for State Health Policy, Early and Periodic Screening, Diagnostic and Treatment Network Call, October 2020. [33] Lee, I., et al., “Estimating the cost savings of preventive dental services delivered to Medicaid-enrolled children in six southeastern states,” Health Services Research, November 2017. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6153169/pdf/HESR-53-3592.pdf [34] The research study focuses on children outside the age range of those receiving services under the First Dental Home. The study also includes claims data that precede implementation of the First Dental Home. [35] “CMS Issues Urgent Call to Action Following Drastic Decline in Care for Children in Medicaid and Children’s Health Insurance Program Due to COVID-19 Pandemic,” U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, September 2020. https://www.cms.gov/newsroom/press-releases/cms-issues-urgent-call-action-following-drastic-decline-care-children-medicaid-and-childrens-healthMichigan Medicaid Addresses Social Determinants of Oral Health through Dental and Medical Contracts
Inequities in dental care are prevalent across the United States, with significant disparities based on age, race, ethnicity, and socioeconomic status. Economic factors, such as ability to pay for dental insurance, and social factors such as food insecurity and access to nutritious food options also play a large role in oral health outcomes.
In Michigan, state Medicaid medical and dental managed care contracts now include requirements to address social determinants of health (SDOH) among enrollees. Examples of these requirements include:
- Incorporating oral health into community health workers’ training curriculum;
- Collaborating with community-based organizations (CBOs);
- Collecting data on enrollees’ SDOH and using it to target outreach and educational activities; and
- Implementing quality assurance and improvement projects that promote equitable access to oral health care.
Michigan’s Medicaid medical and dental managed care contracts demonstrate a proactive approach to identifying and addressing SDOH among Medicaid enrollees. While budget shortages resulting from the COVID-19 pandemic may make it more difficult for states to take on additional initiatives, addressing SDOH in Medicaid contracts can decrease costs and improve oral health outcomes. States that want to encourage dental plans to take on a larger role in promoting equitable access to care and addressing SDOH could adopt initiatives similar to Michigan’s.
These types of Medicaid contractual requirements are important first steps in improving SDOH among enrollees, while strengthening monitoring and enforcement requirements are also critical tools when adequate funding and personnel are available.
Why Focus on Oral Health and SDOH?
SDOH are the conditions in the places where individuals live, learn, and work that may affect their health risks and outcomes. They include factors such as food access, housing stability, educational attainment, poverty, health literacy, and transportation, among others. Social determinants dictate an individual’s access to health care and quality of care, which directly affect physical and oral health and exacerbate health disparities. For example:
- Low-income children are twice as likely to have dental caries (tooth decay) than children from higher-income homes; and
- Individuals who are poor or have less than a high school education have edentulism (toothlessness) at a rate three-times higher than those with higher incomes or more education.
Increasingly, Medicaid medical and dental managed care organizations are implementing initiatives designed to address SDOH among their members in order to improve oral health and promote health equity.
While all states cover dental care for Medicaid-enrolled children under age 21 as part of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, adult dental coverage is optional for state Medicaid programs. Currently, 35 states provide limited dental benefits for adults and 19 states offer extensive adult dental benefits. However, optional adult benefits, such as dental care, may be affected by state efforts to meet continued budget challenges arising from the COVID-19 pandemic. Dental disease, though, not only adversely affects oral health but is also associated with diabetes, heart disease, stroke, and low birth weight and preterm births. Preventive dental care has the potential to improve overall health and well-being and reduce costs.
How Michigan Addresses Oral Health and SDOH
In NASHP’s recent 50-state scan of Medicaid managed care medical and dental contracts, Michigan was one of only three states (out of 19 reviewed) to consistently and directly reference SDOH in their Medicaid dental plan contracts.* Additionally, Michigan’s Medicaid medical managed care organization (MCO) contract includes detailed requirements for addressing SDOH, many of which align with the dental plan’s language and promotes coordination between physical and oral health care. While written contractual requirements do not guarantee that medical and dental plans are actively engaged in implementing SDOH-related initiatives – especially in the absence of funding to monitor these programs – Michigan’s contracts offer valuable examples of potential ways to address SDOH that other states could adopt as a first step.
Michigan Delivery System Overview
Michigan Medicaid uses a managed care system to deliver medical and dental care, and the Medicaid dental benefit is carved out and administered by various dental plans contracted by the state. Michigan Medicaid covers limited dental services for adults, including dental check-ups, teeth cleaning, X-rays, fillings, tooth extractions, and dentures. Additionally, the state offers an enhanced dental benefit for Medicaid-eligible pregnant women that includes emergency dental treatment and some oral surgeries. Michigan also administers the Healthy Kids Dental program, which covers comprehensive oral health care for children under age 21 enrolled in Medicaid.
Dental Contract Language
Michigan stands out because of the state’s frequent and direct mentions of SDOH throughout its Healthy Kids Dental (HKD) model contract. The HKD contract reflects a broad range of required initiatives related to SDOH, including:
- Collaboration with community organizations;
- Data use to target interventions and assess population-wide social needs, and
- Implementation of quality assurance and improvement projects that reduce barriers to oral health care.
Collaboration with Community Organizations
One way dental plans can help address SDOH-related needs is by working with community-based organizations (CBOs). CBOs play an important role in connecting individuals to social services and helping people access health-related social needs, such as healthy food, transportation services, and educational materials that promote health literacy.
Michigan requires dental plans administering the HKD program to “collaborate with community-based organizations to facilitate the provision of enrollee oral health education services to ensure the entire spectrum of social determinants of oral health are addressed, e.g., housing, healthy diet and physical activity.” Michigan also encourages contractors to “build relationships with community partners that will engage in integrated care and promote good oral health practices.”
Through dynamic and active partnerships with CBOs, dental plans can more easily refer individuals to social and community services to help address members’ needs. Additionally, these partnerships with CBOs allow the state to expand its reach to more Medicaid-eligible children through educational initiatives.
Dental plans can also encourage members to work with CBOs and other public health programs by implementing their own educational programs. Michigan lists community-based public health resources on its website, and requires dental plan contractors to institute educational, public relations, and social media programs to increase awareness of available resources, such as CBOs, that can help reduce the impact of social determinants of oral health.
Data Collection, Tracking, and Reporting
While coordinating with social and community resources is an important step in improving health equity, having strong mechanisms in place to collect and track community data is critical to ensure social determinants are addressed. Michigan stands out in its commitment to require that medical and dental plans collect SDOH-related data.
Michigan requires HKD contractors to collect data on SDOH and utilize enrollment files, claims, encounter data, and utilization management data to improve community collaboration and address oral health disparities. The state specifies that the dental plan must “use social determinants of oral health data provided by [the Michigan Department of Health and Human Services] to analyze member-level data to direct the contractor’s efforts of targeted interventions, outreach, enrollee education and health promotion.” Additionally, the dental plan must report on the effectiveness of its population health management programs, including measures identifying the number of enrollees experiencing a “disparate level of social needs,” such as limited transportation access and housing instability.
Michigan’s data utilization requirements range from addressing individuals’ health-related needs to analyzing population-wide equity issues. Plans are required to gather and utilize this information for finetuning their services, such as care management and referrals. However, given that requirements for health plans to collect SDOH-related data are fairly new, and the state has little funding available for this work, the state’s role in monitoring whether data collection is occurring is currently limited. With adequate funding and personnel, states can take a more active role in tracking and data analysis to better understand the social needs of the population and effectively target SDOH-related interventions.
Quality Assurance and Performance Improvement
Michigan is committed to not only reporting on the effectiveness of SDOH-related initiatives, but also working to improve existing systems to better address inequities in oral health. The HKD contract requires the dental plan to have a Quality Assurance and Performance Improvement (QAPI) plan that includes a description of how the contractor will, “develop system interventions to address the underlying factors of disparate utilization, health-related behaviors, and oral health outcomes, including, but not limited to, how they relate to utilization of dental emergency services,” and “ensure the equitable distribution of dental services to contractor’s entire population, including members of racial/ethnic minorities, those whose primary language is not English, those in rural areas, and those with disabilities.”
SDOH can contribute to variances in utilization of dental services and poor oral health outcomes, with factors such as geographic location and language proficiency playing an important role in driving health care access. In addition to using data to better understand the impact of social factors on members’ oral health and population utilization trends, Michigan requires contractors to continue to find new ways to reach all populations and reduce the effects of SDOH on oral health outcomes.
Medical Contract Language
Much of the language related to SDOH included in the Healthy Kids Dental contract is consistent with the language in Michigan’s Medicaid medical MCO contract, which covers adults and children. Both the HKD and MCO contracts require the plan to collaborate with CBOs to provide physical and oral health education and address SDOH, implement community education campaigns to improve public knowledge of community-based resources, report on the effectiveness of SDOH-related population health management initiatives, and promote equitable access to care using Quality Assurance and Performance Improvement (QAPI) projects.
However, the medical contract also offers additional opportunities for investment in SDOH that states could consider implementing in dental contracts. For example, Michigan requires medical MCO contractors to participate in the Medicaid Health Equity Project, which is a statewide effort to address racial and ethnic disparities. Through this project, Medicaid health plans collect and report on data across multiple quality measures, including access to preventive and ambulatory health services. The state then uses data stratification by race and ethnicity to determine how racial and ethnic discrimination affect each quality measure, with the goal of addressing any disparities.
Additionally, the medical contract requires health plans to enter into agreements with CBOs to coordinate “population health improvement strategies,” which address social determinants such as physical environment and socioeconomic status. These agreements with CBOs must include information on data sharing, each partner’s role in care coordination, reporting requirements, and plans for coordinating service delivery with primary care providers.
What are Key Considerations and Next Steps?
Addressing SDOH is critical to improving oral health, overall health, and health equity. Increasingly, Medicaid dental plans across the country are collecting data on community needs and implementing initiatives to reduce barriers to oral health care. In a recent 50-state scan of Medicaid managed care contracts, NASHP found that out of 19 dental contracts and 38 medical contracts reviewed nationally, 13 and 37, respectively, require the plan to coordinate with community services. Efforts to address SDOH are also underway, though they tend to be further along on the medical side than the dental side. This provides an opportunity for states to apply medical contracts’ language in their dental contracts, or work with health plans to link existing SDOH-related programs with the dental system.
In response to budget shortfalls resulting from the COVID-19 pandemic, Michigan’s Medicaid program now faces potential rate changes, particularly for dental payments. However, program staff report they see opportunities to establish shared performance metrics between Medicaid MCOs and dental plans in the future. The state is considering ways to standardize and refine SDOH-related data collection and analysis, especially related to dental care. Michigan health officials noted the necessity of first ensuring data was valid and reliable before using it to drive decisions or implement capitation withhold incentive programs. The state is also discussing leveraging Michigan’s health information exchange to transmit standardized SDOH screening information to plans and providers.
Through the Healthy Kids Dental and Medical MCO contract, Michigan has demonstrated a strong commitment to addressing social determinants of oral health. The contracts present an opportunity for states to adopt similar language in order to encourage dental plans to coordinate with CBOs, effectively collect and use SDOH-related data, and implement performance improvement projects aimed at reducing disparities.
* NASHP scanned Michigan’s Healthy Kids Dental model contract and the Michigan Medicaid Medical MCO sample contract.
Acknowledgements: This fact sheet was made possible by the DentaQuest Partnership LLC. The author would like to especially thank Trenae Simpson for her guidance and assistance, and state officials in Michigan for their helpful feedback. The information, content, and conclusions are those of the author’s and should not be construed as the official position or policy of the DentaQuest Partnership LLC.
For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
