Executive Summary. Burton Edelstein DDS MPH. Donald Schneider DDS MPH. R. Jeffrey Laughlin MPH

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1 SCHIP DENTAL PERFORMANCE OVER THE FIRST 10 YEARS: FINDINGS FROM THE LITERATURE AND A NEW ADA SURVEY Executive Summary Burton Edelstein DDS MPH Donald Schneider DDS MPH R. Jeffrey Laughlin MPH Prepared under contract with the American Dental Association November 2007

2 American Dental Association. SCHIP Dental Performance over the First 10 Years: Findings from the Literature and a New ADA Survey Executive Summary. Chicago: American Dental Association: November Copyright 2007 American Dental Association Permission is hereby granted to copy and distribute all or any portion of this work solely for noncommercial purposes, provided that you prominently display this copyright notice on each copy of the work.

3 Background and Purpose The State Children s Health Insurance Program (SCHIP) was enacted by Congress in 1997 to provide publicly funded health insurance to children from modest-income families commonly called the working poor. Congress offered states the option of expanding Medicaid to cover these children, starting novel programs that could be designed very differently from Medicaid, or combining these two approaches. After 10 years of experience with SCHIP, the American Dental Association conducted this evaluation of dental programs funded by SCHIP in order to determine: which states elected to start novel SCHIP programs rather than expand Medicaid and which included a dental benefit in their novel SCHIP how comprehensive the dental benefits are in the novel SCHIP the adequacy of dental provider networks in the novel SCHIP how many states capped dental benefits in the novel SCHIP what has been learned from the experience of novel SCHIP and how effective novel SCHIP programs have been in providing for dental services. Methods To investigate these issues, the American Dental Association engaged Drs. Burton Edelstein and Don Schneider to review the published SCHIP dental literature and conduct a survey of state authorities views. State authorities surveyed included (1) dental Medicaid program directors; (2) dental SCHIP program directors; (3) dental public health directors; and (4) Dental Association executive directors. Findings 1. State election to start novel SCHIP programs and to provide dental coverage: Nineteen of 20 states that established novel standalone SCHIP programs included a dental benefit at the time of the study. An additional eight states SCHIP Combinations established stand-alone dental programs for some of their beneficiaries while expanding Medicaid for others. 1 These 27 states were the focus of the ADA survey. Of these, two had dropped and reinstated their dental benefit and one was threatening to drop its dental benefit. 2. Comprehensiveness of the dental benefit in novel SCHIP programs: All 27 states cover basic diagnostic, preventive and restorative services with the exception of space maintainers (three states) but a high proportion of these states do not cover prosthodontic (six states), periodontic (seven states) or orthodontic services 1 One other state also is considered to have established a dental benefit for its SCHIP Combination program, for a total of 9 such states, but that state s data were received too late for inclusion in these analyses. 1

4 (14 states). Like commercial dental plans, these new SCHIP plans vary considerably in their service limitations (e.g., allowable treatment frequencies, materials, procedures and ages). These limitations are reasonably consistent with industry standards but fail to meet the needs of the small subset of children with complex oral presentations. These limitations may explain the literature review finding that some SCHIP families continue to experience unmet need for dental care due to cost, even after obtaining coverage. 3. Network adequacy in novel SCHIP programs: Key informants were asked to compare network adequacy in novel SCHIP programs with network adequacy in their Medicaid programs. More than two-thirds of states considered SCHIP network adequacy better than Medicaid network adequacy, citing the higher socioeconomic status of beneficiaries, the higher fees sometimes paid, the commercial-style coverage, and the lack of stigma as reasons for more dentist engagement. 4. Capped benefits and cost sharing in novel SCHIP programs: Eleven states place an annual dollar cap on dental coverage ranging from $350 to $1,000. Unlike Medicaid dental programs, cost sharing is allowed and common. 5. Lessons learned from novel SCHIP programs: Few key informants provided an overall assessment of novel SCHIP program performance but the informants that did so reported that the program is performing moderately well or very well. Overall, respondents noted that novel programs can be effective but are at times limited by benefit design that limits coverage and out-of-pocket expenses and caps. 6. SCHIP effectiveness: The literature review identified 17 articles from peerreviewed and health policy sources that provided quantitative information specific to dental performance in seven states, all of which implemented SCHIP through novel plans. Key findings were that under SCHIP, well funded and well designed programs outperform Medicaid; fewer children have unmet needs for dental care; more children utilized dental care (but, in comparison to national norms, utilization remains modest with states reporting claims-verified utilization rates that average 43 percent); more children have a regular source of dental care; states vary in their SCHIP dental program designs; and there is wide variation in performance. Suggestions for SCHIP improvements included stabilizing and/or increasing funding and incentives, changing dental benefits from optional to required in SCHIP law, requiring data reporting and evaluation, expanding eligibility for dental coverage particularly for people with special health care needs, creating incentives for dentist participation and promoting prevention. Conclusions The literature review and survey demonstrate that children enrolled in SCHIP are accessing dental services at moderate rates higher than children enrolled in Medicaid and lower than children with employer-sponsored coverage. Novel SCHIP dental programs are offering basic preventive, diagnostic and restorative services that 2

5 children need, although access may be hindered by financial barriers or benefit limitations. These restrictions often mirror private sector coverage but may not meet the needs of the subset of children with significant treatment needs, especially in situations where a parent cannot cover the additional outof-pocket costs. Benefits in these programs are designed to limit cost exposure, which can affect the ability of children to receive appropriate services. Providing children access to continuous dental benefits increases utilization, decreases levels of unmet need and provides an opportunity to establish a dental home. Increasing participation by dentists would improve access, especially in locations where the beneficiary-to-dentist ratio is high. States can work to increase reimbursement rates and provide additional incentives to increase dentist participation. Though a few states have voluntarily reported on their dental program performance, there is no federal requirement to provide information on dental services in non-medicaid SCHIP programs. With limited performance data available to periodically measure each program, it is difficult to assess current program performance or to determine where improvements can best be made with respect to benefits, plan design and network adequacy. 3