Download Executive Summary

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
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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:
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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
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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.
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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
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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