Chapter 5:
Policy Options for Improving
the Iowa Title XIX dental program

In this chapter are suggestions for improving the Title XIX dental program as collected from Iowa dentists in the survey. A list of possible policy options for improving the program will also be presented based on these suggestions, along with the potential cost implications for some of these changes.

Dentists' Suggestions for Change

With changes to the Title XIX program proposed at both the state and federal levels, input from dentists was requested in the survey to determine their preference for ways to reduce costs to the Title XIX dental program. Dentists were presented with the question: Like many programs, Title XIX is currently under review for ways to reduce their costs. If it were to become necessary, which of the following options do you feel would be the three best ways for Title XIX to reduce costs (rank first three choices from 1 to 3). Options the dentists could choose from were: 1) eliminate all dental coverage for Title XIX recipients; 2) eliminate all dental coverage for adults; 3) reduce the number of dental services covered for adults; 4) reduce the number of dental services covered for children and adults; 5) eliminate coverage for orthodontic services; 6) reduce the reimbursement rates for selected dental procedures; and 7) other suggestions. These questions were analyzed using the same system used to rank order the perceived problems with Title XIX presented in Chapter 3.

Prior to the analysis, suggestions made by dentists in the other category were collapsed into categories that could be included in the analyses along with the six options presented in the survey question (the entire list of suggestions are presented in appendix B). Iowa dentists made 50 different suggestions in the other category that were grouped into five categories: 1) reduce administrative costs (e.g. reduce unnecessary mailings, use ADA forms, use electronic submission for claims administration), 2) change eligibility (e.g. tighten eligibility requirements), 3) increase patient compliance (e.g. tie eligibility to patient compliance), 4) payment related changes (e.g. increase copayments, set yearly maximum, dentists should donate time to free clinics), and 5) reduce fraud (both recipient and dentist fraud). Some dentists indicated that no changes should be made.

The total points for each option and its rank order are presented in Table 5-1. Two options were ranked significantly higher than the others: eliminate orthodontic coverage and reduce services for adults. These two represented almost two thirds of the points. The third highest ranking option was to eliminate all adult coverage. The options collapsed from the other category were lower at least in part because they were not presented uniformly to all recipients.

Table 5-1. Dentists' preferences if changes are to occur
in the Title XIX dental program

Change	Total score	Percent of total score	Rank
Eliminate orthodontic coverage (braces)	1,582	34%	1
Reduce services for adults	1,256	27%	2
Eliminate adult coverage	484	11%	3
Reduce services for all recipients	362	8%	4
Reduce administrative costs	207	5%	5
Reduce reimbursements	179	4%	6
Eliminate all dental coverage	153	3%	7
Payment-related changes	146	3%	8
Change eligibility	101	2%	9
Increase patient compliance	59	1%	10
Police fraud	43	1%	11
No cuts	23	1%	12
Total	4,595	100%

Policy Options

Any significant changes to the policies of the Title XIX dental program will likely have implications for access to dental services for recipients of the program. In these proposed recommendations, we are focusing on changes that would affect the available supply of dental services to Title XIX recipients rather than other important access issues, such as lack of perceived need for dental care and language and cultural barriers because these are more closely within the purview of the Title XIX program.

Potential changes to the program represent a spectrum of choices rather than an either/or for policy makers and could impact which populations have access to care (e.g. adults, children, nursing home residents, SSI recipients), the types of services they receive (e.g. preventive, basic restorative, comprehensive services), and/or their choice of provider (e.g. dentists choosing not to participate).

A sampling of potential policy options will be presented in this section. The fiscal impact will be estimated for some of these options from the table of total allowed charges by procedure presented in Chapter 4 (Table 4-2). This discussion of potential policy options is not intended to be exhaustive but rather to provide a framework for evaluating alternative approaches with some discussion of the potential impact of each option.

Policy discussion of ways to improve access to dental care for very young children

As discussed previously, one of the principal foci of this project was to assist the new case management program in improving access to care for very young children. These children are required to receive a screening and referral for dental treatment by age one as part of the EPSDT program. This project has thus far followed the traditional approach of trying to locate dentists who would see a one-year-old patient enrolled in Title XIX. The Title XIX provider survey, however, demonstrated that only 30 percent (n=259) of general dentists and pediatric dentists were willing to accept children under age two in their practice. Over half (54 percent) of the dentists who indicated they do accept children under age two, however, were not accepting all new Title XIX patients in their practice. Thus only 15 percent of the general and pediatric dentists in Iowa can be considered likely candidates to provide access for very young Title XIX enrolled children.

The utilization data presented in Chapter Two validates this issue. Very few children had visited a dentist before age three. The costs associated with the care provided in hospital operating rooms emphasizes the importance of identifying as early as possible the children most at risk for oral health problems. The few children who received dental care in the operating room and the low numbers who had made a dental visit indicates the difficulty of identifying children most at risk and preventing problems once they have made a visit to the dentist. Future efforts to effectively identify high-risk children and improve compliance with the oral health screening requirements of the EPSDT program may benefit from expanding the dental screening process for very young children. Two policy options for helping to identify and treat high-risk children that will be discussed are:

…Increase reimbursement levels for dentists who provide routine care including EPSDT screenings to young children.

…Develop alternative methods of providing dental screenings, education and referrals to Title XIX enrolled children under age 3.

Policy option 1: Increase reimbursement levels for dentists who provide routine care including EPSDT screenings to young children

Since dentist participation in Title XIX has been identified as a significant barrier preventing some young children from receiving dental care, increasing the reimbursement for children's services could assist in attracting dentists back to the program. Although the comparable fees were not available from the statewide survey of dentists' fees, a convenience sample of fee schedules from five dental practices from around the state was used to provide a "ballpark" estimate of the average fee for pediatric procedures. These data were also used to estimate the likely impact such a fee increase would have, assuming utilization rates remained at the level they were in 1994. The list of procedures is provided in Table 5-2.

This is a conservative estimate of cost impact since it assumes there is no increase in utilization following the increase in fees. Because the purpose of the fee increase is to increase dentists' participation and improve access to care, utilization is likely to increase an undetermined amount following the fee increase.

Table 5-2. Estimated impact of increasing reimbursement for pediatric dental procedures to 75 percent of the average fee in Iowa

Procedure	Title XIX total allowed charges FY 1994	75 percent of average Iowa dentists' fees	Additional cost to the Title XIX program	Percent change
Comprehensive oral examination	$266,143	$378,396	$112,254	30%
Periodic oral evaluation	$395,957	$473,876	$77,919	16%
Child cleaning	$109,052	$139,301	$30,249	22%
Child cleaning and fluoride	$942,263	$1,083,485	$141,222	13%
Sealants (per tooth)	$118,938	$216,842	$97,904	45%
Silver filling--1 surface, primary	$156,137	$229,156	$73,019	32%
Silver filling--2 surface, primary	$277,867	$366,317	$88,450	24%
Silver filling--3 surface, primary	$52,657	$59,524	$6,867	12%
White filling--1 surface, primary, posterior	$31,269	$40,237	$8,968	22%
Stainless steel crowns, primary	$298,557	$361,758	$63,201	17%
Pulpotomy (remove part of nerve)	$105,778	$121,544	$15,766	13%
Total	$2,754,617	$3,470,434	$715,817	21%

Policy option 2: Develop alternative methods of providing dental screenings, education and referrals to Title XIX enrolled children under age 3.

Currently very few Title XIX enrolled children in Iowa are receiving dental services. This is due in part to the lack of demand on the part of parents of very young Title XIX recipients for dental services and the lack of dentists willing to accept these children in their practice if they seek care. One option to improve the number of children receiving oral health screenings would be to more effectively reach low income children in locations where they already seek other health care or social services such as public health clinics, Maternal/Child Health (MCH) centers, and WIC clinics.

In some of these clinics, oral health screening and education programs are already occurring, but they are currently being provided in a patchwork manner. Some clinics have a dental hygienist on staff part time, while others use nondental health professionals to conduct the oral health screenings. Reimbursement for EPSDT oral health examinations is currently not allowed for nondentists (outside of the medical EPSDT well baby exams), which hinders many clinics from being able to hire or increase the hours of a dental hygienist to conduct oral health assessments.

Access and utilization of oral health screenings would increase, however if public health clinics could be identified as recognized EPSDT providers and reimbursed for the screening exams. Many referrals of the one and two-year-olds from these clinics to a dentist for a screening examination would then be unnecessary. Only those children under age three with identified oral health problems would automatically be referred to a dentist for care, as well as all children age three and above. Children with a regular source of dental care could continue to receive the screening and treatment from their dentist.

Reimbursing public health clinics for the EPSDT oral health screening would provide the centers with the resources needed to retain or hire dental hygienists on a full or part time basis (which they may have lost over the years). It would also provide other low-income children who are not eligible for Title XIX with access to the oral health screenings, education, and referrals to the dentist. This should not interrupt the care already being provided by a dentist, because so few children under age three who are enrolled in Title XIX have ever visited a dentist.

The hygienists employed by public health clinics to conduct the EPSDT screenings and oral health education could be coordinated as part of the EPSDT dental registry and could be provided with pre-screening education and training by a dentist as well as a yearly continuing education program to maintain their ability to be recognized EPSDT providers and allow the public health clinics to be reimbursed for these services.

There are significant limitations to implementing such a program however. The Iowa dental practice act denies hygienists the authority to diagnose. Therefore unless all children who were screened were also referred on to a dentist, (rather than just those children determined to have needs), the hygienist would be essentially diagnosing a lack of need for these children. The referral of all children, however, would require the Title XIX program to pay twice for the examination (once to the public health clinic and once to the dentist). The result is a difficult situation because most dentists indicated they were not willing to see these children in their practice yet it would be against the law for non-dentists to be reimbursed for screening examinations in public health clinics.

Discussions between the Iowa Dental Association, the Iowa Department of Public Health, and the Iowa Board of Dental Examiners could produce other options for screening very young Title XIX enrolled children within the guidelines of the state practice act.

Policy option 3: Establish and monitor an indicator of the effectiveness of the Title XIX dental program

Given the relatively low dental utilization rates found for children under six in this study, it is important to continue to monitor this situation whether or not changes are made to the program. Specific indicators of dental utilization, such as the percentage of children who received an initial exam or the percentage who received dental care in a hospital operating room, could be developed and monitored on a regular basis. The utilization rates of dental services by very young children could also be important as part of a broader set of indicators along with other indicators such as immunization and prenatal care rates to evaluate access to care for Title XIX recipients generally.

Policy options for adults

The options available for changing the dental services provided to Title XIX enrolled adults are more extensive because dental coverage is an optional service for adults. Options for adult dental coverage can vary from retaining comprehensive care to the elimination of all dental care for adults with many possibilities in between. The options that will be discussed in this report are:

…Retain the current benefit package for adults but increase fees closer to dentists' usual fees

…Provide only selective dental services for adults

…Provide only emergency services for adults

…Eliminate all adult dental services

…Provide dental care to only certain Title XIX enrolled populations

…Establish a managed dental care plan

…Implement a yearly maximum dollar amount of coverage

…Increase recipient copayments

Policy option 1: Retain current benefit package for adults but increase fees closer to dentists' UCR fees

This option would change very little within the program but would increase reimbursement as a way of trying to increase dentists' participation in the program and improve access to care. The fee increase could be applied to all services, or it could be implemented selectively such as for routine preventive and restorative services.

If the services for which comparison fees are available were increased to 75 percent of the average dentists' fee in Iowa, the costs to the Title XIX program would increase by 24 percent for these services (Table 5-3). This would translate into an increase of approximately $2.7 million dollars for these services. If this 24 percent increase were applied to all services, (given the mix of services provided in FY 1994), costs to the Title XIX dental program would increase $4.9 million.

If fees were selectively increased to 75 percent of the average fees for only routine preventive and restorative services, the cost to the program would increase by approximately $1.3 million . As with the estimates for children, these estimates are likely to be low because they do not take into account any increases in the number of services provided as a result of; 1) an increase in the number of dentists participating in the program, 2) an increase in the total number of patients seen, and/or 3) an increase in the number of procedures completed per patient.

Table 5-3. Potential impact of increasing reimbursement for adult dental procedures to 75 percent of the average fee in Iowa

Procedure	Title XIX allowed charges FY 1994	75 percent of average Iowa dentists' fees	Additional cost to the Title XIX program	Percent change
Comprehensive oral examination	$532,285	$771,270	$238,985	45%
Periodic oral evaluation	$791,913	$968,541	$176,628	22%
Limited oral evaluation (emergency with Tx)	$120,875	$113,057	($7,819)	-6%
Adult cleaning	$730,822	$734,782	$3,960	1%
Child cleaning	$109,052	$127,929	$18,878	17%
2 bitewing x-rays	$427,674	$473,757	$46,083	11%
4 bitewing x-rays	$112,562	$160,898	$48,335	43%
Full mouth x-rays	$128,886	$132,376	$3,490	3%
Panoramic x-ray film	$578,208	$554,326	($23,882)	-4%
Sealants (per tooth)	$118,938	$202,348	$83,410	70%
Silver filling--1 surface, permanent	$721,065	$992,149	$271,085	38%
Silver filling--2 surfaces, permanent	$761,141	$947,614	$186,473	24%
Silver filling--3 surfaces, permanent	$439,365	$499,609	$60,244	14%
Silver filling--4 surfaces, permanent	$194,733	$219,935	$25,202	13%
White filling--1 surface, anterior	$310,752	$460,193	$149,441	48%
White filling--4 surfaces, anterior	$239,246	$221,967	($17,278)	-7%
White filling--1 surface, posterior	$165,266	$265,129	$99,863	60%
Crown--porcelain/base metal	$1,328,670	$1,522,004	$193,334	13%
Crown--full cast base metal	$879,910	$1,350,969	$471,059	34%
Crown--stainless steel	$23,779	$37,095	$13,316	56%
Root canal--anterior	$302,704	$388,039	$85,335	28%
Root canal--bicuspid	$226,406	$288,690	$62,284	28%
Root canal--molar	$23,301	$27,594	$4,293	18%
Root planning (per quadrant)	$331,307	$335,706	$4,399	1%
Gum maintenance	$27,879	$25,910	($1,969)	-7%
Complete denture--mandibular	$696,144	$845,648	$149,504	21%
Partial denture--maxillary	$353,200	$437,496	$84,295	24%
Extraction--single tooth	$402,462	$624,808	$222,347	55%
Total	$11,078,545	$13,729,839	$456,146	24%

Policy option 2: Provide only selective dental services for adults

Eliminating dental services for children is not currently allowed by the EPSDT program, however, coverage of adult dental services is optional, allowing states to modify the dental benefit package for adult recipients. The most obvious negative impact from this approach is that many recipients will no longer have access to as comprehensive a range of services, especially if the eliminated services are some of the more expensive services. The selective elimination of some procedures for adults, however, would have the benefit of allowing the state to reduce costs in some areas and shift those resources over to other areas without significantly increasing the total cost of the program (other than changes resulting from increases in utilization). This option was supported by the dentists in the survey, and by the Iowa Dental Association in their testimony before the Iowa Senate Human Resources Committee.

When selecting services to include in the benefit package, it is important to prioritize services according to how critical they are for an individual's functioning in society. One approach to modifying the benefit package offered to Title XIX recipients would be to follow a public health oriented prioritization of services, such as the one developed by the US Public Health Service (USPHS). This system categorizes dental procedures into six levels of care (Table 5-4). These levels of care provide increasing levels of services ranging from basic services critical for the relief of pain and infection (level 1) to comprehensive and complex dental services (level 6).

The categorization of services for the Iowa Title XIX dental program could be modified to the needs of Iowa Title XIX recipients. For example, because many nursing home residents qualify for Title XIX, complete dentures could be upgraded to a level three service.

Table 5-4. US Public Health Service levels of dental care

Level		Level
1	Emergency care Limited exam and diagnostics Palliative or temporary care Extractions Repairs, adjustments, recementation Therapy for trauma of dentition, jaws and face	4	Limited Rehabilitation Complex restorative care and build-ups Cast crowns/onlays Bicuspid Root canal Acid etch bridge Deep root planing (CPITN = 4) Denture relines Limited/interceptive orthodontics Prosthetic surgery
2	Primary dental care Preventive education and plan Topical/systemic fluorides Sealants Prophylaxis (CPITN = 2) Periodontal recall Athletic mouth guards Community-based services	5	Rehabilitation Molar Root canal Most periodontal surgery (CPITN = 4) Removable dentures Fixed bridges Most bony impactions Premedication/sedation
3	Secondary dental care Routine examination and diagnostics Simple restorations (alloy and composite) Space maintainers Pulpotomy in primary teeth Root canal in anterior permanent teeth Stainless steel crowns Root planing (CPITN = 3)	6	Complex rehabilitation Exotic and orthodontic diagnostics Professional consultation Unusual or complex surgery Maxillo-facial or complex prosthetics Comprehensive orthodontics TMJ therapy and occlusal adjustments

The following are a list of individual services identified by dentists in the survey, the Iowa Dental Association, and/or by the USPHS, that could be considered for elimination. The dollars saved could potentially be shifted to cover an increase in the reimbursement levels for routine preventive and restorative services.

1)Change the coverage for orthodontic services (braces). Currently the Iowa Title XIX program covers orthodontic cases for children and adults once the case has been screened and prior authorization received. The potential changes could occur in three ways:

…Eliminate all adult orthodontic coverage

…Eliminate adult and child orthodontic coverage except for handicapping malocclusions

…Eliminate all orthodontic coverage

During FY 1994, approximately $1.24 million was spent on orthodontic services. Because multiple visits are required for orthodontic treatment, and because there is a potential for patients not to complete their treatment, orthodontists receive payment for complete orthodontic services at the beginning of treatment. From the data available, it is not possible to determine the amount spent in the three categories listed above.

2)Eliminate coverage for some rehabilitative services. Two primary reasons for retaining teeth are to be able to eat well and look good. For eating, the front teeth are important for tearing food and the posterior teeth are important for chewing. The front teeth are also important for appearance, and are related to quality of life and employability. It is for these reasons that the USPHS has placed rehabilitative services for anterior teeth (crowns and root canals) at a level above the rehabilitation of posterior teeth. Many people function well with some or all of their posterior teeth missing. Therefore the selective elimination of procedures should begin with the more complex rehabilitative services for the posterior teeth (e.g., root canals and crowns).

When prioritizing these services, all complex rehabilitative services for the posterior teeth could be eliminated from coverage, or a minimum level of functioning could be established beyond which Title XIX will not pay for the rehabilitation. For example, coverage could be provided to assure that an individual has at least two opposing molars to chew with. Another option would be to include coverage for complex rehabilitative care for premolars (bicuspids) but not for molars. Beyond this minimum level of functioning, the individual would be responsible for their own rehabilitation. Either eliminating all coverage or selective coverage beyond a minimum level would likely affect the following services:

…posterior crowns

…posterior root canals

…periodontal surgeries and all other periodontal procedures other than routine cleanings. It could also be extended to include removable partial dentures if desired.

The cost impact of such a proposal is difficult to judge because the distribution of crowns on posterior teeth is not available. If it is estimated that one quarter of the porcelain crowns were completed on posterior teeth and all of the metal crowns were placed on posterior teeth, the following cost savings could be estimated from the FY 1994 utilization numbers:

…posterior porcelain crowns = $332,000

…posterior metal crowns = $885,000

…molar root canals = $586,000

…periodontal surgeries and all other periodontal procedures = $30,000

…Total savings all posterior teeth = $1.8 million

It might be estimated that half of these procedures are provided on bicuspids and half on molars. Therefore, the total savings if complex rehabilitative services were eliminated for molar teeth would be approximately $900,000.

It is unlikely that many recipients would be able to afford these services if they were not covered by Title XIX, however. This dilemma is not unlike that faced by many of the general public without dental insurance who face similar choices between paying for a root canal and a crown (approximately $800-$1000) or having a tooth extracted.

Policy option 3: Provide only emergency services for adults

A minimalist approach to adult dental care would be to cover only emergency procedures. This would eliminate coverage for all adult routine preventive and restorative care. Coverage would be primarily for emergency examinations, X-rays, tooth extractions, and the incision and drainage of infections.

The impact on the oral health of Title XIX enrolled adults would likely be significant if only emergency services were covered. Many recipients would lose the ability to address normally preventable oral health problems. These problems would tend to deteriorate over time until a tooth extraction is required. The impact on loss of adult coverage could extend to children as well. A study in Baltimore indicated that 12-13 year old children whose parents both had seen the dentist in the past year were 13 times more likely to have made a dental visit themselves (Bonito and Gooch 1992). In the end, less access to dental care could result in a lower quality of life for some recipients.

There could also be an increase in medical care costs associated with decreased access to dental care. For example, some diseases may be detected at a later stage (e.g. oral cancers and some early manifestations of HIV infection). In addition, some dental emergencies that might otherwise have been prevented or treated in a lower-cost office setting will now be cared for in hospital emergency rooms at significantly higher cost.

The potential cost savings related to such a program are difficult to estimate using the FY 1994 utilization figures because the savings achieved by eliminating routine preventive and restorative would be partially offset over time by increases in treatment for emergent conditions.

Policy option 4: Eliminate all adult dental services

As mentioned previously, unlike children's services, adult dental coverage can be eliminated entirely. If coverage of all adult dental services were eliminated from Title XIX in FY 1995, the program would have saved an estimated $13 million. However, the implications for access to dental care for Title XIX enrolled adults would likely be severe. Similar to the elimination of all services except emergencies, many adults would lose the opportunity to prevent oral health problems and retain their teeth, potentially impacting use of services by their children, their own quality of life, and the total cost of medical care.

Policy option 5: Provide dental care to only certain Title XIX enrolled populations

Rather than prioritizing or eliminating services, another approach would be to provide coverage to select categories of adult recipients (e.g. nursing home residents, disabled adults). As with eliminating services for all adults, access to dental care for many other adults would be greatly affected. The loss of dental coverage would prevent many recipients from receiving routine preventive and restorative care. From the available data, it is not possible to estimate the cost effect of eliminating coverage for these populations.

Policy option 6: Establish a managed dental care plan

Many programs within the Iowa Title XIX program have instituted managed care plans in an effort to control costs for the care of both adults and children. These programs include mental health services, substance abuse treatment, and much of the medical care provided to recipients in Iowa. These managed care plans can take on many forms from a 'gatekeeper' type of system (MediPASS) to a capitated program (Medicaid HMO).

Although not common in Iowa, there are some parts of the country where dental HMOs (DHMOs) and Title XIX DHMOs are more common. A variety of program types could be implemented from a reduced fee-for-service system to a capitated program. In a capitated dental program, the dentist is paid a capitation rate of a set number of dollars per person enrolled with them per month, rather than receiving payment for each service provided (fee for service). The dentists' costs for treating recipients with significant oral health problems are assumed to balance out with the recipients who only require a periodic checkup or do not seek care at all. The recipients who enter the system with significant oral health problems should also theoretically move into a state of improved oral health after their initial burst of treatment, allowing the dentist to recoup some of the financial loss associated with the initial extensive treatment in subsequent years.

A capitated dental program is advantageous for the Title XIX program in two ways. First, the cost of dental care is reasonably predictable at the beginning of the year (dental services will cost a set amount of money per person for the year). The only unknown regarding dental costs is the number of recipients and their length of eligibility during the year. Second, the dentist assumes some of the risk for providing dental care to Title XIX recipients. Because every dental service provided is in essence a debit from an account, the incentive is to provide fewer services, unlike a fee for service system where the more services provided, the more money is generated.

There are some inherent problems with implementing a Title XIX dental managed care plan, however. For example, the transient eligibility of recipients makes the establishment of a capitation rate more difficult. It also becomes difficult for dentists to find the financial balance between recipients with extensive needs and those who only need check-ups or do not seek care at all. If recipients leave the program after receiving their initial burst of treatment, the dentist will not have the chance to recoup the losses incurred in the first year of treatment with less extensive treatment needs the following years.

On the positive side for the dentists financially, the typically lower utilization rates for Title XIX recipients would provide dentists with capitated payment fees for more recipients who never use dental services.

Establishment of a managed care dental plan could also result in fewer dentists participating in the program, decreasing rather than improving access to dental care. Dentists in Iowa are generally unfamiliar with managed dental care and are in many cases openly hostile to the concept. Unless the capitation rates are believed to be 'acceptable' for the services covered by the plan and the plan was marketed effectively, it could be a difficult transition (especially given the current level of discontent with certain aspects of the Title XIX program).

The fiscal impact of establishing a dental managed care plan would be difficult to determine. Often the capitation rate is established by estimating the amount to be spent on dental services in the coming year, reducing it by five percent and calculating how much is left for each month of eligibility expected in the coming year. This amount would be the dentists' monthly capitation rate. This formula in essence 'guarantees' that the Title XIX program would receive a five percent savings in the cost of dental services.

Policy option 7: Implement a yearly maximum dollar amount of coverage

Many private dental insurance plans include a maximum per person dollar amount that will be paid for dental services during a given year. For example, an insurance plan might cover up to $1000 in dental services during a given year. Any spending beyond this amount is the responsibility of the individual. The amount of the yearly maximum is dependent on the amount of money an employer is willing to spend for dental benefits for their employees. For the Title XIX program, the yearly maximum would be established based on the amount the program is willing to spend for an individual in a given year.

The fiscal impact of such a program is difficult to determine. Most people will never approach the yearly maximum while some will have needs well beyond the maximum amount. Even with the yearly maximum, some care will be delayed and covered by the Title XIX program in subsequent years. For others, the costs for their dental care will be avoided by the Title XIX program if they lose their eligibility. The costs for other dental needs beyond the yearly maximum, however, might not be the responsibility of the Title XIX program as people lose their Title XIX eligibility. Unlike many with yearly maximums on their private dental insurance, some Title XIX recipients would be unable to afford necessary treatment if it is above the established yearly maximum.

Policy option 8: Increase recipient copayments

Currently, adult Title XIX recipients must pay a $3 copayment at each dental appointment (copayments are not allowed for children's care). One way to increase dentists' reimbursements is to increase the amount of the copayment without decreasing the amount payable by Title XIX. This would increase reimbursement rates without increasing the cost of the program directly. It could also give the recipients more of a sense of ownership in the care they receive.

The negative impact of increasing copayments is the potential impact it could have on access to care. For some recipients who need to make multiple dental visits in a short period of time, any significant increase in copayments could prevent them from seeking care. One way to minimize this problem would be to selectively increase the copayments for services other than routine preventive and restorative care. If the Title XIX allowed charges were increased at the same rate as the increase in copayments, there would be no net increase in cost to the Title XIX program. Increased copayments may, however, increase the hassle factor for dentists by making it more difficult for dentists to collect the copayment at each visit.

Additional suggestions

There are a number of other suggestions, many made by dentists in the survey to improve the efficiency of the program and reduce the perceived hassles associated with participating in the dental Title XIX program.

•  Use a standard claims billing form such as the one developed by the American Dental Association (ADA) along with the ADA standard list of procedure codes. Currently, Title XIX uses a unique claims form and does not uniformly follow the standard ADA coding system like most other insurers. Use of standard billing forms and procedure codes is particularly important in dental offices that remain primarily solo practices with few or no office staff.

•  Improve the program's relationship with dentists. This could include increasing services through the Title XIX hotline. Numerous dentists commented that they have significant difficulty getting through on the hotline, and if they did get through they were unable to speak to someone who could help with their problem.

•  Establish a dental advisory committee that would meet on a biyearly basis with the leadership of the Iowa Department of Human Services to discuss concerns and strategies for the Title XIX dental program. The membership of this committee could include representatives from the Iowa Dental Association, practicing dentists in Iowa, the Iowa Department of Public Health, and the University of Iowa College of Dentistry. This advisory committee could assist the IDHS in developing the most appropriate indicators to measure the effectiveness of the program for both adults and children.

•  Accept electronic submission of dental claims. According to the survey, 62 percent of dentists have a computer in their office with about 20 percent of all dentists submitting at least some of their insurance claims electronically. Once implemented, submitting claims electronically should make the paperwork process easier for both dentists and the Title XIX program.

•  Establish a way to reduce the number of broken dental appointments. This might include recipient education about benefits and responsibilities for receiving dental care, and explaining to dentists their options for implementing a broken appointment policy for Title XIX recipients.

Reduce unnecessary mailings concerning administrative changes to the Title XIX program. While it might seem like a minor issue, a number of dentists commented that they receive numerous mailings that contain perhaps one dental issue among pages of medical administrative procedural issues. Some dentists indicated that it was sometimes difficult to determine what was important for them, and it appeared to be a waste of time and money to mail them this information. Eliminating this process of batch mailing to all providers would be a visible signal of change to participating dentists.