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Keep ‘em real! Hillsborough County Oral Health Coalition Promoting Dental Health in our Community Hillsborough County Oral Health Improvement Plan “No one should suffer from oral diseases or conditions that can be effectively treated or prevented”. Richard H. Carmona, M.D., M.P.H., F.A.C. Surgeon General Table of Contents Foreword .................................................................................................................................... 3 Executive Summary ................................................................................................................... 4 Background Overview ................................................................................................................. 5 Hillsborough County Oral Health Profile .................................................................................... 11 Plan ......................................................................................................................................... 13 Conclusion ............................................................................................................................... 19 Resources … ............................................................................................................................ 20 Appendices .............................................................................................................................. 21 2 Foreword A broad-based planning team with members representing individuals and organizations from health professions, government agencies, academia, private industry, dental society, and advocacy groups participated in developing this Hillsborough County Health Oral Health Improvement Plan. This team was a subgroup of the larger Hillsborough County Oral/Dental Health Collaborative. The documents include background reports that compare the state of oral health in Hillsborough County with Florida data, previous and current efforts to address oral health issues in Florida, and potential strategies to consider with analyses of the benefits, barriers, impact, and feasibility of each strategy. The Hillsborough County Oral Health Improvement Plan is a working document submitted to the full membership of the Hillsborough County Oral/Dental Health Collaborative for consideration. It is intended to be used as a guide to address improving oral health and increasing access to dental care in our county. We would like to acknowledge the following agencies that have provided valuable input to this plan: Hillsborough County Head Start Children’s Board of Hillsborough County Hillsborough Community College Hillsborough County Dental Association Hillsborough County Dental Hygiene Association Hillsborough County Health and Social Services Hillsborough County Health Department Hillsborough County Minority Dental Association Hillsborough County School District Hillsborough Organization for Progress and Equality Suncoast Community Health Center, Inc. Tampa Family Health Centers Tampa General Hospital USF Department of Pediatrics 3 Executive Summary You must have good oral health to be healthy! During the past several years, more and more scientific evidence has accumulated proving the critical importance of oral health to overall health. Early diagnosis, preventive treatments, and early intervention can prevent or halt the progress of most oral diseases-conditions that, when left untreated, can have painful, disfiguring, and lasting negative health consequences. Even though safe and effective ways exist to maintain oral health, many in Hillsborough County still suffer the needless pain and complications of dental diseases that affect their overall health and well-being. While most people in Hillsborough County have access to and receive oral health care, thousands of children and adults in Hillsborough County lack regular access to routine dental care. Oral health access problems cut across economic, geographic, and ethnographic lines. Racial and ethnic minorities, people with disabilities, and those from low-income families are especially hard hit. It is a disgrace that so many residents still lack access to basic oral health care. The consequences of this are significant. Oral diseases create financial and social costs that diminish quality of life and burden society. People may seek care in hospital emergency rooms, most of which are not well equipped to handle dental emergencies, and where the cost of treatment is far greater than a dental office visit. Children and adults miss sleep, school, and work due to untreated dental disease. They can't eat properly; they can't smile. Everyone has a stake in this issue. It doesn't have to be this way. Most dental diseases are preventable; good oral health is achievable for everyone. Good oral health for all is dependent on equal access to community and school-based preventive and educational programs, routine, periodic professional care, and proper daily home care. Increased awareness is needed for the public and policymakers to better understand that good oral health is essential for overall health and is achievable for all. Currently within Hillsborough County there is a combination of individual, professional and community efforts that focus on improving oral health so that everyone’s teeth can last a lifetime, but resources are limited. Efforts to improve the oral health of disadvantaged persons in Hillsborough County have been fragmented. That's why the entire Hillsborough County community needs to invest in providing access to dental care to underserved people. All of us government, business leaders, insurance companies, health care professionals, community based organizations, and individuals - need to develop access to dental care solutions that work in our community. The Hillsborough County Oral Health Improvement Plan provides a foundation to address the oral health disparities of disadvantaged residents in an effective, unified, cooperative, broad-based collaborative effort among private health care professionals, the public, academia, advocacy groups, and government. The Hillsborough County Oral Health Improvement Plan outlines goals and action steps toward ensuring optimal oral health for all residents and for achieving the standards of Healthy People 2020. It builds upon established oral health programs, proposes the creation of new programs to address unmet need, and calls for the combined efforts of dental providers, educational institutions, state departments, dental insurance providers, dental societies, elected officials, community based non-profit organizations along with other partnering organizations. It is only through this collaborative effort and the sharing of resources that change and improvement can be made. 4 Background Overview Oral Health Oral health is an integral and fundamental part of overall health. Oral health was defined in the 2000 Surgeon General’s report, Oral Health in America, as more than healthy teeth and being free from dental disease. This landmark report brought national attention to disparities in oral health status in the United States, and called for the development of a National Oral Health Plan to improve oral health and reduce those disparities. In April of 2003, “A National Call to Action to Promote Oral Health” was released. It outlines five Actions to stimulate “partnerships at all levels of society to engage in programs to promote oral health and prevent disease.” The Call to Action encourages inclusion of oral health promotion, disease prevention, and oral health care in all health policy agendas set at local, state, and national levels. Florida’s plan, State Oral Health Improvement Plan for Disadvantaged Floridians (SOHIP), began development in 2004. Oral refers to the whole mouth — teeth, gums, hard and soft palate, lining of the mouth and throat, tongue, lips, salivary glands, chewing muscles, and upper and lower jaws. Not only does good oral health mean being free of tooth decay and gum disease, it also means being free of chronic oral pain conditions, oral cancer, and other conditions that affect the mouth and throat. Good oral health includes the ability to carry on the most basic human functions such as chewing, swallowing, speaking, smiling, kissing, and singing. The mouth is vital to everyday life. It serves to nourish our bodies as we take in water and nutrients; communicate our thoughts, our mood, and our dreams; and distinguishes our appearance from others. Because the mouth is an integral part of human anatomy, oral health is intimately related to the health of the rest of the body. For example, mounting evidence suggests that infections in the mouth such as periodontal (gum) disease can increase the risk for heart disease and stroke, can put pregnant women at greater risk for premature delivery, and can complicate controlling blood sugar for people living with diabetes. A full dentition is defined as having 28 natural teeth, exclusive of third molars (wisdom teeth) and teeth removed for orthodontic treatment or as a result of trauma. Most persons can keep their teeth for life with adequate personal, professional, and population based preventive practices. As teeth are lost, a person’s ability to chew and speak decreases and interference with social functioning can occur. The most common reasons for tooth loss in adults are tooth decay and periodontal (gum) disease. Tooth loss can also result from infection, unintentional injury, and head and neck cancer treatment. In addition, certain orthodontic and prosthetic services sometimes require the removal of teeth. Despite an overall trend toward a reduction in tooth loss in the U.S. population, not all groups have benefited to the same extent. Females tend to have more tooth loss than males of the same age group. African Americans are more likely than Whites to have tooth loss. The percentage of Whites who have never lost a permanent tooth is more than three times as great as for African Americans. Among all predisposing and enabling factors, low educational level often has been found to have the strongest and most consistent association with tooth loss. There are a number of factors that contribute to oral health and subsequently general health and wellbeing. Individual biology and genetics; the environment; access to care; the organization of health care; and personal behaviors and lifestyle all interact over the life span and determine the health of individuals, population groups, and communities. Preventive measures and treatments such as water fluoridation, school-based oral health programs and dental sealants, as well as increased use of topical fluorides such as rinses and varnish have significantly reduce the incidence of tooth decay in children, but oral diseases still persist among people of all ages. Poor oral health has many significant social and economic consequences as well as an adverse impact on overall health. Poor oral health in children and young people as well as in adults may result not only in dental decay, eventual tooth loss, and 5 impaired general health, but also in compromised nutrition, in days lost from school and work, and a compromised ability to obtain or advance in education and employment. Disparities most notable in terms of access to oral health care services and oral health status, are related largely to socioeconomic factors and are compounded by the distribution of dental professionals. We have seen improvements in some aspects of children’s oral health and in the oral health of our older citizens, as well as an expansion of the public and private nonprofit dental clinics. Oral Diseases: Dental Caries Dental caries is a disease in which acids produced by bacteria on the teeth lead to loss of minerals from the enamel and dentin, the hard substances of teeth. Unchecked, dental caries can result in loss of tooth structure, inadequate tooth function, unsightly appearance, pain, infection, and tooth loss. Early Childhood: The prevalence of decay in children is measured through the assessment of caries experience (if they have ever had decay and now have fillings), untreated decay (active unfilled cavities), the loss of first permanent molars due to caries, and urgent care (reported pain or a significant dental infection that requires immediate care). Early Childhood Caries (ECC) occurs in young children (typically infants and toddlers) when caries develop on the primary teeth. Typical culprits in the development of ECC include passing harmful bacteria from the mother or caregiver with dental infection to the infant, a lack of parental education about the oral health needs of the child, and inappropriate use of baby bottles and/or sippy cups. Inappropriate use is characterized by bottle feeding with juice or soda, or providing a bottle for overnight use that contains any liquid other than water, including milk and sugary beverages. Repeated inappropriate bottle use can eventually lead to an early onset of rampant caries. Severe ECC requires extensive dental work, including hospital inpatient stays, multiple tooth extractions, and anesthesia. While the immediate effects of ECC can be devastating, long-term effects can be equally damaging. If these primary teeth, which help guide permanent teeth into place, have been lost due to decay, then it can impact how the permanent teeth establish themselves within the mouth. Children who attend school in communities with fluoridated community water supplies have fewer teeth affected by caries than children who attend school in communities with non-fluoridated community water supplies. Fluoride varnishes and sealant programs are evidence based practices to reduce caries incidence and should become standards of care. Adolescents: Recent observations suggest that severe dental conditions similar to ECC occur in teenagers. In this age group, ECC causes severe deterioration of the permanent teeth resulting in more extreme lifetime consequences. The resulting decay can present immediately, but the full impact may not be evident until early adulthood. A frequent cause of extensive caries is cumulative over-consumption of sugarladen beverages such as fruit juices, sodas, and sports drinks. Limited availability and exposure to these beverages during adolescence serve as barriers to preventing caries in adolescence and adulthood. Adults: People are susceptible to dental caries throughout their lifetime. Like children and adolescents, adults also experience decay on the crown (enamel covered) portion of the tooth. But adults may also develop caries on the root surfaces of teeth as those surfaces become exposed to bacteria and carbohydrates as a result of gum recession. In the most recent national examination survey, 85% of U.S. adults had at least one tooth with decay or a filling on the crown. Root surface caries had affected 50% of adults aged 75 years or older. 6 Oral Diseases: Gingivitis Gingivitis is characterized by localized inflammation, swelling, and bleeding gums without a loss of the bone that supports the teeth. Gingivitis usually is reversible with good oral hygiene. Removal of dental plaque from the teeth on a daily basis is extremely important to prevent gingivitis, which can progress to destructive periodontal disease. Periodontitis (destructive periodontal disease) is characterized by the loss of the tissue and bone that support the teeth. It places a person at risk of eventual tooth loss unless appropriate treatment is provided. Among adults, periodontitis is a leading cause of bleeding, pain, infection, loose teeth, and tooth loss. There will likely be an increase in the number of people suffering from gingivitis as tooth loss from dental caries declines or as a result of the use of some systemic medications. While not all cases of gingivitis progress to periodontal disease, all periodontal disease starts as gingivitis. The major method available to prevent destructive periodontitis, therefore, is to prevent the precursor condition of gingivitis and its progression to periodontitis. Periodontal disease has also been implicated as a risk factor for cardiovascular disease and preterm labor. Recent studies also suggest that oral piercing, particularly lower lip studs, may promote gingivitis and gum recession. Diabetes exacerbates gingival inflammation and periodontal disease, furthering the damage and destruction caused by infectious processes on the teeth and gums. As a result, persons with diabetes were more likely than those without diabetes to have lost six or more teeth (37.3% vs. 22.4%). The Burden of Oral Diseases and Disorders The Surgeon General reported that dental caries (tooth decay) is the most common chronic disease of childhood – five times as common as asthma, and low-income children suffer twice as much from dental caries as children who are more affluent. In fact, fewer than one in five underserved children sees a dentist in any given year, according to data collected by the Centers for Medicare and Medicaid Services. These children cannot eat well, resulting in poorer health; they cannot study, reducing their performance in school; and they do not want to smile. Their self-esteem is negatively affected. They grow up to be adults who continue to be affected by the oral disease they faced in their younger years – often at a disadvantage in the job market due to poor oral health and appearance. While nearly every American has or will experience oral disease during their lifetime, our most vulnerable citizens – the poor and uneducated, racial and ethnic minorities, the elderly and the disabled – suffer the bulk of dental diseases. The 2000 Surgeon General’s Report on Oral Health in America made it clear that there are inequities and disparities affecting the very people who are least able to access the resources to attain optimal oral health. Oral health disparities exist across vulnerable and disenfranchised populations of all ages – poor children, the elderly, the disabled, medically compromised, rural populations, the homeless, migrants, immigrants, refugees, and many members of ethnic and racial minority groups suffer a disproportionate burden of oral disease and disorders. The reasons for disparities in oral health are various and complex. Socioeconomic factors, a lack of community infrastructure and programs, workforce issues, physical and mental impairments, behavioral and psychosocial factors, funding issues, a lack of awareness concerning oral health, the perception that oral health is not important, and many other factors act as barriers to providing and attaining optimal oral health care. Racial and Ethnic Disparities: Although there have been gains in oral health status for the population as a whole, they have not been evenly distributed across subpopulations. Non-Hispanic blacks, Hispanics, American Indians, and Alaska Natives generally have the poorest oral health of any of the racial and ethnic groups in the U.S. population. These groups tend to be more likely than Non-Hispanic Whites to experience dental caries, are less likely to have received treatment for it, and have more extensive tooth loss. African American adults in each age group are more likely than other racial/ethnic groups to have gum disease. 7 Socioeconomic Disparities: Low-income families bear a disproportionate burden from oral diseases and conditions. Individuals in families living below the poverty level experience more dental decay and have untreated caries than those living above the poverty level. Nationally, 37% of poor children aged 2-to-9 have one or more untreated decayed primary teeth, compared to 17% of non-poor children. Poor adolescents aged 12-to17 in each racial/ethnic group have a higher percentage of untreated decayed permanent teeth than the corresponding non-poor adolescent group. Adult populations show a similar pattern, with the proportion of untreated decayed teeth higher among the poor than the non-poor. At every age, those at the lowest income level have periodontitis at a higher proportion than those at higher income levels. Adults with some college (15%) have 2-to-2.5 times less destructive periodontal disease than those with a high school education (28%) and with less than a high school education (35%). Overall, a higher percentage of Americans living below the poverty level are edentulous than are those living above. Among persons aged 65 years and older, 39% of persons with less than a high school education were edentulous in 1997, compared with 13% of persons with at least some college. People living in rural areas also have a higher disease burden due primarily to difficulties in accessing preventive and treatment services. Access to Dental Care Although appropriate home oral health care and population-based prevention are essential, professional care is also necessary to maintain optimal dental health. Regular dental visits provide an opportunity for the early diagnosis, prevention, and treatment of oral diseases and conditions for people of all ages, as well as for the assessment of self-care practices. Lack of regular professional care can develop oral diseases that eventually require complex treatment and may lead to tooth loss and health problems. Children should have their first dental visit within six months of eruption of the first tooth and no later than 12 months of age. Also, every child should visit the dentist at least once per year. Efforts to improve access to care for the underserved have largely focused on children served by Medicaid, because significant oral health disparities exist for this population despite the fact that federal law requires states to cover dental services for Medicaid-eligible children through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. Access to dental care for adults served by public programs, particularly the low-income elderly is another underserved population. Providing publicly funded dental benefits to these beneficiaries is within the discretion of the states, and most states including Florida provide only minimal emergency dental treatment for adults. Many people report experiencing challenges in obtaining adequate access to dental care. This is especially true for people who live in areas where a dentist is not available or who cannot afford treatment. Access, or lack of access, is dependent upon several factors, such as geography, availability of oral health care providers, provider willingness to treat certain population groups, costs, insurance coverage and ability to pay, as well as consumer understanding of the need for care and the motivation to seek it. The issue of insurance is a particular challenge, and although recognition must be given to the differences between medical and dental insurance coverage, which is usually much more limited in scope, dental insurance is a major determinant of dental care utilization. Also, medical insurance is a strong predictor of access to dental care. Uninsured children are 2.5 times less likely to visit a dentist and three times as likely to have dental health needs when compared to publicly or privately insured children. Medicaid: Medicaid is the primary source of health care for low-income families, elderly, and disabled people in the United States. This program became law in 1965 and is jointly funded by the federal and state governments to assist States in providing medical long-term care assistance to people who meet certain eligibility criteria. People who are not U.S. citizens can only get Medicaid to treat a lifethreatening medical emergency. Medicaid eligibility is determined based on state and national criteria. 8 Dental services are a required service for most Medicaid-eligible individuals under the age of 21, as a required component of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. Services must include, at a minimum, relief of pain and infections, restoration of teeth, and maintenance of dental health. Dental services may not be limited to emergency services for EPSDT recipients. Medicaid covers emergency, and some restorative, and surgical services for eligible adults. Essential services such as root canals, crowns, and periodontal therapy are not services offered under current Medicaid standards. Due to shortages of Medicaid dental providers, an access gap arises in the percentage of persons receiving services based on their type of insurance coverage. Medicaid, as a safety net for dental services, has been largely unable to address the needs of those who are publicly insured. In 2002, just 30% of Medicaid eligible children visited the dentist and only 28% visited the dentist for preventive care. Children covered by private insurance are more likely to have received any dental service than children under Medicaid, most importantly preventive services. Florida Healthy Kids is a health coverage program using State funds as well as funds authorized under Title XXI of the Federal Social Security Act. It furnishes health care coverage to children under age 19 who are not eligible for Medicaid, whose family income is above 150%, and at or below 200% of the Federal Poverty Level (FPL), and who do not have comprehensive health coverage. The state contracts with health management organizations to provide covered health and dental services to beneficiaries on a per member per month capitation basis. Summary There is no shortage of distressing statistics that describe the prevalence, consequences, and access problems faced by thousands of underserved children, adults, low-income elderly, and others who face complex medical and other special needs. Prevalence: Over 50% of 5-to-9 year-old children have at least one cavity or filling, and that proportion increases to 78% among 17 year-olds. Poor children suffer twice as much dental caries as their more affluent peers, and their disease is more likely to be untreated. Moreover, 25% of poor children have not seen a dentist before entering Kindergarten. Poor children suffer nearly 12 times more restricted-activity days than children from higherincome families. Most adults show signs of gum or periodontal diseases. Severe gum disease affects about 14% of adults aged 45-to-54 and 23% of 65-to-74 year-olds. Consequences: 22% of adults reported some form of oral-facial pain in the past 6 months. Women are twice as likely as men to report two specific types of oral-facial pain, jaw joint pain, and face/cheek pain. Adults living in poverty were more likely to report toothaches than adults living above the poverty level. More than 51 million school hours are lost each year to dental – related illness. Employed adults lose more than 164 million hours of work each year due to dental disease or dental visits. About 30% of adults 65 years and older are missing all of their teeth. These figures are higher for those persons living in poverty. 9 Access to Care: A little less than two thirds of adults report having visited a dentist in the past 12 months. Adults with incomes at or above the poverty level are twice as likely to report a dental visit in the past 12 months as those who are below the poverty level. Financing dental services remains one of the most significant barriers to obtaining necessary oral care. Of persons below 150% of the FPL, 16.4% had unmet dental wants and needs, compared to only 6.3% of families above the 150% poverty level. Moreover, of persons with incomes at or above the FPL are twice as likely to report a dental visit in the past 12 months as those who are below the FPL. Health insurance is a strong predictor of access to dental care. Approximately 44 million Americans lack medical insurance and about 108 million lack dental insurance. For each child without medical insurance, there are at least 2.6 children without dental insurance. Uninsured children are 2.5 times less likely than insured children to receive dental care. Children from families without dental insurance are 3 times more likely to have dental needs than children with either public or private insurance. Many elderly individuals lose their dental insurance when they retire. Nationally, one in five Medicaid-eligible children utilizes dental services. While in Florida only 22% of Medicaid-eligible children utilized dental services. Nationally, only 1% of total Medicaid expenditures are on dental services. Barriers to Dental Care There are barriers to care that need to be overcome in order to help underserved people get needed professional dental care. 1) The dental components in Medicaid and State Child Health Insurance Program (SCHIP), which are supposed to provide health care to disadvantaged Americans, are chronically underfunded. 2) Federal law mandates that Medicaid cover basic preventive and restorative services. But many state programs fail to deliver care to even half of their eligible children. 3) Adult dental coverage through public health programs is even worse; many states simply don't provide it. 4) Patients covered under public programs still face hurdles, such as transportation and difficulty missing work. 5) Poor oral health literacy and awareness about the importance of oral health. A critical component of oral health is taking care of yourself, and too many Americans lack a basic understanding of preventive oral health - things like brushing, flossing, eating a healthy diet, and drinking fluoridated water. 6) Low Medicaid reimbursement rates. 7) Excessive paperwork and administrative complexities. 8) Lack of case management to assist patients in receiving care, resulting in high no show rates. 9) The distribution or location of dentists within some areas and communities. 10 Hillsborough County Profile: Dental Needs and Existing Resources Fluoridation of public water, the key primary prevention for oral disease, is available to 88.5% of the Hillsborough County population on a public water system. Public education programs are provided but not in a systematic and comprehensive method to reach high risk populations. Programs such as fluoride varnish and sealants for children currently only reach a relatively small proportion of the community, although school based programs are being developed. Oral health care in Hillsborough County relies primarily on services delivered through the private sector by dental professionals (dentists, dental hygienists, and dental assistants), and many people do and will continue to seek and obtain the dental care they need through this model. For those who do not, the public health infrastructure and safety net health services providers are a significant source of care. Needs within both the public and private spheres remain unmet. Together, these two spheres comprise the oral health infrastructure. The needs, interventions, and dental health infrastructure for children and adults are different. It is best to examine the dental health care needs and existing resources for these two groups separately. Children in Hillsborough County As of 2005, there were 320,125 children under the age of 20 living in Hillsborough County (Appendix1) Approximately 41% or 141,103 of these children live under the 200% FPL ($42,400 for family of four in 2008 Appendix 2). During the past year, school nurses provided 102 dental education classes to 444 students. The Hillsborough County Dental Collaborative conducted a survey of the main public providers of oral health services to individuals with incomes less than 200% FPL. The organizations surveyed included faith-based and community based organizations as well as those from the governmental sector. Of the 12 organizations who responded to the survey, the scope of services they provide covered the spectrum from no dental services to preventive and restorative care including routine fillings and extractions. Funding to provide these services come from both public and private sources. The results of the survey can be found in (Appendix 3). Tampa Family Health Center and Suncoast Community Health Centers are both Federally Qualified Health Centers (FQHCs) and are the primary providers of dental care to Medicaid and uninsured children in Hillsborough County. Tampa Family Health Centers have a total of 30 dental chairs staffed by 10 full-time dentists and 2 dental hygienists. Last fiscal year they had 10,381 dental visits. Suncoast Health Centers have a total of 18 dental chairs staffed by 6 full-time dentists and 4 dental hygienists. Last fiscal year they had 14,000 dental visits. There is no direct data that measures how many of these children have dental insurance or see a dentist, but as noted earlier, lack of health insurance is a strong predictor for lack of dental coverage. A national study estimated that for every child without health insurance there are 2.6% lacking dental insurance. About one in five children in households with incomes between 0-200% of FPL lack health insurance. A recent study of Florida’s children’s insurance status found that 12.6% of all children are uninsured. Using these statistics, approximately 40,812 children in Hillsborough County would be uninsured and 106,000 would lack dental insurance. Furthermore, since 50.3% of children have employment based health insurance, during these tough economic times, the number without health and dental insurance is sure to grow. Also, children between 12-to-18 years old are disproportionately likely to be uninsured (16%); the same age that which the need for dental care is highest. Hispanic and Non-Hispanic black children account for a disproportionate share of uninsured children in Florida compared to the overall child population. Statewide Non-Hispanic children account for 23% of the uninsured while Hispanic children account for 36%. Both groups represent significant minority populations in Hillsborough County. 11 Most uninsured children (73%) have at least one employed parent, but the parent is insured only 24% of the time. In comparison, 84% of insured children have at least one insured parent. Children with no employed parents in the household and those with uninsured parents are much more likely to have public health insurance compared to children who have an employed or insured parent. A very important statistic is that approximately 72% of uninsured children in Florida are eligible for free or subsidized KidCare coverage: 49% are eligible for Medicaid, 2% are eligible for Medikids, and 21% are eligible for Healthy Kids. These estimates are consistent with recently published national estimates that 74% of uninsured children in the United States are eligible for Medicaid or SCHIP. Having health or dental insurance does not ensure access to care. While there are 11 pediatric dentists enrolled as Medicaid providers, only five are active Medicaid providers. Many parents reported that finding a dentist, difficulty getting an appointment, or inconvenient dental hours contributed to their inability to obtain dental care for their child. Transportation barriers also contributed to inability to obtain dental care. Studies have shown that only 20% of children see a dentist during the year. For Hillsborough County, that would mean that approximately 100,000 children that have Medicaid have not seen a dentist during the past year. One critical group is the Pre-Kindergarten children. It is estimated that 25% have not seen a dentist prior to starting school, meaning that over 19,000 children under 5 years old in Hillsborough County have yet to see a dentist. Adults in Hillsborough County The adult population of Hillsborough County in 2005 totaled 801,098 with 132,316 or 16.5% being 65 years or older. Approximately 25% or 200,733 live below 200% FPL ($28,000 for family of 2 in 2008). The dental needs for the underserved adult population of Hillsborough County are profound. The impact of this problem was revealed in a Florida BRFSS survey done in 2002 that showed 26% of adults over 65 had no teeth and for low income adults over 65 it was 46% without teeth. Only 54% of all adults surveyed have not had any teeth removed, which fell to only 38% for low-income adults. The same 2002 survey provided some information regarding access to dental care in the prior year. Overall, 18.5% of adult’s surveyed reported being unable to see a dentist because of cost. Again there were significant differences between ages and race/ethnicity. For adults aged 45-to-64, 24% reported being unable to afford dental care compared to 18% of 18-to-44 year olds and 10% of over 65. Non-Hispanic blacks were more likely to report not being able to afford a dentist (26%). Overall approximately 23% of adults in Hillsborough County reported they had no health care insurance coverage. The rate was highest for ages 18-to-44 (35%) vs. the 45-to-64 and over 65 which was 85% and 55% respectively. The majority of Hispanic adults (52%) reported they did not have any health care insurance. Fortunately for the residents of Hillsborough County, there is an indigent health care program, the Hillsborough County Health Care Program (HCHCP). This sales tax supported program provides health care to those who are legal residents of the county and have income below 100% of FPL (Appendix 2). This program serves upwards of 20,000 persons a year. Dental services for HCHCP recipients have been limited to emergency treatment to relieve pain and suffering only since March 1, 2005. Overall out of the 617 active licensed dentists in Hillsborough County, only 95 are enrolled and 59 or less than 10% are active Medicaid providers. 12 Plan The Plan is based on the following fundamental values: Good oral health is a foundation of wellness and overall health The Plan, while focused on low income persons, is for all residents Access to oral health services is crucial Education is a key component in improving oral health Prevention is more cost effective than treatment Care should be patient-centered; that is, the individual receiving care is the focus of care and participates in related decisions The objective of the Hillsborough County Oral Health Improvement Plan is to establish common goals among stakeholders that promote action, increase awareness, encourage collaboration, communication, and result in unified efforts to improve oral health for all. A single resource is needed that provides readily accessible and comprehensive information to educate the public and policymakers about the oral health status and problems of disadvantaged Floridians, that suggests solutions to address these problems, and that provides information on current initiatives. Adults under 200% of FPL are much more likely to be uninsured and more likely to have pre-existing dental disease than children. These factors produce an extreme imbalance between need and access to dental care. Given the differences in needs, dental insurance availability, and dental care system, separate oral health improvement plans for children and adults in Hillsborough County were developed. Additionally, a plan to advocate for adequate financing of oral health services for underserved children, low income adults, and other special populations including frail elders and the disabled is included. Prevention is the key to improved oral health. Dental disease is almost entirely preventable. Tooth decay is an infectious disease that starts as a reversible white spot that, without preventive intervention, progresses to visible irreversible tooth decay. Programs that emphasize disease prevention are important for improving the public’s health (community water fluoridation, sealant programs, as well as school-linked health education and care programs). People need to become empowered about their oral health - how simple measures like brushing and flossing their teeth and eating a balanced diet can protect against tooth decay, and understanding the importance of drinking fluoridated water. Effective community and individual prevention measures were considered during the development of the plan (Appendix 4-5). Prevention programs are a viable way to reach underserved populations and to reduce the incidence and prevalence of oral and dental diseases. Preventive care is inexpensive compared to the treatment costs associated with these diseases. “For every dollar spent on preventive oral care, $8 to $50 is saved in restorative and emergency care.” Prevention focuses on changing personal oral health behaviors as well as community factors and environmental influences. Providing education and early preventive interventions for children reduces the future demand for dental services. In addition, community involvement is necessary in order to build support for those interventions. Expansion of current dental disease prevention and oral health promotion programs is necessary in order to both increase the overall oral health of people and reduce the costs of treatment needs and care. Oral health education for the community is a process that informs, motivates, and helps people to adopt and maintain beneficial health practices and lifestyles; advocates environmental changes as needed to facilitate this goal; and conducts professional training and research to the same end. Although health information or knowledge alone does not necessarily lead to desirable health behaviors, knowledge may empower people and communities to take action to protect their health. 13 However, prevention programs are not a substitute for comprehensive care provided by dentists to diagnose and treat disease. Unfortunately, no matter how many treatment resources are established, the treatment of dental disease cannot solve the problem. The effort to improve access to oral health care focuses on the 341,836 in Hillsborough County who live below the 200% of FPL. A number of strategies to expand access to oral health care services were considered (Appendix 6). Coordination and collaboration of private sector dental professionals with safety net providers can maximize the resources of both to better meet the needs. By enhancing partnerships and collaborations within the existing oral health infrastructure while utilizing current professionals both in innovative ways and to the maximum of their education, training, and abilities, oral health services can be delivered more effectively and with maximum quality. Expanding the knowledge base of non-dental health providers along with that of dental professionals is also critical to the best and most effective and efficient use of these resources. As noted above, other health professionals need training specific to preventive oral health care. Adequate and sustainable funding is critical to support the development and implementation of preventive care programs and training for all health professionals. Any plan to address barriers to oral health must first incorporate a strategy for funding the reimbursement for all Medicaid services. Enhanced Medicaid rates of payment to general dentists and dental specialists is critical to assure that private dentists remain significant providers of oral health services for low-income and vulnerable populations. 14 Hillsborough County Oral Health Improvement Plan: Children A. Prevention: Public Health 1. Fluoridation of drinking water for 33,890 children who currently live in communities that do not fluoridate public drinking water. Working with the Environmental Health section of the Hillsborough County Health Department, these populations will be mapped using geographical information. Contacts for the drinking water systems will be identified and encouraged to fluoridate their water if the residents they serve include pre-school children. For communities that do not receive fluoridated water and persons at high risk for dental caries, additional fluoride measures might be needed. Community measures include fluoride mouth rinse or tablet programs, typically conducted in schools. Individual measures include professionally applied topical fluoride gels or varnishes for persons at high risk for caries. 09 - Currently, State of FL, DOH Dental program, water fluoridation offers a block grant to assist municipalities to implement water fluoridation projects. A) Identified Plant City’s public water system of having less than optimal concentrations of fluoride in its water system. Current concentrations are at .4 ppm naturally occurring fluoride in its public water system. B) .7 ppm is the State of Florida optimal water fluoridation recommendations to achieve the most dental benefits. Nov. 09, Plant City manager and water utilities operators are exploring the cost of implementing this project. Jan. ’10 Plant City commissioners met with dental providers, health advocates, children advocacy agencies and concerned citizens to educate the city commissioners on the benefits of water fluoridation. Measurable benefits are 20 -30% less dental decay in all ages, more children free of dental decay, many fewer children having permanent teeth extracted because of dental decay, more adults keeping their teeth for a lifetime, prevention and reversal of early stages of tooth decay, lower dental bills, less need for procedures that require anesthesia and drilling. C) On June 13, ’11 Plant City Commissioners passed a resolution to install a water fluoridation system for the city. 2. Oral Health Education A) School Based: work with school educators and nurses (SHAC) to educate employees and develop a curriculum for children that emphasizes nutrition, brushing, and flossing B) Community Based: Identify community based organizations to provide educational programs. 09 -MORE HEALTH, Inc. received a grant from the DOH, Office of Minority Health to teach dental health lesson plans throughout Hillsborough County for minority children . Lesson plans target elementary schools with higher then 50% minority students Kindergarden, first and second grade. Estimated 18,000 children to receive preventative dental health lessons for the school year ‘09-10. 3. Develop school based dental screening programs: June ’09, FL dental practice act allows a Dental hygienist without supervision in public and private educational institutions of the state and Federal Government, nursing homes, assisted living and long-term care facilities, community health centers, county health departments, mobile dental or health units, and epidemiological surveys for public health. As well as, a dental hygienist is permitted to perform dental charting on a volunteer basis at health fairs. Section 466.0235, F.S B. Dental Care 1. Insurance coverage a) Increase the number of children who are eligible for Kidcare to become enrolled. Coordinate with community based organizations such as, Hillsborough Kidcare 15 b) c) Foundation, medical providers to enroll some of the estimated 30,000 children that are eligible but not insured. Encourage employers through incentives to provide dental insurance; including coverage for preventive services such as topical fluoride and dental sealants for children. Encourage local dental providers to participate in the Kidcare network. 2. Recruit more local dentists to see children on Medicaid or Healthy Kids. Recent legislation passed in 2008 recognizes that there is an important state interest in attracting dentists to practice in underserved health access settings in this state and further, that allowing out-of-state dentists who meet certain criteria to practice in health access settings without the supervision of a dentist licensed in this state is substantially related to achieving this important state interest. Therefore, the board of dentistry shall grant a health access dental license to practice dentistry in this state in health access settings. "Health access settings" means programs and institutions of the Department of Children and Family Services, the Department of Health, the Department of Juvenile Justice, nonprofit community health centers, Head Start centers, federally qualified health centers (FQHCs), FQHC look-alikes as defined by federal law, and clinics operated by accredited colleges of dentistry in this state. A) 3rd Annual legislation summit 2010 priorities included “Increase Medicaid reimbursement rates for dental providers” and add “dental only” buy in option to Florida KidCare). Also to support 12 month continuous coverage across all children’s health insurance programs. Red Book created for local legislators information and advocacy. 3. Encourage Fluoride varnish programs in pediatrician’s offices. Dr Frank Catalanotto, UF School of Dentistry, presented “Train the Trainer for ECC Prevention through Physician/Nurse Practitioner Applied Varnish” to the Hillsborough County Oral Health Dental Collaborative. Fluoride varnish is a protective coating painted on teeth to help prevent new cavities and help stop cavities that have already started. It is sticky, so it attaches to the teeth easily and makes the enamel of the teeth harder. The varnish releases fluoride over several months, which strengthens the teeth in addition to helping prevent decay. As little as one fluoride varnish treatment a year can cut the cavity rate in half for infants and small children. The treatment is easy to administer and has no known side effects. a). USF Ronald McDonald van currently provides training in oral health risk assessments for their pediatric residents. b) Suncoast CHC provides fluoride varnish in their infant/toddler healthy/wellness checkups. c) Identify and educate other community health providers on the importance of early oral health risk assessments and fluoride varnish application for children at risk. 4. Advocate for school based sealant programs targeting schools with highest % of students enrolled in the free and reduced lunch programs. a) Suncoast CHC was approved by the HCSD superintendent to begin a pilot Dental Sealant Program for second and seventh graders attending one of the elementary and one of the middle schools in their service area. If pilot meets everyone’s satisfaction, it will be implemented for second and seventh graders in 22 targeted schools. As of July ’09, the Hillsborough County School District has rescinded their interest in support of a school based sealant program. Since the early 1970s, childhood dental caries on smooth tooth surfaces (those without pits and fissures) has declined markedly because of widespread exposure to fluoride. Most decay among school-age children now occurs on tooth surfaces with pits and fissures, particularly the molar teeth. Pit-and-fissure dental sealants — plastic coatings bonded to susceptible tooth surfaces — have been approved for use for many years and are recommended by professional health associations and public 16 health agencies. First permanent molars erupt into the mouth at about 6 years of age. Placing sealants on these teeth shortly after their eruption protects them from the development of caries in areas of the teeth where food and bacteria are retained. If sealants were applied routinely to susceptible tooth surfaces in conjunction with the appropriate use of fluoride, most tooth decay in children could be prevented. Second permanent molars erupt into the mouth at about 12 to 13 years of age. Pit-andfissure surfaces of these teeth are as susceptible to dental caries as the first permanent molars of younger children. Young teenagers need dental sealants shortly after the eruption of their second permanent molars. The Healthy People 2020 Oral Heatlh Objective (OH) – 12 Increase the proportion of children and adolescents who have received dental sealants on their molar teeth. This includes: OH- 12.1 Increase the proportion of children aged 3 -5 year who have received dental sealants on one or more of their primary molar teeth OH – 12.2 Increase the proportion of children aged 6 – 9 who have received dental sealants on one or more their permanent molar teeth OH – 12.3 Increase the proportion of adolescents aged 13-15 years old who have received dental sealants on one or more of their permanent molar teeth. 5. Expand existing “safety-net” clinics. a) Federally Qualified Health Centers (FQHC): Tampa Family Health Centers and Suncoast Community Health Centers. Suncoast Community Health Centers, Inc. (SCHC), Portable Dental Program and Tampa Family mobile dental programs target children participating in the Head Start programs. Suncoast targeted 24 schools located within their service area. Estimated at 3,500 children. 09 - They received grant funding from HRSA and the State of Florida to purchase equipment (2 portable chairs), supplies, hire a program coordinator, and additional assistants for the outreach portable dental program. At this time, Aug. 09 School District voted against having Suncoast CHC provide preventive dental health services. b) School Based/After School programs: Partnerships between the Hillsborough County Health Department and local dental providers to provide dental services at schools. Current plans to provide dental screening services for 500 minority children are scheduled to begin Jan ’09 –June ‘11. Partnership with MORE HEALTH, Hillsborough County Health Department, Suncoast CHC and Tampa Family CH will provide these services for non-funded children based on grant monies received from the Department of Health, Office of Minority Health, ‘Closing the Gap’ grant. Preventive dental health services, including sealants, were provided by Suncoast CHC at the Boys and Girls clubs in Plant City and Dover. c) Mobile Dental Vans: i. Partner with USF and the Ronald McDonald mobile van to develop programs to bill Medicaid for services to eligible children. ii. Tampa Family Health Centers, Inc. iii. South Baptist mobile van iv. Mission Smiles of Tampa v. Suncoast Community Health Centers, Inc.- Suncoast launched a 3 operatory mobile dental clinic in Oct.’10. Dental preventive health services were provided at following organizations: Wimauma Academy, charter Title I School, Good Samaritan Mission in Wimauma, Boys and Girls Clubs of Plant City and Dover Redland Christian Migrant Association RCMA in Plant City, Dover and Wimauma, Hillsborough County Bealsville Recreation Center, Head Start Centers in Eastern Hillsborough County, Suncoast Pediatric Clinic in Plant City and the Plant City Housing Authority. 17 Hillsborough County Oral Health Improvement Plan: Adults A. Prevention: Public Health 1. Oral Health Education: Community based programs to promote good nutrition, brushing, and flossing B. Dental Care 1. Insurance coverage: Dental benefits at sufficient reimbursement level to encourage provider participation. a) Expand dental services covered by Medicaid. Impact 87,321 b) Restore dental services to Hillsborough County Health Care Program recipients. Impact = 15,000 2. Expand safety net clinics a) FQHC: Tampa Family Health Centers and Suncoast Community Health Centers. 11- Tampa Family CHC is expanding from 9 to 30 dental chairs. 11- Suncoast CHC expanding from 15 to 18 dental chairs. 3. Expand dental Volunteer Healthcare Provider Program (VHCPP) – Expand the dental Volunteer Healthcare Provider Program (VHCPP) offered by the Department of Health that provides sovereign immunity to dental providers enrolled in the program. Under the VHCPP, clients must meet financial eligibility requirements for uninsured patients under 200% FPL. a) Plans are to coordinate outreach dental events with area dental providers enrolled in the VHCPP. (i.e. Smile Friday and Give-Kids-A-Smile) b) Enroll eligible patients in the VHCPP that meet financial requirements. c) Coordinate client services for the VHCPP for scheduled outreach dental events. d) Train and certify dental health care providers to complete VHCPP registration forms and to complete and report data from the event. e) Create VHCPP days with dental outreach events with Suncoast CHC and Tampa Family HC. C. Community dental health coordinator – Hillsborough County Health Department, Community Dental Health Program. The community dental health coordinator assists in building partnerships between community organizations and community dental providers to increase access to care. This program has developed a resource guide outlining available public dental services and oral health education programs. August ’09 –‘11 HCHD Dental Health Consultant provided in kind services for MORE HEALTH, Inc. to expand children dental health services in Hillsborough County, dental health education for medical and other healthcare providers. g) Developed strategic plans to increase water fluoridation systems within Hillsborough County. Identified Plant City of not having water fluoridation. Organized meetings with Plant City officials, oral health coalition members, medical and dental providers. Developed and orchestrated community involvement to increase awareness of the importance of water fluoridation. h) Explore partnerships between community dental providers and Hillsborough County Community College and Erwin Dental Research to offer clinic hours for the adult uninsured. (i.e. Smile Fridays) f) 18 i) j) Developed WIC Smiles 4 U early intervention dental prevention program for WIC clients with local community dental health providers, Tampa Family CHC and Suncoast CHC. Developed educational programs for ‘Enhancing the Integration of Dental Health and Maternal Health and Child Health’ and ‘Healthy Mouth…Healthy Body’ for Medical Healthcare providers, WIC, Headstart and Hillsborough County Employees. Hillsborough County Oral Health Improvement Plan: Advocacy 1. Oral health links to general health a) Educate medical providers, pediatricians, and family care physicians about importance of screening and connection between oral health and general health b) Educate elected officials on the importance of oral health education and access to dental care. 2. Dental Care a) Medicaid coverage for adults b) Restoration of full dental benefits to individuals who qualify for the Hillsborough Health Care Program c) Resource guide - Resource guide compiled by HCHD Dental Health Consultant 09 Dec d) Healthy food and drink options in school vending machines -09 MORE HEALTH Working on initiative to remove candy and soda machines from schools. e) Increased funding for community and school-based oral health education programs k) Dental workforce reform to better utilize the existing workforce to achieve improved access to oral health services l) Volunteer recruitment through incentives such as tax breaks or credits, licensure fee discounts, continuing education credits, and sovereign immunity/liability coverage. 4. Develop web sites to host where to locate local dental programs and resources. http://www.hillscountyhealth.org http://www.211atyourfingertips.org/ http://www.doh.state.fl.us/family/dental/resources/index.html (click on Hillsborough County) 19 Conclusion Based on the principle that oral health is a critical and integrated component of overall health, excellent access to high quality oral health care services will contribute to the quality of life of all. Caries, periodontal disease, gingivitis, and oral cancer are all facets of oral disease that can detrimentally affect overall well-being. The bad news is that not all residents of Hillsborough County enjoy oral health. The good news is that this can be changed, that oral disease is preventable. The last 40 years have seen dramatic reductions in the prevalence of tooth decay, thanks in part to the efforts of the dental public health programs such as community water fluoridation, dental sealants, and education. The Hillsborough County Oral Health Improvement Plan outlines goals and action steps toward ensuring optimal oral health for all residents and for achieving the standards of Healthy People 2020. It builds upon established oral health programs; proposes the creation of new programs to address unmet need; and calls for the combined efforts of dental providers, educational institutions, state departments, dental insurance providers, dental societies, elected officials, community based non-profit organizations along with other partnering organizations. It is only through this collaborative effort and the sharing of resources that change and improvement can be made. It is worthwhile to note that while the plan was drafted, some of the strategies have been initiated. 20 Resources 1. 2000 Surgeon General Report: http://www.surgeongeneral.gov/library/oralhealth/ 2. 2003 National Call to Action to Promote Oral Health: http://www.surgeongeneral.gov/topics/oralhealth/nationalcalltoaction.html 3. State Oral Health Improvement Plan for Disadvantaged Floridians: http://www.doh.state.fl.us/Family/dental/sohip/index.html 4. Healthy People 2020 Oral Health Objectives: http://www.cdc.gov/oralHealth/topics/hp2010.htm 5. Florida BRFSS Survey 2002: http://www.floridacharts.com/charts/brfss.aspx 6. American Association for Community Dental Programs: http://www.aacdp.com/ A number of State Oral Health Plans were reviewed that provided valuable background information in the development of this document. They include: 7. Oral Health and Access to Dental Care for Ohioans, 2007: http://www.groundworkohio.org/resources/otherresources_pdf/2007%20Access%20Brief%20Ex ec%20Summ%20FINAL.pdf 8. Oral Health Strategic plan for Pennsylvania: http://www.dsf.health.state.pa.us/health/lib/health/oralhealth/finalstrategicplan.pdf 9. Smart Mouths, Healthy Bodies: An Action Plan to Improve the Oral Health of Coloradans: http://www.beasmartmouth.com/pdf/stateplanf.pdf 10. Maine Oral health Improvement Plan: http://maine.gov/dhhs/boh/files/odh/MEOralHealth_Plan07.pdf 11. Michigan Oral Health Plan: http://www.michigan.gov/documents/oral_health_work_plan_final_color_140634_7.pdf 12. The Illinois Oral Health Plan II: http://www.ifloss.org/OralHealth/plan2.html 13. Rhode Island Oral Health Plan, 2006: http://www.health.state.ri.us/disease/primarycare/oralhealth/pdf/RIOHPlan2006.pdf 14. 2006-2007 North Carolina Oral Health Section Strategic Plan: http://www.communityhealth.dhhs.state.nc.us/dental/ed_resources/OHS_06_07_Strateg ic_Plan.pdf 15. Hawaiian Islands oral Health Task Force: http://hawaii.gov/health/family-child-health/dental/hiohtf-actionplan.pdf 21 Appendices 22 Appendix 1 Hillsborough County Profile Kids (0-19) Total Population < 200% FPL Enrolled in Medicaid Enrolled in Medikids Enrolled in Healthy Kids Uninsured Number of Kids 336,485 141,103 130,000 1,211 10,123 30,000 Source 1 2 3 4 4 5 Adults Total Population < 200% FPL Enrolled in Medicaid Enrolled in Hillsborough County Health Care Plan Uninsured Number of Adults 801,098 200,733 87,321 15,000 Source 1 2 3 160,000 5 Source: 1. Florida Department of Health, Public Dental Health Program (Data obtained from FL DOH CHARTS) (As of 12/18/06) 2. Florida Department of Health, Public Dental Health Program 3. Florida Department of Health, Public Dental Health Program (Data obtained from Agency for Persons with Disabilities) 4. Florida Department of Health, Public Dental Program (Data obtained from Florida KidCare Update 12/1/06 5. 2007 Florida BRFSS Data Report 23 Appendix 2 2008 HHS Poverty Guidelines 100% FPL Persons 48 Contiguous in Family or Household States and D.C. Alaska Hawaii 1 $10,400 $13,000 $11,960 2 14,000 17,500 16,100 3 17,600 22,000 20,240 4 21,200 26,500 24,380 5 24,800 31,000 28,520 6 28,400 35,500 32,660 7 32,000 40,000 36,800 8 35,600 44,500 40,940 3,600 4,500 4,140 For each additional person, add 2008 Income Limits 200% FPL Family Size Gross Annual Income Gross Monthly Income 1 2 3 4 5 6 7 8 9 10 20,800 28,000 35,200 42,400 49,600 56,800 64,000 71,200 78,400 85,600 1,734 2,334 2,934 3,534 4,134 4,734 5,334 5,934 6,534 7,134 SOURCE: Federal Register, Vol. 73, No. 15, January 23, 2008, pp. 3971–3972 24 Appendix 3 Agency Information Program Melanie Hall Population Served Phone (813) 615-0589 Baycare Mobile Health Clinic & Cranial/ Facial Clinic Contact e-mail [email protected] Agency Children Adults Special Ethnic Groups Services Provided Other Eligibility 0-18 Education (e.g. Awareness, Diet, &/or Nutrition Counseling) Mobilepreventive education, toothbrushes, etc. Prevention Intervention Procedures (e.g. Sealants, Varnish, Cleaning) Screening & Referrals (e.g. problem identification/visual exam) Location Provided (X all that apply) Comprehensive Exam (e.g. Xray, charting of disease) Treatment (e.g. extractions, root canals, etc.) Private office Public clinic Schoolbased Faithbased cleft palate and other congenital disorders are diagnosed & treated ? Dorrie PaquinBrown (813) 349-7589 [email protected] Suncoast Community Health Center, Inc. 4) Financial Qualifications: 5) Funding Source: 6) Insurance Requirements: 7) Payor Information: 6 months 17 years 18+ Hispanic (Latino); Migrant & Seasonal Farmworkers Low-income, uninsured. We do not ask immigration status Geographic Area: specific census tracks; all of South and East County Central County (East of I-75) Provided in Public Clinics and School Based Clinic provides all services Education only 4) Financial Qualifications: Sliding Scale Fee 5) Funding Source: 6) Insurance Requirements: Medicaid, Medipass, Aetna, Guardian, CMS; Under 21: Staywell (Dental), HealthEase, CitrusCare, Amerigroup, United 7) Payor Information: 25 Suncoast Community Health Center, Inc. M, W, Th, F, 7:00-5:00; Tu, 9:00-7:00 (from JR/HxSt) Ruskin: (813) 349-7800 / Dover: (813) 349-7700 / Plant City Family Care: (813) 349-7700 x508 Parental Consent needed for women under 18 Yes Bilingual staff or translators available Self Referral/No appointment needed. Picture ID if possible, (they have a digital camera if patient does not have picture ID), Proof of income (if no pay stub, then something written on paper by employer). Ruskin: 2814 14th Ave. S.E. Ruskin, FL 33570 Dover: 14618 SR 574, Dover, FL 33527 Plant City Family Care: N. Maryland Ave., Plant City, FL 33566 Catholic Charities Mobile Medical Services Sister Sara K. Proctor - DW, PAC cell (813) 690-7467 [email protected] 4) Financial Qualifications: are various classes of fees. Call for fees. Also a sliding fee scale. 5) Funding Source: N/A 6) Insurance Requirements: Medicaid accepted 7) Payor Information: N/A Provides health care for people who need, but can’t afford, basic medical services; comprehensive primary and dental care: Family Practice, Internal Medicine, Mid-wives, Doulas. Pediatrics, pharmacy; (Ruskin and Dover clinics), x-rays (Ruskin and Dover clinics). Suncoast collaborates with various organizations to provide services which include Lifetime Mobile Bus, USF physicians to read ultra-sounds, and speakers who come to clinics to educate patients. Once enrolled in the program, the primary care center will become patient’s “medical home” where they will go for any health need that is not an emergency. Very few children and ONLY thouse who have NO form of health coverage/any age All adults without health coverage and at incomes of 200% poverty or below Primarily Hispanic but not exclusively Services are No Dental No Dental No Dental Services No Dental Countywide Services Services Provided Services and NOT Provided Provided Provided limited by Zip codes. We do see people from the surrounding Counties if they can get to where services are being held 4) Finanicial Qualifications: 200% Federal Poverty Guidelines or less. 5) Funding: Private 6) Insurance Requirements: They must have None 7) Payor Information: Free with donations accepted 26 Marlinda Fulton - Executive Secretary, Hillsborough Dental Association (813) 259-6304 [email protected] Hillsborough County Dental Association/ Hillsborough Community College Smile Fridays 2+ All adults All Clients Countywide seen at HCC/ Dale Mabry campus Oral Hygiene Sealants, Cleanings Screenings X-rays, exams Restorative (fillings) HCC/ Dale Mabry campus HCC/ Dale Mabry campus HCC/ Dale Mabry campus HCC/ Dale Mabry campus Hillsborough Community College 4) Finanicial Qualifications: 200% Federal Poverty Guidelines or less. 5) Funding: Volunteer Dentists, Student Assistants/Hygieneists, monetary donations/grants 6) Insurance Requirements: No dental insurance or Medicaid, client must not have either 7) Payor Information: Free, must qualify through state DOH guidelines through qualified certifier 4001 Tampa, Bay Blvd., Tampa, FL 33614 (from JR/HxSt) M 8:00-12:30; Tu, Th 12:304:00 Parental Consent needed for women under 18 (813) 2596301 Yes Bilingual staff or translators available Self Referral; Appointment Needed; Photo ID needed Dental Cleaning, sealants exams, radiographs HCC/ Dale Mabry campus USF Pediatrics Ronald McDonald Care Mobile Jeannette Fleischer, ARNP/Program Director (813) 259-8754 [email protected] 4) Finanicial Qualifications: range from $30-85. Call for further information. The clinic accepts Mastercard and Visa, personal checks and cash. 5) Funding: N/A (The dental work is done by student Dental Assistants and Hygienists with supervision by Dentist and faculty). 6) Insurance Requirements: Does not accept Medicaid 7) Payor Information: N/A all ages up to 21 yrs old None All underserved (either no funding source or no access to health care or unable to pay copay) As above per Pediatric Resident, ARNP, dentist Fluoride Varnish Referrals to the HCC Smiles Friday Program May do extractions in the future but none now. Referred to HCC Program All services are school based 4) Finanicial Qualifications: No Funding Source. 5) Funding: None 6) Insurance Requirements: None 7) Payor Information: None 27 Debbie DeWitt/ Contracts Manager (813) 301-7337 (813) 301-7339 [email protected] Hillsborough County/Health & Social Services Department Hillsborough County Health Care Plan/Oral surgery contract Indigent Residents of Hillsborough County in the Hillsborough County Health Care Plan (HCHCP) County-wide for HCHCP clients only Emergency Dental Care Only by General Dentists and an Oral Surgeon Hillsborough County Dental Research Clinic at Irwin Tech. Judeo Christian Health Clinic, Inc. Kelly Nelson, Executive Director (813) 870-3231 (813) 301-7339 [email protected] 4) Finanicial Qualifications: To qualify as an HCHCP client individuals must be Non-Medicaid and Non-Medicare indigent residents of Hillsborough County whose income is at 100% or below the federal poverty level guidelines and whose assets are below $5,000 for a single person or higher depending on the number of people in a family. 5) Funding: Half-cent Indigent Health Care Surtax. 6) Insurance Requirements: No other health insurance payon, nor Medicaid or Medicare 7) Payor Information: Hillsborough County through the Clerk of the Circuit Court, 13th Judicial District Dental hygiene education Friday afternoons (ages 4-17) Simple extractions on Tuesday and Wednesday evenings (no wisdom teeth, no teeth broken below the gumline) any none, serves all Hillsborough County Dental hygiene education Friday afternoons (ages 4-17) Simple extractions on Tuesday and Wednesday evenings (no wisdom teeth, no root canals, no teeth broken below the gumline) 4) Finanicial Qualifications: None for Dental, Income requirements for medical: 100% - 250% of poverty level. 5) Funding: Private donations, fundraisers, and grants 6) Insurance Requirements: N/A 7) Payor Information: N/A 28 Sandra Gallogly and Shelly Olsson (813) 273-7020 [email protected] [email protected] School District of Hillsborough County Hillsborough County Public Schools Ages 3 through 21 None languages spoken among students N/A Classroom in elementary schools Grant in progress with Sun Coast Through school clinic. Referrals as available with community None None Hope Tackett and Cheri Wright Jones Central Hillsborough Healthy Start Closing the Gap in Infant Mortality (813) 974-2005 (813) 974-1267 [email protected] [email protected] 4) Finanicial Qualifications: N/A 5) Funding: $5000 per year available for emergency treatments/Migrant services has small amount for emergency treatment also 6) Insurance Requirements: N/A 7) Payor Information: N/A Women 18-44 Black and Hispanic women Resident of Hillsborough County - No income requirement. Participants receive $20 Wal-Mart gift card and incentive bag with marketing aids and brochures. Bacterial Vaginosis, Periodontal Disease, Nutrition and Baby Spacing/Family Planning Education None Periodontal disease screening (Screening is free to the participant) – xrays and periodontal exam, referral for dental services if needed Periodontal evaluation – bitewing xrays and generalized evaluation of tissues (probing, plaque assessment) None Classroom in elementary schools Grant in progress with Sun Coast Through school clinic. Referrals as available with community None None Albert Boholst, DMD Hillsborough County Public Schools Sandra Gallogly and Shelly Olsson (813) 273-7020 [email protected] [email protected] School District of Hillsborough County 4) Finanicial Qualifications: N/A 5) Funding: DOH and Children's Board 6) Insurance Requirements: N/A 7) Payor Information: N/A Ages 3 through 21 None languages spoken among students N/A 29 Dental Research Clinic at Erwin Technical Center 4) Finanicial Qualifications: N/A 5) Funding: $5000 per year available for emergency treatments/Migrant services has small amount for emergency treatment also 6) Insurance Requirements: N/A 7) Payor Information: N/A M-F 8:0011:00; 12:003:00; On Monday and Wednesday later hours are available by appointment. (from JR/HxSt) (813) 238-7725 None Only Adults are seen at this clinic Bilingual staff or translators available Self Referral; Appointment Needed; Photo ID needed Provides routine dental care and treatment including preventive treatment for public assistance clients. Provides routine dental care and treatment including preventive treatment for public assistance clients. E. Hillsborough Ave., Tampa, FL 33610 Tampa Community Health Centers 4) Finanicial Qualifications: Call for fee schedule. Co-payment is required. Low-income residents must pay cash at time of appointment. 5) Funding: N/A 6) Insurance Requirements: Does not accept Medicaid 7) Payor Information: N/A It is a comprehensive care facility and there are long waits. It is expected that clients who come for dental care will use the clinic for their dental home. Lee Davis Dental Clinic/ M-F 8:005:00 (from JR/HxSt) (813) 272-6240 Parental Consent needed for women under 18 Yes Bilingual staff or translators available Self Referral; Call or walkin. Fill out application, will need income verification or verification of homelessness. dental services, exams, cleaning, extractions and fillings. dental services, exams, cleaning, extractions and fillings. dental services, exams, cleaning, extractions and fillings. 3402 N. 22nd St., Tampa, FL 33605 Provides dental services, exams, cleaning, extractions and fillings. Provides dental services, exams, cleaning, extractions and fillings. Provides dental services, exams, cleaning, extractions and fillings. 1229 E. 131st Ave., Tampa, FL 33612 Tampa Community Health Centers 4) Finanicial Qualifications: Sliding fee scale. 5) Funding: N/A 6) Insurance Requirements: Medicaid Accepted 7) Payor Information: N/A North Tampa Dental Clinic (from JR/HxSt) (813) 866-0950 Parental Consent needed for women under 18 Yes Bilingual staff or translators available Self Referral; Call or walkin. Fill out application, will need income verification or verification of homelessness. 4) Finanicial Qualifications: Sliding fee scale. 5) Funding: N/A 6) Insurance Requirements: Medicaid Accepted 7) Payor Information: N/A 30 Appendix 4 Effective Community and Individual Preventive Measures for Dental Caries Prevention Measure Method of Application Target Period of Use Community Programs Community water fluoridation Systemic Entire Population Lifetime School water fluoridation Systemic Schoolchildren School years School fluoride tablet program Systemic Schoolchildren Ages 5–16 School fluoride rinse program Topical Schoolchildren Ages 5–16 School sealant program (professionally applied) Topical Schoolchildren Ages 6–8 and 12–14 Pre-School Ages 3-5 Primary Molars Individual Approach Prescribed fluoride tablets or drops Systemic Children Ages 6 months–6 years Over-the-counter treatments Topical Individual need High-risk populations Professionally applied fluoride treatment Topical Individual need High-risk populations Fluoride toothpaste Topical Entire Population Lifetime Professionally applied dental sealants Topical Children Ages 3-5, 6-8 and 12-14 Source: Allukian Jr. M. 2003. Oral disease: The neglected epidemic. In Scutchfield FF, Keck, CW, eds., Principles of Public Health Practice (2nd ed.). Albany, NY: Delmar Publishers. 31 Appendix 5 Comparison of Five Effective Community Prevention Programs for Dental Caries Program Effectiveness (%) Adult Benefits Cost per Year Practicality Community fluoridation 20–40 Demonstrated 50.51 per capita‡ 50.72 per capita† School fluoridation 20–30§ Expected but not demonstrated $0.85–$9.88 per child‡ Good; if there is no $1.19–$13.83 per child† central community water supply, no individual effort necessary School dietary fluoride 30 Expected but not demonstrated $0.81–$5.40 per child‡¥ $1.13–$7.56 per child† Fair, continued school regimen; daily supplement program required for children ages 8– 10 School fluoride mouth rinse program 25–28§ Not expected $0.52–$1.78 per child‡¥ $0.73–$2.49 per child† Fair, continued daily or weekly school regimen required School sealant program 51–67¶ Expected but not demonstrated $13.07–$28.37 per child‡ $18.30–$39.72 per child† Good; primarily done for children ages 6–8 and 12– 14 Excellent, most practical; no individual effort necessary *This table is a simplified comparison of these prevention programs. A thorough analysis of the literature should be undertaken to understand the relative merits of these programs. † In 1999 dollars. In 1989 dollars. § This range may now be high; no recent studies are available. ¥ Includes use of volunteer personnel. ¶ First molar chewing surfaces only over 5-year period. ‡ Source: Allukian Jr. M. 2003. Oral disease: The neglected epidemic. In Scutchfield FF, Keck, CW, eds., Principles of Public Health Practice (2nd ed.). Albany, NY: Delmar Publishers. 32 Appendix 6 Strategies to Expand Access to Oral Health Services A. Ensuring Adequacy of Coverage Adult dental coverage Child dental coverage, including EPSDT requirements Federally Qualified Health Centers and Local Healthcare Plans School-based health services Adult dental coverage: Under Medicaid law, dental services for adults are classified as an "optional service." In Florida, dental services for adults are specifically listed as a covered service in the Medicaid State plan. However, the fact that dental services are specifically listed as a covered service State does not mean that all services are covered. A State can select the dental services it wishes to cover for adults. In some States coverage is comprehensive, including regular cleanings, X-rays and dental repair similar to employer-sponsored dental insurance. In other States, like here in Florida coverage is limited to the immediate relief of pain and infection, dentures and denture related procedures. Appropriate dental care and good oral health enhance employability among adults on Medicaid and increase the likelihood that they will get a job, keep their job and achieve independence from the welfare system. In this way good dental coverage for adults can contribute to increasing employment and success in welfare reform, and offset some of the costs of dental services for this population. Mainstream dental coverage for adults can also be expected to make the program more attractive to dentists and contribute to improved participation by dentists in the program. In this way improving dental coverage for adults can be both a strategy to improve oral health and improve access to needed services for persons of all ages. Child dental coverage, including Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Program requirements: Under the requirements of EPSDT, Medicaid must provide comprehensive coverage of all needed dental services for children and adolescents from birth through age 20. EPSDT is a specific program under Medicaid that provides well-child and comprehensive pediatric care including dental care for children and adolescents through age 20. EPSDT also requires coverage of any necessary medical or dental service reimbursable under Medicaid for the treatment of a condition identified under a periodic or "as needed" exam, even if the service is not otherwise a covered benefit in that State. Under EPSDT, dental coverage includes complete preventive care, restorative services, medically necessary orthodontic care, and emergency care. A common complaint among dentists concerns patients who do not keep their appointments. Missed appointments cause resentment among dentists because of the office management and financial problems they create. More importantly, the patient does not receive a needed service. The likelihood of a patient keeping a dental appointment is improved with a system of case management that addresses the logistical, cultural and behavioral barriers to dental care. Medicaid can pay for case management as a medical service or as an administrative activity. Case management services are an integral component of EPSDT and (at the discretion of the State Medicaid agency) can be provided directly by the Medicaid agency, by participating providers, or by case managers employed by State or local public health agencies. State and local maternal and child health providers can and do play a very beneficial role in providing case management services. Case management can assist parents in scheduling appointments for screening, diagnosis or treatment, can arrange transportation and follow-up to ensure that appointments are kept, re-schedule missed 33 appointments, and work with the parent and the dental office to be sure the child obtains care. Oral health services in Federally Qualified Health Centers (FQHCs and through local healthcare initiatives): FQHCs and local healthcare initiatives have the potential to provide dental services and play a crucial role in the availability of these services. Expanding the availability and capacity of dental services in FQHCs and in local government funded healthcare plans can be a significant strategy in increasing service availability for uninsured populations, especially in areas where there are few dental providers. School-based health services: Medicaid can reimburse for medical and dental services covered under a State's Medicaid program when they are provided in school-based health clinics or settings to children, including adolescents who are enrolled in Medicaid and are qualified for services under the Individuals with Disabilities Education Act (IDEA). A "school-linked" dental service program is also a strategy where prevention programs and screenings are provided in schools and students are "linked" to community based dental providers for any needed reparative and surgical care. These programs and services may qualify for Medicaid reimbursement, depending on how they are structured and provided and the extent the students are enrolled in Medicaid. In addition to Medicaid, the Title V Maternal and Child Health Program and other HRSA funding supports dental sealant programs which utilize portable dental equipment to serve classrooms consisting primarily of Medicaid eligible children. These programs provide dental sealants for underserved children, assist children in enrolling in Medicaid and SCHIP, and refer children for followup restorative care, if required. Local public health early intervention programs and school districts may enroll as Medicaid providers and receive payment for covered services for eligible children and adolescents. Services often covered in school settings include: therapies; case management; transportation; screening and evaluation; health education; dental sealant application; and other services that may fall under EPSDT. Medicaid reimbursement for services in school settings may be limited when children are enrolled in a managed care organization (MCO) unless the State Medicaid agency has agreed to pay for these services on a fee-for-service basis. The key factor is what medical or dental services are included in the Medicaid capitation rate to the MCO. When a service is included in the capitation rate, a medical or dental provider will need to seek payment for services for an enrolled Medicaid patient from the MCO instead of the Medicaid agency. Some States "carve out" certain services from the MCO capitation rate, so payment may be made directly to schools on a fee-for-service basis. B. Ensuring Adequacy of Payment Fee-for-service payment rates to dental providers Managed care payment rates to dental providers Fee-for-service payment rates to dental providers: Participation in Medicaid and serving Medicaid patients is voluntary for all providers. Those who do participate must agree to accept Medicaid payment as payment in full. The amount that Medicaid pays for services is a key factor in a dentist's decision to serve Medicaid patients. Low payment is one of the most frequently cited reasons for not participating in Medicaid. Dentists have indicated that Medicaid reimbursement often does not cover the direct cost of providing services. Federal law requires that State Medicaid payments to providers be "sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area." To achieve the desired level of dental participation, dental services merit special attention in Medicaid rate setting. For dental and medical services provided by Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs), Federal law requires Medicaid payment to be based on reasonable costs. Medicaid also has the option to pay local health departments, community mental health clinics or other public providers on a reasonable cost basis. However, many of these clinics and health centers do not 34 provide dental services, and those that do are unlikely to have enough capacity to meet all the needs of the community. Substantial participation of dentists in the community will likely be required to achieve adequate coverage of oral health services. To have Medicaid payment rates regarded as acceptable to dental providers is necessary to dental participation, but it is not likely to be sufficient. Dental providers are often concerned about program administrative requirements and procedures. Program improvements and administrative streamlining are an important adjunct to adequate reimbursement in increasing dentists' service to Medicaid patients. Managed care payment rates to dental providers: In many States, almost all families on Medicaid receive medical care through a managed care organization. In these States, the Medicaid program has several options for covering dental services. Medicaid can include dental care as a service covered by the medical managed care organization, can contract directly with dental managed care vendors, or can "carve out" (exclude) dental services from managed care. When Medicaid decides to contract dental services through managed care, Medicaid must have a contract with the managed care organization that spells out the expected coverage, the required network of dental providers and the required levels of performance. The specific provisions of this contract are critical to the success of this approach to dental coverage. A key issue is whether the amount Medicaid pays to the managed care organization for dental services is sufficient for the expected use of services, and whether payment rates used by the managed care organization to reimburse dentists are sufficient to assure access. The amount in the managed care organization's capitation rate targeted to dental services is usually based on an actuarial assumption that the use of dental services will be the same in managed care as it was under the state-administered fee-for-service program. This assumption will not be correct when the use of dental services was low due to limited access under the State-administered fee-for-service program, and where the managed care plan improves access and the use of dental services. In this case, the amount of money available to the managed care organization for dental care will be inadequate. The Medicaid agency must address this issue when the managed care rates are being set, and do so within the Federal "upper payment limit" requirements. The upper payment limit constrains the State Medicaid program's capacity to enhance funding for a specific service such as dental in its managed care rate setting. Managed care offers an opportunity to address several key issues relating to good oral health care. The Medicaid agency can use the contract with managed care organizations to address oral health standards of access, quality, utilization, reimbursement and data reporting, and can require a relationship with Title V and other public health agencies. C. Improving Dentists' Participation In recent years, States have invested considerable resources in addressing low dental provider participation in Medicaid and poor access to dental services. Several strategies are being used in an effort to improve access and availability of dental services. The clear message from recent State experience is that the problem is complex, multifaceted and difficult to resolve. Reimbursement issues are important, yet improving reimbursement alone may not improve dental access. Strategies to Improve Dentists' Participation in Medicaid: A number of issues need to be addressed to successfully establish and improve dentists' participation in Medicaid. These include the issues cited above relating to adequate coverage and reimbursement, plus others that relate to improving the business relationship between Medicaid and the dentist. Success requires a comprehensive set of strategies. Strategies include the following: Improved reimbursement: Dentists often cite low reimbursement as a primary reason for not serving Medicaid patients. Small increases may not improve payment levels to a point that a dentist believes actual costs are covered by Medicaid payment. 35 Administrative streamlining: Improve the business relationship with dentists by minimizing the hassle of being a provider with Medicaid. Actions have included: 1) simplifying the process of becoming a Medicaid provider; 2) providing a simple process to verify patient enrollment with Medicaid; 3) simplifying the process for prior authorization for services, or eliminating prior authorization entirely for many services; 4) reducing the number of services requiring prior authorization; 5) adopting the American Dental Association coding structure and standard claim forms; 6) establishing provider hotlines; 7) establishing patient ombudsmen; and 8) simplifying provider manuals and program requirements. Creating mainstream benefit structure: The more Medicaid dental coverage is comparable to employer-sponsored dental insurance, the greater likelihood dentists will participate and serve Medicaid patients. Achieving dental coverage regarded as mainstream by the dental community may involve adding or updating covered services and procedures so they reflect modern dental practice and terminology. Creating a special advisory committee or task force to recommend strategies: Participation in an advisory committee or task force can raise awareness within the dental community of the urgency and need to serve this population. Significant contributions of a State oral health coalitions include: 1) helping to educate beneficiaries about the importance of oral health; 2) working with the dental community to improve participation and availability of services; 3) bringing the problems and issues to the attention of State officials and legislators; 4) engaging the public in advocacy for oral health; and 5) identifying best practices that can be adopted for State and local use. Outreach and marketing to dental providers: The distribution and supply of dental providers is often problematic. Many inner city and rural areas (where large numbers of Medicaid beneficiaries reside) may have few or no dental providers. Special efforts need to be focused where there is a shortage of dental providers. These efforts may include: 1) special articles in dental journals; 2) letters to individual dentists; 3) meeting with local dental societies; 4) seeking input from dentists on how to recruit additional providers; 5) improving the conditions of participation in Medicaid; and 6) using Head Start and WIC programs to assist in recruiting dentists for Medicaid. Case management to reduce missed appointments: Missed appointments are a serious issue for dentists. Reducing the rate of "no shows" for scheduled dental appointments can be a very important part of an overall strategy to improve dentists' participation. Medicaid can pay for case management provided by health departments, managed care organizations, state and local maternal and child health programs, FQHCs, other providers, enrollment brokers or the Medicaid agency can provide case management itself. Case management can include: 1) sending reminder postcards; 2) using case managers to assist is setting up appointments and emphasizing the importance of keeping their appointments; 3) following up on appointments whether kept or missed; and 4) creating a toll-free hotline for dentists to call if a patient misses an appointment. Outreach to parents of children: Medicaid can help educate parents about the importance of oral health, the need for early care to prevent common dental problems and how to use the dental delivery system. Medicaid can provide this outreach directly or contract with other organizations, such as local health departments, schools, managed care organizations or dental provider groups. Transportation and making appointments: Medicaid can pay for transportation and the scheduling of appointments. A State agency or a private provider can provide both, and both can be classified as a service or an administrative activity. Working with schools and Head Start programs: Medicaid can provide schools and Head Start programs with literature and information to encourage early and continuing good oral health and dental check ups. Working with managed care: Managed care organizations under contract with Medicaid must guarantee access and quality, and comply with specific contract performance requirements. Medicaid is 36 obliged to enforce these requirements. Where dental services are the responsibility of managed care organizations, Medicaid can facilitate good oral health services through adequate capitation rates and contract requirements for access and quality that are that are clear and enforceable. Working with safety net providers: Dental services often are available through community providers. FQHCs, Rural Health Clinics and hospitals may serve as safety net providers of dental care. Encouraging safety net providers to offer dental services can be an important part of an overall strategy, together with measures to encourage good participation of community-based dentists. D. Ensuring that Eligible Persons are Enrolled Adults and children eligible for Medicaid Children eligible for the State Children's Health Insurance Program Adults and children eligible for Medicaid: A primary strategy for fully utilizing Medicaid is to enroll all persons who are eligible under existing eligibility standards. Medicaid cannot pay for services for persons who are not enrolled, even if they are eligible. Experience has shown that many eligible persons are not enrolled. A number of strategies can increase the likelihood of their enrollment. These strategies include: 1) outreach, public service announcements and paid radio and TV ads; 2) simplified application forms and enrollment procedures; and 3) assistance for persons applying for Medicaid. These strategies apply to enrollment of adults, as well as children. The key to getting children enrolled seems to be providing good information and making the process as easy as possible for the parent. Research has shown the following strategies improve the likelihood that parents will enroll their child: Allowing enrollment by mail or phone; Permitting immediate enrollment ("Presumptive Eligibility") with forms completed later; Extending enrollment office hours; Improving the way applicants believe they are treated at enrollment centers; Allowing enrollment at a clinic, doctor's office or dentist's office; Allowing enrollment at Head Start programs, WIC clinics and faith centers; Allowing enrollment at school or day care center; Using a toll-free telephone information line; and/or Simplifying and shortening the enrollment form. Other policies adopted by many States include: Dropping the assets test Adopting presumptive eligibility Not requiring a face-to-face interview Providing continuous 12-month eligibility Providing information and outreach Adopting common policies for both Medicaid and the State Children's Health Insurance Program (SCHIP) Making the program as much like mainstream health and dental insurance as possible. States have found that creating an image of Medicaid that is more like private health and dental insurance can help overcome a lingering stigma in the minds of some potential beneficiaries 37 E. Improving Eligibility Standards for Medicaid or the State Children's Health Insurance Program Medicaid Eligibility for Children to Age 18: States have the opportunity to expand eligibility specifically for children. Many States have taken advantage of the opportunity to expand Medicaid eligibility above the levels required by federal law. Under Section 1902(r)(2) or Section 1931 of the Social Security Act, a State can expand eligibility to the level it chooses. A few States have expanded eligibility under Medicaid to 275% or 300% of the FPL using this approach. Other States are using their State Children's Health Insurance Program as the vehicle to expand coverage for children. State Children's Health Insurance Program (SCHIP): SCHIP has provided an excellent opportunity to expand access to needed health and dental care for children. SCHIP programs qualify for an enhanced Federal matching rate that is higher than the Medicaid. Federal matching rates for SCHIP range from 65% up to 84%. F. Other Alternatives Volunteerism/ Charitable Care: Altruism alone will not fundamentally provide sustained access to care for the many in need. Private contraction between government and community based organizations and private dentists for a dental care safety net are an alternative. 1) Workforce Innovation: The overall number of dentists is not the only reason for limited access to dental care. It is where dentists are located, how many people they're able to treat and whether people can afford treatment or whether there's a way to pay for their care. 2) Senate Bill 1319. Implementation of this law will allow greater access to preventive dental care in health access settings to serve indigent children at highest risk for tooth decay by allowing dental hygienist to place dental sealants without prior examination by a dentist. 38