The nonpartisan Urban Institute publishes studies, reports, and books on timely topics worthy of public consideration. The views expressed are those of the authors and should not be attributed to the Urban Institute, its trustees, or its funders.
About the Series
Assessing the New Federalism is a multiyear Urban Institute project designed to analyze the devolution of responsibility for social programs from the federal government to the states, focusing primarily on health care, income security, employment and training programs, and social services. Researchers monitor program changes and fiscal developments. In collaboration with Child Trends, the project studies changes in family well-being. The project aims to provide timely, nonpartisan information to inform public debate and to help state
and local decisionmakers carry out their new responsibilities more effectively.
Key components of the project include a household survey, studies of policies in 13 states, and a database with information on all states and the District of Columbia, available at the Urban Institute’s Web site (http://www.urban.org). This paper is one in a series of occasional papers analyzing information from these and other sources.
Contents
Executive Summary
Tooth decay is one of the most prevalent chronic illnesses facing children in the United States today (Edelstein and Douglass 1995). Almost 60 percent of children ages 5 to 17 have dental disease in their primary or permanent teeth (NCHS 1996). Moreover, dental disease is concentrated in low-income populations. Poor children have five times more untreated dental disease than children in higher-income families (Vargas, Crall, and Schneider 1998). Eighty percent of untreated dental disease in permanent teeth is found in roughly 25 percent of 5- to 17-year-old children, most of whom come from low-income and other vulnerable populations (Kaste et al. 1996).
The State Children’s Health Insurance Program (SCHIP) provides states with an opportunity to expand health insurance and, by extension, financial access to dental care. In this paper we analyze whether and how the coverage and delivery of dental services is changing under SCHIP. In particular, we focus on the key differences between new separate SCHIP initiatives and traditional and expanded Medicaid programs. This study begins to address these issues based on a qualitative analysis of the implementation experiences of the 18 states in our sample.
Key Findings
- The Policy Debate. The study findings suggest that states did not focus particular attention on dental issues during SCHIP program development. However, policymakers generally agreed that dental coverage constituted a fundamentally important component of a child health program. It is noteworthy that although dental service coverage is optional under SCHIP separate programs, all but two states (Colorado* and Delaware) with a separate health insurance program have chosen to include dental services in their benefit package, and with the sole exception of Florida, all offer dental coverage statewide. The states analyzed here mirror this national trend—17 of the 18 study states have elected to cover dental benefits.
- Scope of Benefits Coverage. In addition to near-universal inclusion of dental benefits, we found the extent of dental coverage under SCHIP to be quite broad, although not as comprehensive as Medicaid dental coverage. Preventive and diagnostic services are covered by virtually all states, including coverage of professional oral exams, teeth cleanings, fluoride treatments, and bitewing x-rays. Advanced dental care services are less likely to be covered under separate SCHIP programs. Most states cover extractions and some endodontic services, but few cover periodontic, prosthodontic, or orthodontic services. Virtually all states impose limits on preventive services, such as two exams and cleanings per year; however, these limits are consistent with guidelines from the American Academy of Pediatric Dentistry. In addition, three of the study states (Alabama, Michigan, and Texas) have annual dollar limits on their dental benefits.
- Cost-Sharing Arrangements. Despite increased flexibility to impose cost sharing under separate SCHIP programs, copayments on dental services were nominal in most separate programs among the study states. Copays in the study states range from $0 to $10 for dental visits. No states were imposing premiums or coinsurance intended specifically for dental services.
- Service Delivery and Payment Arrangements. As policymakers have learned from their Medicaid experiences, covering dental services does not guarantee that children will be able to gain access to them. We found that several states were using SCHIP as an opportunity to test new delivery systems for dental services. Under separate programs, more states are using managed care arrangements to deliver dental services than is typical under Medicaid. The decision to use managed care was made with the primary goal of improving access—by using managed care, states are purchasing a clearly established and identified network of providers. Furthermore, separate programs are more likely than Medicaid programs to contract directly with dental managed care plans than with general managed care plans. However, because most general managed care plans sub-contract to dental managed care plans, virtually all children are receiving care from a dental managed care plan. Almost without exception, states reported paying managed care plans on a capitated basis, either through all-inclusive capitation amounts paid to general managed care plans or through partial capitation amounts paid to dental plans. Importantly, though, regardless of the arrangement, general health plans and dental plans were reported as paying individual dentists on a fee-for-service basis.
States using managed care can impose certain network standards upon plans through their contracts. We found that the states’ most common contracting requirements addressed provider-to-enrollee ratios, traveling times and distances, and waiting periods for appointments. Finally, most respondents in states with separate programs believed that the managed care networks were affording good access to dental services and were an improvement over Medicaid.
- Payment Amounts. For years the most common complaint lodged by dentists against Medicaid has been that the program pays fees well below dentists’ usual and customary fees. Our findings suggest that under separate SCHIP programs some states have raised dental payment levels above Medicaid’s in an effort to raise dental provider participation. In contrast, other states appear to be paying about the same for dental services under their separate SCHIP and Medicaid programs.
- Other Efforts to Enhance Provider Participation. Although low fees are the most common reason cited by dentists for not participating in Medicaid, other Medicaid policies, such as cumbersome administrative and billing procedures, as well as high rates of missed appointments by Medicaid recipients, have also undermined support for the program in the provider community. We found that a number of strategies were being undertaken to address these issues, including simplifying billing procedures, reducing prior-authorization requirements, and expanding dental hygienists’ scope of practice. We did not find any strategies to address the issue of missed appointments by Medicaid recipients.
- Impact of SCHIP Dental Programs on Medicaid Programs-the "Spillover" Effect. In two states—Alabama and Michigan—officials reported that the early successes of their SCHIP dental programs had hastened reform efforts under their state’s Medicaid dental program. In Alabama, the success of the ALL Kids dental program has prompted fee increases for dental services under Medicaid, while in Michigan, the state has established a pilot project that replicates the MIChild dental delivery system for a portion of its Medicaid enrollees.
- Early Measures of Provider Supply and Service Use. Although data on supply and use are preliminary and were not submitted in a consistent manner across states, the data suggest that improvements in access may be occurring under separate SCHIP programs that are paying dental providers at market rates when compared with Medicaid. For example, Michigan’s separate SCHIP program reports that 90 percent of licensed dentists are enrolled as providers in the two largest SCHIP dental plans, compared with 27 percent of licensed dentists enrolled as participating providers in Medicaid. In California, 70 percent of children enrolled in the largest separate SCHIP dental plan received a dental service within their first six months of enrollment. In contrast, in 1999, only 36 percent of Medicaid enrollees in California received dental care.
Conclusions and Policy Implications
This study has found that, although it is not a requirement under SCHIP legislation, nearly every separate SCHIP program is offering dental coverage, and benefits appear to be fairly comprehensive. Although not as broad as Medicaid’s Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program, coverage under most separate SCHIP programs includes all basic preventive, diagnostic, and restorative services, and cost-sharing requirements appear to be quite low. Some states with separate programs are using different delivery systems for dental care than those used under Medicaid. These approaches often reflect state policymakers’ explicit decision to deliver dental services under SCHIP through managed care arrangements in an effort to secure a network of dentists who can be available to serve SCHIP enrollees. Some separate SCHIP programs appear to be supporting their delivery systems with higher payment rates, although this trend was not seen for all states. The use of different delivery systems supported by competitive payments appears to be contributing to improved provider participation and better access to dental care in some state SCHIP programs. Early evidence from two states in particular—Alabama and Michigan—shows higher rates of dental provider participation in SCHIP compared with Medicaid. However, as promising as these SCHIP initiatives appear, widespread improvements in oral health for low-income children will occur only if the improvements seen in some separate SCHIP programs also occur in the Medicaid program.
Tooth decay is one of the most prevalent chronic illnesses facing children in the United States today (Edelstein and Douglass 1995). Almost 60 percent of children ages 5 to 17 have dental disease in their primary or permanent teeth (National Center for Health Statistics [NCHS] 1996). Moreover, dental disease is concentrated in low-income populations. Poor children have five times more untreated dental disease than children in higher-income families (Vargas et al. 1998). Eighty percent of untreated dental disease in permanent teeth is found in roughly 25 percent of children ages 5 to 17 years old, mostly in low-income and other vulnerable populations (Kaste et al. 1996).
The State Children’s Health Insurance Program (SCHIP), newly authorized under Title XXI of the Social Security Act, provides states with an opportunity to expand health insurance and, by extension, financial access to dental care. Under SCHIP, states may choose to expand Medicaid for higher-income children, develop a new separate health insurance program, or combine these approaches. States that expand Medicaid are required to provide the full Medicaid benefit package, which includes comprehensive dental coverage. In contrast, states that implement a separate program are allowed the flexibility to design new benefit packages that may, or may not, include dental benefits. This flexibility also permits these states to design new service delivery systems, establish new payment rates and methods, and impose cost sharing on enrollees, all of which may have implications for the manner in which dental care is covered and provided.
The purpose of this paper is to analyze whether and how the coverage and delivery of dental services is changing under SCHIP. In particular, this paper focuses on the key differences between new separate SCHIP initiatives and traditional and expanded Medicaid programs.
This study was conducted as part of the Urban Institute’s Assessing the New Federalism project and, more specifically, its evaluation of the impact and implementation of SCHIP. The qualitative component of the Institute’s SCHIP evaluation involved site visits (four to five days in length) to 15 states and in-depth telephone interviews in 3 additional states, selected based on their diversity in size, population characteristics, geographic location, and SCHIP policies. The study states are listed below.1
| SCHIP Study States |
| Alabama |
Michigan |
North Carolina |
| California |
Minnesota |
Ohio |
| Colorado |
Mississippi |
Pennsylvania |
| Connecticut |
Missouri |
Texas |
| Florida |
New Jersey |
Washington |
| Massachusetts |
New York |
Wisconsin |
During the site visits, interviews were conducted with a broad range of key informants. At the state level, we interviewed SCHIP, Medicaid, and Title V/Maternal and Child Health officials; governors’ health policy staff; state legislators involved with child health policy; representatives of provider groups (such as the American Academy of Pediatrics and the primary care association); and representatives from leading child advocacy organizations. At the local level; we interviewed representatives from clinic- and office-based pediatric providers, managed care organizations, social services departments responsible for SCHIP or Medicaid eligibility determination, and community-based organizations involved with outreach. To ensure the consistent gathering of information across sites, we used a set of detailed interview protocols that explored a broad range of SCHIP implementation issues, including those related to children’s access to dental care.
To better understand the degree to which states were using SCHIP as an opportunity to try new approaches to dental service coverage and delivery, we designed a specific study component to collect information on these issues. After completing our site visits, we conducted supplemental telephone interviews with SCHIP and Medicaid officials in 14 states2 to obtain detailed information on (1) the policy debates that surrounded the inclusion or exclusion of dental benefits under SCHIP, (2) the scope of dental services covered, (3) the delivery systems used to furnish dental care under SCHIP and Medicaid, (4) the payment arrangements implemented to finance this dental coverage and provision under SCHIP and Medicaid, and (5) other efforts to enhance the participation of dental providers in SCHIP and Medicaid.
The results of this inquiry are contained in this report, which is organized as follows:
- The "Background: Oral Health Status, Utilization, and Barriers to Care" section provides information from the research literature on children’s need for and access to dental services, as well as the historical role of Medicaid in furnishing dental services to low-income children.
- "SCHIP Dental Coverage and Provision Policies" details the specific dental policies implemented by states under their SCHIP initiatives, comparing and contrasting separate SCHIP programs with Medicaid programs, where appropriate. Findings are presented on the state-level policy debate that surrounded dental coverage under SCHIP, benefit package designs, cost-sharing arrangements, service delivery and payment arrangements, payment amounts, and efforts to enhance provider participation.
- "Early Measures of Provider and Supply Service Use" presents preliminary data gathered from the study states on provider participation and dental service utilization under SCHIP.
- "Conclusions and Policy Implications" summarizes our findings and their implications for future policy.
Background: Oral Health Status, Utilization, and Barriers to Care
The issue of children’s oral health has recently received a great deal of national attention. Heightened awareness and concern has been evidenced by the publication of numerous reports and studies documenting children’s oral health status, particularly that of low-income children. Most recently, the Surgeon General released a report calling attention to the disparities in oral health between low- and higher-income individuals, noting that, despite tremendous advances in understanding and treating oral and gum diseases, some populations, notably poor children, are disproportionately affected (U.S. Department of Health and Human Services [HHS] 2000a).
It is clear from many studies that low-income children are not receiving dental care even near the levels recommended by the American Academy of Pediatric Dentistry (AAPD 1999) and the Maternal and Child Health Bureau of the U. S. Department of Health and Human Services (Kenney, Ko, and Ormond 2000; Edelstein, Manski, and Moeller 2000; Vargas et al. 1998). Data from the 1997 National Survey of America’s Families (NSAF) showed that nearly twice as many low-income children as higher-income children reported unmet dental needs and that low-income children were 15 percentage points more likely than higher-income children to have had no dental visits in the preceding year. Low-income children were also much less likely to have had two annual visits compared with higher-income children—42 percent versus 60 percent, respectively (Kenney et al. 2000). Similarly, data from the 1996 Medical Expenditure Panel Survey (MEPS) showed that half as many 11- to 18-year-olds from lower-income households as children from higher-income households had at least one dental visit (Edelstein et al. 2000). Such disparities in utilization led the government to include improvements in preventive dental care use among low-income children and adolescents as one of its Healthy People 2010 Oral Health goals (HHS 2000b).
What is preventing low-income children from accessing appropriate levels of care? Factors that have been identified as possible barriers to access can be broadly categorized into two groups: demand factors (i.e., the underlying reasons that families do or do not seek dental care) and supply factors (i.e., the availability and geographic distribution of dental providers across the country).
There is evidence that inability to pay is a barrier to obtaining care. Although insurance coverage for dental services has been increasing throughout the 1990s, for every child under 18 without medical insurance, there are at least two children without dental insurance (Vargas, Isman, and Crall forthcoming). Children from families without dental insurance are three times more likely to have unmet dental needs than children with either public or private insurance (HHS 2000a). In addition, for children with private dental insurance, copayments and deductibles can be considerable, and private dental packages often only cover a narrow range of dental services. Low-income families with privately insured children may be deterred from obtaining
needed care for their children due to potentially high out-of-pocket cost.
There is also some evidence that consumers’ lack of knowledge about recommended levels of dental care is a barrier. Although this is a difficult area to assess with precision, low-income parents have many competing demands and may not be able to place a high priority on obtaining preventive dental care for their children. Issues such as taking time off from work to take a child to the dentist or arranging for transportation, while inconveniences for higher-income families, may constitute significant barriers to obtaining care for lower-income families. In addition, low-income parents, particularly those with less education, may be less aware than higher-income, more-educated parents of the recommended levels of preventive dental care (Kenney et al. 2000).
Supply factors are also likely to prevent low-income children from getting recommended levels of dental care, especially for those who lack comprehensive benefits or who are covered by Medicaid. In both cases, the supply of dentists willing to provide service seems inadequate (U.S. General Accounting Office [GAO] 2000).
Children without dental coverage have fewer resources from which to obtain free dental care than they would for free medical care. For example, in 1998, just over half of federally funded Community and Migrant Health Centers provided dental services, with long waiting periods for appointments reported (GAO 2000). Most health centers are limited in their capacity to expand their dental service provision because of the expense of obtaining dental facilities and equipment and the difficulty in recruiting providers. Other public programs that offer free or subsidized dental services to the low-income population are the National Health Services Corps and the Indian Health Service dental program. However, these programs are small in scope and none have sufficient capacity to address the large existing need.
A central issue for children with Medicaid coverage has been gaining access to care. In 1997, prior to SCHIP, 39 percent of low-income children were covered by public insurance, primarily the Medicaid program (Brennan, Holahan, and Kenney 1999). Through Medicaid’s Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program, states are required to provide dental screening, diagnostic, preventive, and treatment services to all Medicaid-covered children regardless of whether the state has elected to cover dental benefits under its Medicaid program. This protection translates, on paper, into comprehensive dental coverage for children. Unfortunately, for most Medicaid-covered children, this coverage has not resulted in actual care: The Health Care Financing Administration (HCFA) reports that just 21 percent of children on Medicaid received a dental assessment in 1997 (HCFA 1997). Although the data from HCFA may underrepresent dental utilization by Medicaid children, they are consistent with analyses of both Medicaid claims and household survey data that indicate that Medicaid-covered children receive fewer dental visits than recommended (Kenney et al. 2000, GAO 2000, Edelstein et al. 2000).
Supply constraints appear to contribute significantly to children’s poor access to dental care under Medicaid, as states historically have struggled to recruit and retain adequate numbers of dentists to participate in the program. Recognizing the significance of this issue, the General Accounting Office recently released a study to examine the reasons for poor access to dental services among children enrolled in Medicaid and SCHIP (GAO 2000). Low provider participation was identified as a primary cause, with reasons cited including traditionally low reimbursement rates, administrative hurdles and red tape, and reported high rates of patients not keeping their appointments. The complaints about the program appear to have some basis in fact. The GAO compared 1999 state Medicaid payment rates with the average regional fees that dentists charged for 15 selected procedures and found that Medicaid rates were well below dentists’ usual fees. Tremendous variation in reimbursement levels was found across states, with several states paying as little as one-third of dentists’ usual fees for certain procedures. Administrative burdens associated with the Medicaid program include excessive paperwork, frequent denials of claims, preauthorization requirements, and use of outdated forms or billing systems (GAO 2000). Finally, a common complaint from dentists is that Medicaid patients fail to show up for their appointments at a higher rate than do private-pay patients. The American Dental Association (ADA) reports that one-third of Medicaid patients failed to keep their appointments; however, the ADA does not track a similar statistic for privately insured patients (GAO 2000). Because Medicaid prohibits billing a patient for a missed appointment (as dentists are able to do under private insurance), the cost of Medicaid "no-shows" is higher than the cost of private patients who miss appointments, even if no-show rates are similar.
With the advent of SCHIP, states have been afforded another opportunity to address the need for improved access to dental care. This opportunity, however, challenges states to understand the roots of low utilization among the low-income population, to learn from prior problems associated with the Medicaid program, and to design initiatives that promise not just to provide coverage but to ensure access.
SCHIP Policies on Dental Coverage and Provision
This section describes the choices states made in designing and implementing their dental programs through separate programs financed under SCHIP, and compares these policies and experiences with those under Medicaid. Key informants were asked about a variety of major policy issues, including the discussions surrounding the decision whether to include dental coverage in the benefit package, the scope of covered dental services, the delivery systems used to provide services, reimbursement rates and methods, and other efforts to improve and enhance access to dental services. Informants were asked about how dental systems under separate state programs compared with those of Medicaid, and finally, were queried about what they had learned from the implementation of dental initiatives under SCHIP.
The Policy Debate-Was Dental Care a Salient Issue?
Given the well-documented problems surrounding low-income children’s access to dental care, including the Medicaid program’s shortcomings in extending widespread access to eligble children, we were interested in exploring whether dental care coverage was prominent among the issues debated by policymakers as states designed their SCHIP programs. In no state was dental access described as a dominant issue. Rather, the topics that tended to garner attention included the broad choice of whether to use Title XXI authority to expand Medicaid or to create a separate program, outreach and eligibility strategies to maximize enrollment, the extent to which cost sharing should be imposed on families, and strategies for preventing SCHIP from crowding out private insurance coverage.
At the same time, however, state officials acknowledged that there had been widespread agreement among SCHIP designers that dental coverage constituted a fundamental component of a child health program, with similarly widespread support for the inclusion of dental benefits in most states’ SCHIP benefit packages. For example, it is noteworthy that, despite their status as an optional benefit under SCHIP separate programs, dental benefits have been included by virtually all states. Of the 33 states that chose to implement a separate health insurance program, all but two—Colorado3 and Delaware—chose to include dental services in their benefit package, and all but one of these states—Florida—have offered dental coverage statewide. The states studied in this analysis mirror this national trend—17 of the 18 states have elected to cover dental benefits.
In most of our study states, key informants told us that the inclusion of dental benefits in their program was not controversial; in fact, many noted that the issue of dental coverage was not even brought up during their state’s policy debate. The reasons for this were varied. Once again, some states were occupied with the larger debate over expanding coverage through Medicaid versus separate program strategies, while many others viewed dental care, along with vision and hearing services, as "core pieces of kids’ health care." For example, when officials in North Carolina were designing their SCHIP program, a Medicaid expansion was initially promoted based on the premise that Medicaid provided the best benefit package for children. For a variety of reasons, however, the state instead opted to implement a separate program using the state employees’ health plan as a benchmark. Importantly, though, dental, vision, and hearing services were added to make the package more appropriate for children. Finally, for some states, the inclusion of dental benefits was not controversial because SCHIP was being modeled after an existing package that already included dental services. For example, California modeled its SCHIP benefit package after the state employees’ package, the California Public Employees’ Retirement System (CalPERS), which contained a dental benefit.
Among those included in this study, two states were exceptions to the general pattern—Florida and Colorado. Initially, dental service coverage under Florida’s separate SCHIP program was optional on a county-by-county basis, while under Colorado’s separate program dental services were not covered at all. However, both states have since taken steps to expand dental coverage for children. The reasons for the initial exclusion, and subsequent inclusion, of dental services are broadly similar in the two states: Both were building their SCHIP program on existing health insurance programs that, while not including dental benefits, were still widely regarded as successful models of state-designed health insurance programs for children. In crafting these programs, policymakers in both states noted that their aim was to offer a primary and preventive medical care product that would not be too costly and, thus, would be politically viable. The following two vignettes describe in detail the process by which Florida and Colorado have moved to cover dental benefits in their SCHIP programs.
Florida’s KidCare Program
When policymakers were developing the state-funded Healthy Kids program, the precursor to KidCare, in the early 1990s, their aim was to design a program with an emphasis on preventive services. The decision to exclude dental services was not explicit; the combination of cost constraints and lack of dental-community participation in the planning process contributed to dental benefits being left out of the original benefit package. In 1994, Healthy Kids made dental benefit coverage the option of individual counties. By the time federal SCHIP legislation passed, 11 of Florida’s 67 counties had opted to provide these benefits, with 75 percent of the enrolled population living in these 11 counties. The scope of the benefit package was limited to two cleanings per year, two x-rays per year, and a 25 percent discount on other dental services. The dental program’s premium was $3 per member per month, and all services were subject to a $5 copay.
The passage of Title XXI, with its spotlight on children’s health and the promise of the enhanced matching funds from the federal government, sparked more widespread interest among state legislators in expanding dental coverage under the Healthy Kids component of KidCare. In the summer of 2000, the legislature authorized a pilot project to provide an expanded set of dental services to Healthy Kids enrollees. The benefits are to mirror those of Medicaid, and implementation is to occur over a 24-month period beginning in July 2000. In accordance with the Title XXI legislation, copayments will be eliminated and the dental component premium will be dropped.
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Colorado’s Child Health Plan
Colorado’s SCHIP program built upon the state’s Colorado Child Health Plan (CCHP), which was implemented in the early 1990s to provide preventive and primary care services to low-income children in rural areas of the state. At first, CCHP did not include dental benefits. When the federal SCHIP legislation was passed, Colorado chose CCHP as its basis for a SCHIP program, and began examining options for broadening the benefit package so that it met Title XXI specifications.
The choice of the benefit package was heavily influenced by the policy context in which SCHIP was debated and implemented. Three interconnected issues influenced the selection of a benefit package. First, the state is, in general, politically conservative. Second, as Medicaid had grown to be the second-largest program in the state’s budget, there were concerns about the cost of a new insurance program—and dental was perceived to be an expensive service. Third, the state was firmly committed to creating a program that resembled a commercial insurance product to the greatest extent possible, and most private policies did not cover dental benefits. To this end, the state followed a conservative path and chose a benefit pack-age equivalent to that mandated by the state for the small group insurance market—the most common benefit package offered in the state, and one which does not cover dental benefits.
During the first two years following the implementation of CCHP, considerable attention began to be focused on children’s oral health problems. In 2000, the governor appointed the new Dental Access Commission to examine strategies for improving access to dental services under both Medicaid and SCHIP. The Colorado legislature also began addressing the issue and, in early 2000, passed a bill adding a dental benefit to the SCHIP program. The state plan was to begin covering dental services in 2001, if an adequate network of providers was recruited to contract with CCHP.
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Scope of Benefits Coverage
To what extent are SCHIP programs working to improve children’s access to dental care? A fundamental measure is whether states have included dental coverage in their benefit packages. As mentioned above, 17 of the 18 study states have covered dental benefits in some form. Once again, this finding is noteworthy given the optional nature of dental coverage for non-Medicaid expansions. If a state opts for a Medicaid expansion it must provide the Medicaid benefit package, which, with the protection of EPSDT, covers all medically necessary services for children, including dental services. States that opt for a separate state program must, at a minimum, provide a benefit package that is the same as or actuarially equivalent to the benefits offered under one of three benchmark plans: the Blue Cross/Blue Shield plan available to federal employees; the health plan offered to state employees; or the state’s most popular HMO plan. Importantly, though, the federal employees’ package does not include dental benefits. Typically, under state employees’ plans and typical commercial products, dental benefits are either offered on an optional basis for an additional premium payment or excluded altogether.
To gauge the extent of coverage adopted by separate SCHIP programs, we analyzed coverage policies with respect to three major categories of services: preventive and diagnostic; restorative; and advanced dental care services. The major service categories encompass 14 subcategories. The preventive and diagnostic services category comprises the following subcategories: professional oral exams, teeth cleanings, sealants (which protect teeth’s chewing surfaces), fluoride treatments, space maintainers, and full-mouth and bitewing x-rays. Restorative services comprise fillings and crowns. Advanced care services comprise simple and complex extractions, endodontics (services to treat tooth-pulp diseases), periodontics (services to replace gum diseases), prosthodontics (services to replace missing teeth), and orthodontics (services to prevent or correct irregularities of the teeth).
We found that virtually all states cover preventive and diagnostic services, as seen in table 1. Of the 15 separate SCHIP dental packages analyzed here,4 virtually all cover professional oral exams, teeth cleanings, fluoride treatment, and bitewing x-rays. In contrast, other preventive services are covered less often; for example, only eight of the dental packages cover space maintainers. Restorative services are, for the most part, as well-covered as preventive and diagnostic services: 12 of the 15 benefit packages cover fillings and stainless steel crowns.
| Table 1. Dental Benefits in Separate SCHIP Programs, 2000 |
| Service |
AL |
CA |
CO |
CT |
FLa |
MA |
MI |
MS |
NC |
NY |
NJb |
NJc |
PA |
TX |
WA |
| Preventive and Diagnostic Services |
| Professional oral exams |
 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Prophylaxis (teeth cleanings) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Sealants |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Fluoride treatment |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Space maintainers |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Full-mouth x-rays |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Bitewing x-rays |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Restorative Services |
| Amalgam restoration (fillings) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Stainless steel crowns |
|
|
|
|
|
|
|
e |
|
|
|
|
|
|
|
| Advanced Care Services |
| Extractions |
|
|
|
|
|
|
|
f |
|
|
|
|
|
|
|
| Endodontics |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Periodontics |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Prosthodontics |
|
|
|
|
|
|
|
e |
|
|
|
|
|
|
|
| Orthodontics |
|
d |
|
d |
|
d |
|
e |
|
|
|
|
|
|
|
| Total |
13 |
14 |
0 |
12 |
3 |
14 |
10 |
11 |
10 |
13 |
13 |
3 |
11 |
10 |
13 |
Source: Urban Institute State Children’s Health Insurance Program Evaluation.
Notes:
a. Florida’s dental benefit is not offered on a statewide basis.
b. New Jersey’s KidCare Parts B and C.
c. New Jersey’s KidCare Part D.
d. Covered only to treat severe or handicapping malocclusion.
e. Covered only to treat conditions arising from an accident or if recommended by a physician or dentist for treatment of severe craniofacial anomalies or severe malocclusion.
f. Covered only for impacted teeth. |
Advanced care services are less likely to be covered under separate SCHIP programs. Most states cover extractions, and some cover endodontic services, but few cover periodontic or prosthodontic services. Orthodontic services, which are needed by children more often than the other advanced care services, are covered by four states only under certain circumstances. California, Connecticut, and Massachusetts cover orthodontic services for children with severe or handicapping malocclusion5 but not for less complex "bad bites." Mississippi covers only orthodontic services, crowns, or prosthodontic services to treat conditions arising from an accident or if recommended by a physician or dentist to treat severe craniofacial anomalies or severe malocclusion.
Almost all states impose limits on preventive and diagnostic services, such as two exams and cleanings per year. These limits are consistent with guidelines from the AAPD. X-rays tend to be limited to one set of full-mouth x-rays every one to two years and one set of bitewing x-rays every six months to a year. Fillings are typically covered when they are made of silver amalgam; composite resin fillings (enamel-colored or white fillings) are typically restricted to anterior teeth only.
Three of the study states have annual dollar limits on their dental benefits. Alabama imposes an annual limit of $1,000 per child and Michigan imposes a $600 per child annual limit. Texas has a more complex cap structure: Preventive services are subject to a $172 cap per 12–month period for children ages 1 through 12, and a $181 cap for children ages 13 through 18; "therapeutic services," defined as non-preventive services, such as fillings and crowns, are subject to a $300 cap per enrollment year for children of all ages. Thus, the cap for dental services is $472 for children ages 1 through 12 and $481 for children ages 13 through 18.
Two states stand out as having particularly narrow dental benefit packages: Florida and Texas. As described above, Florida currently has a "screen and clean" benefit that covers cleanings and x-rays only, with a 25 percent discount for any treatment service identified by x-rays. (Once again, however, Florida is in the process of substantially expanding the scope of its dental benefit to mirror a Medicaid dental benefit.) Texas, although appearing on paper to cover a broad range of services, is the only state to impose limits on preventive services that are more restrictive than AAPD recommendations. In addition to having a per-child cap on expenditures associated with dental services Texas limits coverage of oral exams and teeth cleanings to once every 12 months, while AAPD guidelines recommend children obtain these services once every 6 months (AAPD 1999).
One component of New Jersey’s KidCare program is also rather narrow, limiting dental coverage to oral exams, cleanings, and fluoride treatment for children under the age of 12. However, only a small proportion of KidCare recipients are enrolled in this component of the state’s separate SCHIP program.
Cost-Sharing Arrangements
The Title XXI legislation allows states adopting separate programs considerable flexibility to impose cost sharing. States that opted for Medicaid expansions, unless operating under an 1115 waiver, are severely restricted in the type and amount of cost sharing they can require. Under separate programs, states cannot impose copayments on preventive services but can charge premiums and require deductibles and coinsurance, with certain limitations.
Despite fewer restrictions on cost sharing, copayments on dental services were nominal in most separate programs among the study states. As seen in table 2, copays in the study states range from $0 to $10 for dental services. We did find three states that are charging copays for preventive dental services. As mentioned above, SCHIP legislation prohibits states from charging copays for preventive services, but it does not specifically address preventive dental services. Dental visits can include both preventive and nonpreventive services. It appears that some states are charging families copays for dental office visits that include preventive services. No states were imposing premiums or coinsurance specifically with respect to dental services.
| Table 2. Copays for Dental Services under SCHIP Programs |
| State |
Preventive Dental Services ($) |
Restorative Dental Services ($) |
| Alabama |
0 |
5 |
| California |
0 |
0–5 |
| Coloradoa |
— |
— |
| Connecticut |
0 |
0 |
| Floridab |
5–10 |
— |
| Massachusetts |
0 |
0 |
| Michigan |
0 |
0 |
| Minnesota |
0 |
0 |
| Mississippi |
0 |
5c |
| Missouri |
5 |
5–10 |
| New Jersey |
0 |
0 |
| New York |
0 |
0 |
| North Carolina |
0 |
0 |
| Ohio |
0 |
0 |
| Pennsylvania |
0 |
0 |
| Texas |
2–10 |
2–10 |
| Washington |
0 |
0 |
| Wisconsin |
0 |
0 |
Source: Urban Institute State Children’s Health Insurance evaluation.
Notes:
a. In 2000, Colorado authorized the addition of a dental benefit to its separate SCHIP program if an adequate provider network can be recruited.
b. Florida is modifying the dental benefit package offered under Healthy Kids, a component of its SCHIP program, to include restorative dental services and eliminate copays on preventive services.
c. No copay is charged for fillings. |
Service Delivery and Payment Arrangements
As policymakers have learned from their experiences with Medicaid, covering dental benefits does not guarantee that children will be able to gain access to these services. Therefore, we were particularly interested in whether SCHIP programs were adopting the same service delivery and payment arrangements used in Medicaid or whether they were using different arrangements. We examined whether (1) SCHIP programs were using managed care or fee-for-service arrangements for dental care delivery, (2) managed care contracts were with mainstream health plans or dental care plans, (3) managed care plans were receiving capitated or fee-for-service payments, and (4) contracts contained any access provisions specific to dental care. We also asked state officials to comment on the perceived adequacy of dental care provider networks under SCHIP compared with Medicaid. Indeed, our findings suggest that policymakers in many states have designed and implemented new, alternative arrangements in a concerted effort to better translate dental coverage into access.
Use of Managed Care
States creating new programs could choose to use the same delivery system as the Medicaid dental program or to design a new system. We found that several states were using SCHIP as an opportunity to employ new delivery systems for dental services, while other states relied on the preexisting Medicaid dental care delivery system. Traditionally, dental services under Medicaid have been provided on a fee-for-service basis, as the study states reflected. Under Medicaid (both Title XIX and Title XXI expansion programs), 9 of the 18 study states are using fee-for-service arrangements, exclusively to deliver dental services, as shown in table 3. There has been some movement in Medicaid to incorporate dental services into managed care arrangements but this phenomenon has not been widespread—8 of the 18 study states are using a combination of fee-for-service and managed care arrangements, and only 1 state is using managed care exclusively to deliver dental services under Medicaid.
In contrast, under separate programs, more states are using managed care arrangements to deliver dental services. Of the 13 states providing dental services under separate programs, 8 are using managed care arrangements exclusively, while 5 are using fee or service arrangements exclusively.
| Table 3. Dental Service Delivery Arrangements for Children in SCHIP and Medicaid Programs |
| State |
Separate SCHIP programs |
Medicaid (both SCHIP
and regular Medicaid) |
| |
Fee-For-Service |
Managed Care |
Fee-For-Service |
Managed Care |
| Alabama |
X |
|
X |
|
| California |
|
X |
X |
X |
| Colorado |
Dental not covered |
X |
|
| Connecticut |
|
X |
|
X |
| Floridaa |
|
X |
X |
|
| Massachusetts |
X |
|
X |
|
| Michigan |
|
X |
X |
|
| Minnesota |
No separate program |
X |
X |
| Mississippi |
X |
|
X |
|
| Missouri |
No separate program |
X |
X |
| New Jersey |
|
X |
X |
X |
| New York |
|
X |
X |
X |
| North Carolina |
X |
|
X |
|
| Ohio |
No separate program |
X |
X |
| Pennsylvaniab |
|
X |
X |
X |
| Texas |
|
X |
X |
|
| Washington |
X |
|
X |
|
| Wisconsin |
No separate program |
X |
X |
| Total |
5 |
8 |
17 |
9 |
Source: Urban Institute State Children's Health Insurance Program evaluation.
Notes:
a. In Florida's Medicaid program, a small number of children were receiving dental services under a managed care system. Since state officials noted this was a very small proportion of children, we classified Florida as using fee-for-service arrangements exclusively under Medicaid.
b. In Pennsylvania's SCHIP program, state officials noted that a small number of children were receiving dental services on a fee-for-service basis. As was the case with Florida, state officials noted this was a very small percentage of enrolled children and thus we classified this state as using managed care arrangements exclusively under SCHIP. |
The choice of service delivery arrangement is important because it has implications for how families locate and select a dentist for their child. Key informants provided two scenarios for selecting dentists, depending on whether dental services were being provided under fee-for-service or managed care arrangements. For children in fee-for-service dental systems, no clear entity is responsible for linking families with participating dentists. Some respondents reported that families who want to get an appointment with a dentist must call the SCHIP or Medicaid program office, or a local social services office, to obtain a list of participating dentists in their county. Then, families must call the dentists on the list and find out whether they are accepting new patients. In contrast, all states using a managed care system to furnish dental services reported that, when families enroll either into the SCHIP program or into the managed care plan, they are given a handbook that lists available providers. As in the fee-for-service dental system, families are still required to call dentists listed in the plan handbook to find out whether they are accepting new patients. In a managed care system, however, if families need assistance locating a dentist, they can usually call a member services phone number provided by the plan and speak with a representative who can help. Some states also reported that plans will make dental appointments for a child if requested by the family.
Contracting Arrangements
The entities with which states contract to deliver services under managed care differ between Medicaid and SCHIP programs. Generally, states using managed care can contract with a general managed care plan to provide or arrange for all services, including dental. The general managed care plan can then either subcontract with a dental managed care plan or contract with individual dentists or dental groups. Alternatively, states can contract directly with dental managed care plans that are exclusively responsible for providing dental services.
Of the eight states in our study that use managed care in their separate SCHIP programs, five (Connecticut, Florida, Pennsylvania, New Jersey, and New York) contract with general managed care plans, and three (California, Michigan, and Texas) contract with dental managed care plans. Of the eight states using managed care in their Medicaid programs, seven are using general managed care plans (Connecticut, Missouri, Ohio, Pennsylvania, New Jersey, New York, and Wisconsin), while only one (California) is contracting directly with a dental managed care plan.
The decision to contract directly with dental managed care plans instead of general managed care plans seems to have been made with a view to improving access to services. Officials in states that elected to do this believed that dental plans may have greater experience and success with locating clients for their semi-annual exam or cleaning than the Medicaid program. Furthermore, whereas a general managed care plan might be evaluated on a host of quality or utilization measures relating to a variety of service types (e.g., measures pertaining to medical or ancillary therapy services), dental managed care plans are, obviously, judged solely on how well they provide dental services, giving them a potentially greater incentive to provide required dental care to their enrollees.
From the enrollee’s perspective, there may not be much difference between managed dental care under Medicaid and under SCHIP. In all but one (New Jersey) of the seven states using general managed care plans to furnish Medicaid dental services, the general managed care plan subcontracts with a dental managed care plan to actually provide services. Thus, among states using managed care in either Medicaid or separate programs, virtually all children are receiving care from a dental managed care plan.
In addition to being more likely to use managed care arrangements to provide dental services than Medicaid programs, separate programs were also somewhat more likely to contract directly with a dental managed care plan. Under both types of programs, states reported paying managed care organizations on a capitated basis—with all-inclusive capitation amounts paid to general plans, and partial capitation amounts paid to dental plans.6 Regardless of the arrangement, however, general health plans and dental plans reportedly paid individual dentists on a fee-for-service basis.
Dental Access Contract Requirements
States using managed care can impose certain network standards upon plans through their contracts. To determine how prevalent these requirements are, we asked states about the nature of their contracting specifications. We found that the most common contracting stipulations used by states were provider-to-enrollee ratios and requirements with respect to traveling times or distances and waiting times for appointments. For example, New Jersey, under both its separate program and its Medicaid expansion, requires each plan to have one full-time equivalent primary care dentist per 1,500 enrollees. New Jersey is also the only study state to require pediatric dentists to be included in a plan’s network, although the exact number of pediatric dentists required is not specified. Connecticut, which has a combination program that uses managed care for both its separate SCHIP program and its Medicaid expansion, requires one dental provider per 739 enrollees.
Michigan’s separate program, MIChild, is notable for its dental service appointment policy, which prohibits plans from treating MIChild enrollees differently from other insured or self-pay patients. Specifically, the state requires dentists participating in MIChild plans who are accepting new insured or self-pay patients to also accept new MIChild patients. Similarly, if a privately insured or self-pay patient is able to get an appointment with a plan dentist in three weeks, then the dentist must apply this same waiting period to a MIChild patient.
Several states have requirements with respect to travel times and distances, and waits for appointments, that apply to all providers, including dentists. Missouri, under its Medicaid expansion, requires plans to provide an appointment for urgent, serious care at any time; for urgent care on the same day; for urgent, nonroutine care within two days; and for routine care within thirty days. Missouri also requires that each plan enrollee have access to a provider within 30 miles of his or her home, with allowances made for plans serving rural counties. Wisconsin, under its Medicaid expansion, requires plans to provide access to primary dental care within 35 miles and 90 days. Florida’s separate program requires that plans provide an appointment for preventive care within four weeks and for emergency care the same day. Florida also requires that each plan enrollee have access to a plan provider within 20 miles or 20 minutes from his or her home.
Network Adequacy
Most state officials in separate programs believed that the managed care networks afforded good access to dental services and were an improvement over Medicaid. Certain states, such as Michigan and California, reported that their SCHIP systems had significantly increased the number of dentists available to children and that this increased supply had led to greater access to care. A few states, such as New York, reported that it was still a challenge to develop adequate networks for SCHIP enrollees living in rural areas in the state. In contrast, Connecticut, which is using essentially the same dental system for Medicaid and its separate program, reported that the managed care system, like the fee-for-service system, is not providing good access to dental services.7 State officials speculated that this was due to the low reimbursement rates being paid under both Medicaid and SCHIP.
Officials had mixed views of network adequacy under SCHIP in the small number of states that used fee-for-service arrangements for their separate programs. In Alabama, where fee-for-service systems are used for both SCHIP and Medicaid, state officials reported significantly more dentists were participating in ALL Kids, leading to higher utilization rates among the SCHIP enrollees compared with those in Medicaid. Mississippi officials, on the other hand, could not yet assess the adequacy of the state’s SCHIP dental network, reporting that it was too early in the program’s history to reach any conclusions.
The few states using managed care to deliver dental services under Medicaid also gave mixed reviews. Officials in Missouri, whose Medicaid program uses managed care in urban portions of the state and fee-for-service in rural regions, reported that dentists are more willing to participate in the managed care system than in the fee-for-service system, due in part to the higher fees being paid by managed care plans. In Wisconsin, where the Medicaid program also uses both managed care and fee-for-service to deliver dental services, state officials believe that managed care holds the promise of better access because plans contracting with the state must agree to provide access to primary care dentists to all enrollees. However, state officials also acknowledge that access, as measured by utilization of dental services, is similar across the two systems. Representatives from Pennsylvania’s Medicaid program, which also uses both managed care and fee-for-service arrangements, also reported some difficulty establishing adequate dental networks in the state.
Finally, the traditional fee-for-service Medicaid system was almost universally described as having an inadequate number of providers. Respondents repeatedly described the main problem as "not having enough dentists." For some states, the shortage was specific to the Medicaid program, while other states had an overall shortage of dentists. Many states, including Colorado, Florida, New York, and Alabama, noted that dentist shortages were particularly acute in rural areas.
Among the states in our study, three emerged as having taken notable steps under their separate SCHIP programs to redesign dental care delivery and payment arrangements to improve children’s access. Two of these states—California and Michigan—used managed care strategies, while one—Alabama—introduced a new fee-for-service arrangement. All three states reported supporting their new initiatives with competitive payment amounts. These states’ early experiences are summarized in the following vignettes.
Alabama’s ALL Kids Dental Program
Like many states, Alabama has a history of providing poor access to dental services under Medicaid. Importantly, though, at the time of SCHIP implementation, the state was beginning to take steps aimed at improving dental access. In 1998, the state created a task force that brought together dentists from across the state to identify the concerns that discouraged dentists from signing up as Medicaid providers. The task force identified three primary concerns: low fees, missed appointments, and an outdated or confusing billing system. With the proceeds from the tobacco settlement, the Medicaid agency planned to increase fees, offer training to help providers with billing software, and recruit new providers.
When developing its SCHIP program, Alabama adopted the benefit package of its largest commercial HMO, United Health Care, for its separate program. State policymakers chose to implement a separate SCHIP program in combination with a Medicaid expansion. Most agreed that, although in theory the Medicaid package was richer than the coverage chosen for ALL Kids, access to some services in the Medicaid program, including dental, was so severely limited due to lack of participating providers that in fact that Medicaid program was far more restrictive than it appeared on paper. The SCHIP dental package includes all major preventive, diagnostic, and restorative services. It also covers endodontic, periodontic, and prosthodontic services, but does not cover orthodontic services.
Alabama has contracted with Blue Cross/Blue Shield (BC/BS), the largest insurance carrier in the state, to use its preferred providers network (PPO), which includes a dental network to serve ALL Kids enrollees8. The BC/BS network includes about 70 percent of the state’s active licensed dentists and at least one dentist in each county. To help ensure access to care, the state’s contract with BC/BS requires that if a dental practice participating in the BC/BS PPO network is accepting new private or self-pay patients, then it must accept ALL Kids enrollees as well.
The state uses a fee-for-service system to pay BC/BS, with fees significantly higher than those under Medicaid. For example, a periodic oral evaluation is reimbursed at $17 under ALL Kids, compared with $13 under Medicaid; a teeth cleaning is reimbursed at $29 under ALL Kids, compared with only $16 under Medicaid; and a silver filling is reimbursed at $49 under ALL Kids, compared with only $27 under Medicaid.
Within the first three months of enrollment, BC/BS reminds all enrollees to get a dental and medical appointment. Then BC/BS staff check to see whether a claim has been filed for a dental appointment. If not, staff will follow up with the family to encourage them to make an appointment. The state had planned to call these families, but found that the volume of calls made the strategy unfeasible, and is revisiting how to handle this procedure.
ALL Kids officials report that they saw some early evidence of pent-up demand for dental services and that overall utilization of dental services has been higher than under Medicaid. The state reports that 20 percent of ALL Kids expenditures in fiscal year 1999 and 35 percent of claims in calendar year 1999 were for dental services.
Alabama’s SCHIP program shows promise for improving access to dental services for low-income children because of the strong commitment from state leaders to improve dental access under Medicaid and to use SCHIP as a standard that Medicaid could emulate. Prior to SCHIP implementation, the state had already stated its commitment to using funds from the tobacco settlement to increase Medicaid fees. In September 2000, the governor announced a significant increase in Medicaid reimbursement rates, including a $6.4 million increase for children’s dental services. The increase raises dental fees from 60 percent to 100 percent of BC/BS rates.
|
California’s Healthy Families Dental Program
California implemented a separate state program, Healthy Families, because of the strong anti–Medicaid sentiment in the state and the desire of state policymakers to develop a plan that resembled private insurance. While the federal SCHIP legislation was being developed, California policymakers began formulating ideas about how the state SCHIP program should look. They recognized that a private insurance component would be a sine qua non for the approval of any expansion, because the governor at the time was a strong opponent of any entitlement program expansions. The decision made was to use a private insurance model, namely the state employee health benefits plan, CalPERS, which included a dental benefit. The result was minimal controversy over including dental services in the package.
The dental package includes all major preventive, diagnostic, and restorative services. The package also covers endodontic, periodontic, and prosthodontic services, but does not cover orthodontic services except in cases of severe malocclusion. No copayment is required for preventive and most restorative services. A $5 copay is required for oral surgery, endodontic services, crowns, prosthodontic services and other complex procedures.
The state uses dental managed care plans to deliver services, and currently contracts with five dental plans across the state. The state negotiated per-child-per-month capitated payment amounts with each plan. Healthy Families will not release the amount of its capitation rate allocated for dental services, but the state tried to set its payment rates to be comparable with those in the private market. Three of the plans reimburse providers on a capitated basis for most services, and the other two reimburse providers on a fee-for-service basis. Families select a dental plan during the enrollment process. The application packet provides information on the available dental plans and their providers, and a toll-free phone number is available for families to call for help selecting a dentist.
Delta Dental, the plan with the largest number of Healthy Families enrollees, has seen higher-than-anticipated utilization. The plan, which enrolls about 60 percent of Healthy Families enrollees, reports that of these, about 70 percent had a visit within the first six months of enrollment. This rate is about 11 percent higher than seen in an average employer-sponsored group. About 60 percent of these visits have been for preventive services, and the rest for restorative care. The plan reports tha |
