Testimony of Jane Perkins, JD, MPH
Legal Director, National Health Law Program
US House of Representatives Committee on Oversight and Government Reform Subcommittee on Domestic Policy
Hearing on Oversight of Dental Programs for Medicaid-Eligible Children
Good afternoon. My name is Jane Perkins. I am the Legal Director of the National Health Law Program, an organization working at the local, state and national levels on behalf of working poor and low-income people. I have been at the National Health Law Program for over 22 years, focusing on children?s health and public insurance, particularly Medicaid.
My testimony today addresses the performance of states in assuring that children obtain dental services through the Medicaid Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program?a mandatory benefit for children and youth under age 21. I will also discuss the role of managed care organizations (MCOs) in the provision of EPSDT dental services and oversight by the Centers for Medicare & Medicaid Services (CMS) in assuring that states operate their programs in compliance with the Medicaid Act and implementing rules.
States? performance. The Subcommittee has heard the story of Deamonte Driver. The problems highlighted by his story are not unique to Maryland.
Congress requires states to report to CMS annually on the number of children receiving dental services.1 States are to use a uniform reporting form, called the CMS-416, to collect and report the data. In the states reporting in FY 2004 (seven states are missing), only 30 percent of children received any dental services, and only 22 percent had a preventive visit. Even fewer children, 16 percent, received any dental treatment services. There was significant variation according to the child?s age and the state where the child lived.2 Please note: Although CMS has released CMS-416 data for FY 2005, it was not used for this testimony because 15 states? reports are missing. Examples from individual states help explain the national data:
- In California, our office serves as the lead agency for the Health Consumer Alliance (HCA), a partnership of independent consumer assistance programs in thirteen counties that are home to over three-fifths of California?s low-income residents. Together with the Health Rights Hotline in Sacramento, HCA responds to approximately 1,400 requests for assistance each month. Since its inception nine years ago, access to dental care has remained among the top five service problems for which beneficiaries seek assistance from HCA. A 2002 study found that denial of essential dental services was the number one problem for beneficiaries who called about dental issues (32 percent of the services problems). Other frequent problems involved delays in obtaining authorization from the State or MCO for dental services, difficulties obtaining specialized treatment, quality of care, language barriers, and misunderstandings among providers and MCOs about what dental services EPSDT covers (e.g. medically necessary orthodontia to address handicapping malocclusions?for example, a nine-year-old who needed orthodontia to address a significant overbite which caused her lower incisors to cut into the soft tissue of her upper palate).3 California?s dental utilization rates, as reported on the CMS-416, are among the lowest in the country.
- According to a June 2003 report from the Court Monitor in the ongoing Salazar v. District of Columbia case, ?substantial evidence indicates that the majority of eligible children in the District?s EPSDT program are not receiving adequate dental care.?4 The Medicaid Act requires each Medicaid-participating MCO to assure CMS and the State that it maintains a sufficient number, mix and distribution of providers.5 However, there have been problems verifying the extent of dentists? participation in the District?s program. In March 2005, the District provided a list of participating dentists to the Salazar legal counsel. Counsel surveyed dentists on the list. Of the 135 unduplicated dental providers named, only 45 individual dentists and one clinic confirmed that they accepted Medicaid-eligible children. Of the 45 dentists, 29 were general dentists; six, oral surgeons; three, pediatric dentists; and one, an orthodontist (with the remaining 6 dentists unidentified by specialty). The other 89 dentists or dental offices were no longer serving Medicaid clients, had moved, had closed, or numerous attempts to make contact were unsuccessful. In March 2006, the District submitted an updated list. By counting each name only once (a number of dentists were enrolled in more than one MCO and in fee-for-service), a total of 63 dentists, nine oral surgeons, and one orthodontist were available to treat all EPSDT eligible children in the District (over 90,000 children). Notably, these data say nothing about the extent of dentists? participation, for example whether the dentist is accepting new Medicaid patients or limiting the number of children served.
- In Miami-Dade County, a pilot project proposed by Governor Bush and approved by CMS in record time has enrolled Medicaid children in a dental home and pays a per member per month amount for each child. A report from the State?s contractor, the University of Florida Institute for Child Health Policy, found that the number of children who received dental care through the Medicaid program dropped 40 percent during the first year. Only 22 percent of eligible children visited a dentist, compared with 37 percent under the old fee-for-service system. The number of participating dentists declined from 669 to 251. Other reports showed a dental group, which was paid $4.25 a month for each of 790 children, provided services to only 45 (5.7 percent) during the first six months of 2005. Thus, the group was paid $20,145 for treating 45 children.6 An analysis from the College of Dental Medicine at Columbia University found that costs under the program stayed about the same and that the State of Florida lost value by paying the same amount for less care and less quality.
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