State Medicaid Authorities' Policy Communications With Providers on Individualized Pediatric Dental Care

Abstract

Objectives: Medicaid's Early and Periodic Screening, Diagnostic and Treatment (EPSDT) pediatric benefit is designed to meet children's medically necessary needs for care. A 2018 Centers for Medicare & Medicaid Services (CMS) Bulletin advised Medicaid programs to ensure that their dental payment policies and periodicity schedules include language that highlights that medically necessary care should be provided even if that care exceeds typical service frequency or intensity. We assessed the extent to which Medicaid agencies' administrative documents reflect EPSDT's flexibility requirement.

Methods: From August 2018 through July 2019, we retrieved dental provider manuals, periodicity schedules, and fee schedules in all 50 states and the District of Columbia; analyzed these administrative documents for consistency with the CMS advisory; and determined whether instructions were provided on how to bill for services that exceed customary frequencies or intensities.

Results: Dental-specific periodicity schedules were not evident in 11 states. Eighteen states did not include flexibility language, for example, as advocated by the American Academy of Pediatric Dentistry. Flexibility language was not evident in 24 dental provider manuals or in 47 fee schedules. Only 8 states provided billing instructions within fee schedules for more frequent or intensive services.

Conclusion: Updating Medicaid agency administrative documents-including dental provider manuals and periodicity and fee schedules-holds promise to promote individualized dental care as ensured by EPSDT.

Keywords: Medicaid; children; dental care; oral health; pediatric dentistry; preventive health.

Figure

Number of states with EPSDT-consistent Medicaid documents reflecting dental providers’ requirement to provide, and Medicaid agencies’ obligation to appropriately pay for, medically necessary dental services for children and adolescents per guidance in the May 2018 Centers for Medicare & Medicaid Services Informational Bulletin, 50 states and the District of Columbia, 2018-2019. Abbreviations: AAPD, American Academy of Pediatric Dentistry; EPSDT, Early and Periodic Screening, Diagnostic and Treatment.