You asked for information regarding access to dental care by low-income individuals. You specifically asked (1) whether the legislature considered legislation offering loan forgiveness to University of Connecticut (UConn) School of Dentistry students who agree to serve the state's low-income residents after they graduate, (2) for information on Michigan's use of a statewide contractor (Delta Dental) to provide dental services to Medicaid recipients, and (3) for the status of the lawsuit filed against the Department of Social Services (DSS) alleging the department's failure to adequately provide dental care to the state's low-income children.

We could find no proposed legislation to offer loan forgiveness to UConn dental students agreeing to serve low-income residents. (PA 05-213 provides a way for foreign-trained dentists to get a Connecticut license by working in community clinics or school-based health centers. ) But for over 15 years, the state has offered loan repayment assistance to dentists and hygienists who make a commitment to serve these individuals. The Department of Public Health (DPH) runs the program, which assists a small number of dental professionals each year using state and federal funds.

Michigan's Medicaid dental program for children, HealthyKids Dental, uses a statewide health insurance organization, Delta Dental, to provide dental care to almost 200,000 children enrolled in Medicaid. The state pays Delta a monthly fee (capitation) that is higher than what it paid under the old fee-for-service system. An early evaluation of the program found that it increased access and the number of dentists serving the low-income population. Budget constraints have forced the state to scale back its reimbursement, but it is still higher than fee-for-service rates.

Although DSS' FY 07 budget includes money to pay for a settlement in the Greater Hartford Legal Aid lawsuit against DSS for failure to provide children adequate access to dental care, DSS' Medicaid director, David Parrella, told us recently that no discussions have been held in a while.

The DPH loan repayment program was created in 1990 (CGS § 19a-7d) with the goal of enticing more primary care providers to serve the state's low- income residents. Dentists and dental hygienists are included in the list of eligible providers.

The program is available to clinicians working in “eligible practice sites. ” These are defined as nonprofit, community-based, primary care that are willing to serve people regardless of their ability to pay. (They include the state's federally qualified health centers (FQHC) and other community health centers, but private practice clinicians could also qualify if they can demonstrate they are treating underserved populations. ) They must be located in one of the state's 25 federally-designated Health Professional Shortage Areas (HPSA, a list of these is available at http: //hpsafind. hrsa. gov. )

The employing clinic and provider apply to DPH for one of a limited number of slots. DPH pays the clinician, with a federal match, if he agrees to work either part- or full-time for two years. The grant is up to $ 30,000 for a full-time commitment and up to $ 22,500 for a part-time commitment (the clinician works as Medicaid or Medicare provider for a minimum of 900 hours per year for two years).

Although the grant payment goes directly to the clinician, the employer clinic is expected to ensure the clinician's compliance. Clinicians are expected to demonstrate that they use the payments to repay their student loans.

Funding for the program has remained fairly steady over the last few years following a sharp drop in FY 04. Table 1 shows the state appropriations since FY 03. The average number of participants has ranged between 20 and 25, according to program director Mario Garcia, and about 20% of these are dental professionals.

Table 1: State Appropriations for Loan Repayment Program

^{Source: Department of Public Health}

DPH does not track participants to determine whether they continue to serve low-income residents once their two-year commitment ends. Nor has it evaluated the program to determine whether it has improved access.

In 1998, Michigan began its efforts to increase dental access when it created its State Children's Health Insurance (SCHIP) program, MIChild. The dental component gave dental providers the same reimbursements as private dental insurance plans. This approach was successful. An evaluation of the program's effect on access reported that in its first year, the proportion of MIChild enrollees who had at least one dental visit was nearly identical to the proportion of privately insured children with visits.

In 1999, the legislature added nearly $ 11 million to the state's Medicaid budget to address concerns about oral health disparities and the lack of access to dental care in the Medicaid program. The state's Medicaid agency used this money to initiate a demonstration program to pair the state's public health agency with a private dental contractor to determine if using a statewide dental contractor to serve Medicaid recipients (initially rural residents only) would result in greater access.

Delta Dental Plan of Michigan (DDPM), the sole contractor that replied to the state's request for proposals, was chosen to administer the program, named Healthy Kids Dental (HKD). DDPM agreed to (1) reimburse dentists at the same level it reimbursed dentists covered in commercial insurance plans, (2) handle all administrative transactions for the program as it did for its commercial business, and (3) and allow enrolled children to receive care from any participating DDPM provider in the state. Unlike its commercial business, DDPM would not require HKD families to make co-payments.

When it started, the HKD operated in 22 of the state's 83 counties. Eighteen of these offered care through DDPM Premier, which provided fee-for-service reimbursement to any DeltaPremier dentist in the state. The children in the remaining four counties were enrolled in DDPM's preferred provider program; they could use only DDPM participating dentists. (At that time, 90% of the state's dentists participated in the premier program and 20% in the preferred program. )

In October 2000, the state added 15 counties. By June 2004, 29 counties offered premier care and eight provided preferred care, in part reflecting the state's desire to reduce program costs. (The preferred option program is considered a high volume, discount program, that is, reimbursements are lower but patient volumes are higher. )

Although HKD is run by a third party, it is not a risk-based program. Rather, the state's Medicaid program pays DDPM an administrative rate per member based on a negotiated monthly rate. (The current rate is $ 14. 61. ) And at the end of the year, MDCH and Delta determine if a “settlement” payment is needed (e. g. , if the state capitation was less than Delta's costs, the state pays Delta the difference). According to Chris Farrell of the Michigan Department of Community Health, as of January 1, 2006, HKD is using the preferred option (now called Delta Dental PPO) exclusively. Continuing to use the premier plan would have been too costly.

A 2001 evaluation of HKD's first 12 months suggested the program was quite successful in increasing children's access to dental care. It found that 32. 3% more children received dental care over the previous year and utilization increases occurred across all ages. And 183 more dentists served Medicaid-eligible children than in the previous 12 months. The evaluation found 85% of the dentists in the 18 DDPM Premier counties who treated any DDPM-insured children also treated HKD-enrolled children. It also found that travel times were cut in half and became virtually identical to those experienced by privately-insured children (“Michigan Medicaid's Healthy Kids Dental Program,” Journal of the American Dental Association, November 2003).

The American Dental Association (ADA) compiles state-by-state overviews of Medicaid and SCHIP dental programs. Its 2004 report (the most recent) graphically depicts how reimbursement rates to dentists improved under HKD. Table 2 compares Medicaid reimbursement for selected children's dental procedures in Michigan among the three possible payment options: traditional fee-for-service, HKD Premier, and HKD Preferred. It also shows how these rates compare to claims submitted by all state dentists to other payers for the same procedures.

^{Source: American Dental Association (2004)}

^{[1] The state is no longer paying premier rates, effective January 1, 2006.}

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