Objectives: In May 2018, the federal Centers for Medicare and Medicaid Services (CMS) directed states to align their pediatric dental payment and periodicity schedules with benefits required under EPSDT -- benefits that support medically necessary individualized care. This action reflects growing awareness that intensity and frequency of dental services must be tailored to individual risk. The objective of this study was to determine alignment of state documents in DHHS Region 4 states (AL, FL, GA, KY, MS, NC, SC, TN) with individually-tailored risk-based care.
Methods: Structured internet searches retrieved Medicaid dental provider manuals, periodicity schedules, and fee schedules to assess each state’s information on: 1) coverage limits, prior authorization procedures, and fees; 2) flexibility of services generally and specifically for increased prevention services for high risk children; and 3) reimbursement for additional services beneficial to children at high caries risk including caries risk assessment, nutrition counseling, oral hygiene instruction, and case management.
Results: Considerable misalignment and inconsistency with federal policies are evident in state documents. Examples include: lack of flexibility in periodicity schedules, unclear policies regarding preventive service frequency for children with high caries risk, and misalignment of fee and periodicity schedules. Among the 8 states, 2 referenced flexibility in the covered services portion of provider manuals, 0 in fee schedules, and 1 in its periodicity schedule.
Conclusions: There are significant opportunities for improvement in aligning Medicaid documents for both providers and consumers that will enable more appropriate and timely individualized care to children, particularly those with high caries risk.