The State of Medicaid: Oral Health National Association of Medicaid Directors Arlington, VA November 7, 2016 Laurie Norris, JD Senior Policy Advisor for Oral Health Centers for Medicare & Medicaid Services (CMS)

Steady Progress on Access to Dental Care

CMS Advances Oral Health Initiative 2.0 Aim: Increase by 10 percentage points the proportion of children receiving a preventive dental service National Goal: FFY 11 Baseline = 42% FFY 15 Progress = 46% FFY 18 Goal = 52% Each state has its own baseline and goal.

Preventive Dental Services, by State, 2015 Source: FFY 2015 CMS-416 reports, Lines 1b and 12b. Note: With the exception of OH, the national FFY 2015 percentage used data reported by states as of August 30, 2016.

Identify and Leverage Partnership Opportunities Assessing States Using Key Elements of a High Performing Dental Delivery System Supply Side Demand Side Medicaid System adequate rates know about the dental benefit good data quality low administrative burden can find a dentist strong contracts fast payment can make an appointment use EQROs well expedited credentialing have a dental home effective monitoring reasonable prior authorization transportation high stakeholder engagement help with broken appointments adequate agency staff fair audits   strong collaboration with sister public health agency collaborate with PCPs Identify and Leverage Partnership Opportunities local, state and national funders ∙ dental schools ∙ preschools ∙ WIC ∙ Head Start

Florida: 33% of children had a preventive dental service in FFY 2015 CMS’s 2013 approval of Florida’s 1115 waiver required MCOs to undertake Performance Improvement Projects (PIPs) on children’s oral health Florida Medicaid agency: Modified MCO contracts to include specific improvement goals and sanctions for not achieving them Cleaned up dental claims and encounter data and reporting processes Launched statewide branded outreach campaign Achieved 12.4 percentage points of improvement by FFY 2015 Let’s take a look at two of those orange states, and what is going on to improve their performance. First, Florida.

California: 37% of children had a preventive dental service in FFY 2015 In December 2015 CMS approved the state’s 1115 waiver renewal The waiver dedicated $740M to dental improvement over five years $194M for incentives to dentists for providing preventive dental services $187M for incentives to dentists for providing year-over-year continuity of care $172M to reduce early childhood caries using bundled payments for prevention, disease management and behavior change $185M for local dental pilot projects The state is required to achieve at least 10 percentage points of improvement in preventive dental services use by 2020 The state can earn an additional $10M by exceeding targets, up to 15 percentage points of improvement Next California.

Technical Assistance Topic CMS Can Help States . . . Planning Assess system strengths and opportunities for improvement Identify focused improvement goals linked to prioritized actions Contracting and Managed Care Strengthen managed care contracts Develop approaches to performance incentives and disincentives with health and dental plans Work with plans to create impactful oral health performance improvement projects Leverage opportunities in External Quality Review Organization contracts Data Learn how to report accurate and complete dental and oral health services data on the Form 416 and the child core measures Workforce Deploy payment policies to support robust use of non-traditional dental providers Identify ways to simplify provider credentialing Engage physicians to provide oral health services and refer to a dental home Payment Design alternative payment models to encourage change in provider practices to improve care and reduce costs

Distribution of dental delivery system types (by % of children ages 0-20) Source: Medicaid.gov State Medicaid Profiles https://www.medicaid.gov/medicaid-chip-program-information/by-state/by-state.html

Medicaid Adult Dental Coverage Varies Widely AZ WA MN WY CO OR NV CA IA WI MI NE ME MO KS OH NY KY TN NC NH MA VT PA VA NJ DE MD RI HI AK SC NM OK GA TX IL UT CT WV ID AL ND DC MS LA MT SD IN AR FL Emergency services only or no dental services covered (18) 1 to 4 services (18) 5 or more services (15) Source: Medicaid Coverage of Dental Benefits for Adults, Medicaid and CHIP Payment and Access Commission, February 2015

Measuring Progress in Use of Dental Services CMS Form 416 EPSDT Data States report annually on 7 types of children’s dental and oral health services CMS Child Core Set of Quality Measures PDENT (preventive dental services) TDENT (dental treatment services) SEAL (sealants on permanent molars) HEDIS Measures ADV (annual dental visit) Dental Quality Alliance pediatric oral health quality measures (tested and validated) adult oral health quality measures (under development)