Many states are transforming their health care delivery systems to improve health and control costs. Reducing health disparities — and addressing their social and economic causes — is at the heart of many of these efforts.
Inequities in oral health and health outcomes are driven by upstream factors, including diet, education, transportation, and access to care. A growing number of states are working to improve the oral and physical health of Medicaid enrollees and reduce costs by addressing these social determinants of health in their managed care contracts.
A 50-state review by the National Academy for State Health Policy (NASHP) of Medicaid dental and medical managed care contracts, requests for proposals, and other similar documents publicly available through September 2020, identified how states address social determinants of oral health. Dental contracts were reviewed for a comprehensive list of social determinants and medical contracts were analyzed for references to care coordination, community resources, food access, social determinants of health screening, and coordination with dental contractors. In total, NASHP scanned dental contracts in 19 states and medical contracts in 38 states.
Of the dental contracts, nine referenced coordination between dental plans and medical plans and 13 referenced coordination with social and community services. Other common references in dental contracts included equity/cultural competence, education, and transportation (each referenced in 10 state contracts).
All but one of the 38 medical contracts referenced coordination with social and community services. Thirty-three states referenced food in their medical contracts, 25 referenced adverse experiences (such as domestic violence and child abuse), and 15 referenced care coordination between dental and medical care. Three states (Florida, Michigan, and Virginia) referred to food in both their dental and medical contracts, while only one (Virginia) referenced adverse experiences in both contracts.
State Medicaid Program Delivery of Dental Care
While Medicaid covers some form of adult dental care in 47 states and Washington, DC, and all states cover dental care for children under 21 as part of the Early Periodic Screening, Diagnosis and Treatment (EPSDT) program, adult dental coverage is optional for state Medicaid programs. Currently, 35 states provide limited dental benefits for adults and 19 states offer extensive adult dental benefits.
States have different options for delivering dental care. Some states with managed care use a carve-in model, where the dental benefit is integrated into medical managed care programs. With a carved-in benefit, managed care organizations (MCOs) may administer the dental benefit or subcontract the dental benefit to another vendor. In carve-out dental programs, states contract with a dental MCO or dental benefits manager (DBM). Alternatively, states with Medicaid managed care medical delivery systems may have fee-for-service dental systems.
Medicaid dental and medical contracts illustrate how states can consider social determinants affecting oral health and overall health through:
- Screening, referral tracking, and follow-up;
- Educational initiatives;
- Staffing and training requirements;
- Data sharing and technology;
- Coordination between dental and medical systems; and
- Performance improvement.
Social Determinants of Health in Dental and Medical Medicaid Contracts
Almost all states scanned have some requirement for plans to refer members to community resources and social services. NASHP focused specifically on requirements that are applicable to the general population, rather than individuals designated as high risk or high needs. States use a variety of strategies to encourage investment in SDOH.
Screening for SDOH Needs
Sixteen states use routine screenings for certain social determinants, including employment status and access to food and transportation. The scan of 14 medical contracts and two dental contracts indicate that states are more likely to require medical plans to conduct needs assessments, often within a specified time frame after enrollment, than dental plans. States may also require medical plans to use this data to appropriately target interventions to meet enrollees’ needs.
While dental plans do not necessarily have the same explicit requirement to conduct a screening, some states do ask their dental plans to use SDOH data to target their educational and outreach activities.
- Michigan’s dental plan is required to use social determinants of oral health data from the state in order to target interventions, outreach, and education efforts.
- Nevada’s dental contract requires the contractor to complete a community-based needs assessment to inform their health promotion and educational activities, including ensuring that any interventions are culturally appropriate and meet the needs of the target population.
Referral Tracking and Follow-up
While screening is an important first step in identifying members’ social needs, it also raises a question of how states use the data to address social determinants. NASHP found that in almost every state with publicly available contracts, Medicaid agencies partner with community-based organizations to meet the social needs of enrollees. For example, plans may facilitate referrals to these community agencies based on information collected through SDOH screenings. States can use tracking, follow-up, and reporting requirements to ensure that referrals to community resources and organizations are effective and successful. Contractors can support these efforts by documenting “closed-looped” referrals that ensure that an enrollee is successfully connected with a community-based organization to address other health and social needs.
- In Louisiana, the Dental Benefit Program Manager is required to connect enrollees with community-based service providers and document referrals and referral outcomes in enrollees’ dental records.
Dental contracts are less likely to require or encourage the plan to monitor referral follow-up. However, dental plans could adopt some of the medical MCOs’ language in order to track the status of referrals, strengthen care coordination between insurance plans and community resources, and ensure individuals are receiving adequate social services that meet their evolving needs. For example, New Hampshire requires MCOs to track the effectiveness of community-based providers and resources, and Oregon requires reporting on referrals to culturally diverse social and support services.
Healthy People 2020 identified health literacy as a component of SDOH, noting that individuals’ ability to access and understand relevant health information affects their health and health outcomes. To help improve health literacy, many states require managed care plans to implement educational initiatives. For dental plans, this includes educating members about the importance of oral health or launching community oral health initiatives designed to help eliminate barriers to dental services and improve population oral health.
- In both Nevada and Texas, the dental contractor must develop and implement programs designed to educate members about nutrition, the importance of oral health, and the relationship between oral health and overall health.
- Florida’s dental plan includes incentives for participation in health education classes. Examples of incentives members can receive that support healthy child development include clothes, food, books, safety devices, publications, and memberships in health and education clubs.
- In its response to Nebraska’s request for proposals (RFP), dental contractor MCNA referenced a program it implemented in Texas that uses the fotonovela (a comic book-style communication popular in the Latinx community) to distribute health information materials to children of migrant farm workers.
Staffing and Training Requirements
Plans may also be responsible for training their employees to better meet members’ needs. In their contracts, states can prioritize the type of training that a plan’s staff receive.
- Nebraska’s dental contract requires all staff to be trained on how social determinants (including food, housing, education, violence, and physical and sexual abuse) affect members’ health and wellness. Staff also receive training on how to find community resources and make referrals.
Both medical and dental plans also employ staff members who are responsible for care coordination, addressing social determinants, and improving access to care for historically marginalized populations.
- Nebraska’s dental contract requires the plan to employ a tribal network liaison to coordinate and expand dental services to Native Americans and connect them to community resources. Arizonaand New Mexico both require medical MCOs to employ someone to coordinate services with Native Americans.
Examples of other medical plans’ required staff positions include a community liaison in Illinois, who connects enrollees with community-based services, and a service coordination director in Kansas, who oversees quality improvement initiatives related to SDOH. Dental contractors could potentially leverage medical MCO positions and their expertise to streamline care experiences for enrollees across medical and dental systems.
Coordination between Dental and Medical Systems
To better integrate dental and medical care, dental and medical managed care use staff members to connect physical health and oral health services across contracts. These staff members also connect Medicaid enrollees to community services to meet social needs.
- In its dental contract, Tennessee requires a coordinator to work with the medical MCO and develop a system to exchange data with the MCO.
- Florida requires MCOs to have a liaison for their prepaid dental health plan to help integrate medical care, behavioral health, and long-term benefits with the dental plan.
- Iowa requires the dental contractor to send a care facilitation plan to the state with information on how the plan will facilitate coordination between dental and medical plans and providers.
Data Sharing and Technology
Eleven states require some form of data sharing between dental and medical plans, or between plans and community organizations. Requirements for integrating different agencies’ social determinant data and sharing information across systems allow medical, dental, and social services to work together to coordinate care for members and encourage referrals and follow-up tracking.
- In Tennessee, the dental benefits manager must facilitate data exchange with school-based health programs to coordinate any needed follow-up care.
- Washington State tasks its dental contractors with using health information technology and health information exchanges to coordinate care between physical health, behavioral health, and social services and other community-based organizations.
Other states are creating their own online platform or mobile applications to improve access to social services for their Medicaid enrollees. These platforms are mentioned specifically in medical managed care plan contracts, but have the potential to be used by dental contractors as well.
- Kansas developed a web-based, mobile-friendly application that connects service coordinators to community resources, such as food banks and pantries, housing, clothing, legal resources, and transportation.
- Medicaid Prepaid Health Plans in North Carolina will use a telephonic, online, and interfaced IT platform to refer members to social services and track the outcomes of these referrals.
A number of states encourage both dental and medical plans to engage in performance improvement projects (PIPs) in order to address SDOH.
- In Nevada, dental vendors are required to conduct both a clinical and non-clinical PIP every year. Non-clinical PIPs can focus on cultural competency and accessibility of services, among other SDOH.
- Oregon Coordinated Care Organizations (CCOs) must implement PIPs that address at least four of eight designated focus areas, which include addressing SDOH and equity, and integrating primary care, behavioral health care, and/or oral health care.
Through these PIPs, state managed care plans (both dental and medical) can launch pilot interventions to improve health outcomes by addressing SDOH and reducing barriers to care.
Research shows that addressing individual social needs leads to better oral health outcomes. Despite having different levels of funding and varying Medicaid adult dental benefits, states across the country are finding ways to invest in SDOH. While not all states have started to include SDOH requirements in their dental contracts, these examples show potential opportunities for dental plans to integrate some of the medical plans’ language and guidance into their own work. To learn more about how state Medicaid programs include SDOH-related language in their dental and medical Medicaid managed care contracts, view this interactive map.
Acknowledgements: This blog and map were made possible by the DentaQuest Partnership LLC. The authors would like to especially thank Trenae Simpson for her guidance and assistance, and Trish Riley and Jill Rosenthal for their helpful feedback. This information, content, and conclusions are those of the authors’ and should not be construed as the official position or policy of the DentaQuest Partnership LLC.
Below are examples of how states can address new needs, including housing, food, transportation, education, and employment, and how the CARES Act can support and amplify their work.
Housing: Homeless or housing-insecure individuals are at unique risk and more susceptible to the spread of COVID-19 because they have limited places to self-quarantine or isolate. These individuals may not have access to running water to practice safe hand-washing techniques. Title XII of the CARES Act includes funding to help sustain and expand states’ investments in homeless services and other emergency measures to ensure those individuals are able to stay healthy and to lessen the risk of community spread. These funds are intended to prevent, prepare for, and respond to COVID-19 and include appropriations of:
- $4 billion in Homeless Assistance Grants, available until Sept. 30, 2022;
- $1.25 billion to the Tenant Based Rental Assistance program, available until expended;
- $1 billion to the Project Based Rental Assistance program, available until expended;
- $6.85 million to the Public Housing Operating Fund, available until Sept. 30, 2021; and
- $5 million to the Office of Public and Indian Housing, available until Sept. 30, 2021.
The CARES act also appropriates funds for communities at higher risk of infection from COVID-19, including, under Title X, a $14.4 billion investment for veterans who are homeless or at risk of becoming homeless and under Title XII, $50 million directed to Housing for the Elderly, and $15 million to housing for people with disabilities, with funds available through Sept. 30, 2023.
- Examples of states’ current investments in shelter and emergency housing:
- California has authorized $150 million to protect homeless Californians from the spread of COVID-19. About $100 million is directed towards local government for shelter support and emergency housing to address COVID-19 in the homeless population and $50 million is directed to purchase trailers and lease rooms in hotels, motels, and other facilities in partnership with cities and counties throughout the state for immediate isolation placements for homeless individuals.
- Washington State’s Department of Commerce announced it is making $30 million available to use to expand shelters, buy more cleaning supplies, and other strategies, such as leasing motel rooms.
- State and federal initiatives to halt eviction processes:
- States, including New York, California, Maryland, and North Carolina, have implemented differing versions of a moratorium on evictions of residential and commercial tenants to ensure rent-insecure individuals do not lose their housing during this crisis and become more at risk. California’s order instructs its Public Utilities Commission to oversee customer service protections for services such as water, Internet, gas, and cell phone services.
- The US Department of Housing and Urban Development announced on March 18, 2020, an immediate foreclosure and eviction moratorium for single family homeowners with FHA-insured mortgages until the end of April.
- The CARES Act (Title IV Sec. 4024) also requires a temporary (120-day) pause on evictions proceedings, for any covered housing program as defined in section 41411(a) in the Violence Against Women’s Act, any rural housing voucher program, or has a federally backed mortgage loan.
Education: Most states (48 states and Washington, DC as of March 29, 2020) have closed schools and many are working to implement distance learning to comply with the CDC’s guidelines restricting social interactions. Distance learning is a strategy to keep not only children safe, but also their families, teachers, and administrators. However, it is important to consider that not all children and families have the appropriate technology or Internet capabilities at home to continue their education. School shutdowns illuminate the country’s “digital divide” – those who have access to the Internet and technology and those who do not – and demonstrates the inequities between wealthy and poor school districts, which can perpetuate and possibly worsen socio-economic and other disparities for individuals who have faced discrimination and are already underserved.
The CARES Act (Title VIII Sec. 18001) appropriates $30.75 billion in grants to school systems and higher education institutions to remain available through Sept. 30, 2021 through the Education Stabilization Fund, which provides emergency funds to aid in the continuation of educational services and supports both domestically and abroad. The act directs 1 percent of these funds for grants to states with the highest COVID-19 burden.
- Using state and federal funds allocated through public-private partnerships and local jurisdictions, many school districts, including in Connecticut, Florida, and Montgomery County, Maryland are distributing laptops and other technology as well as information about Wi-Fi hotspots to students, and encouraging parents of students with disabilities to reach out for extra support. New York City is prioritizing iPad distribution for students in temporary housing. Every district is trying to address the challenge of the digital divide in their community, including making hard-copy resources available for students who do not have immediate access to the Internet, and providing free Wi-Fi hotspot services from buses.
- The US Department of Education (DOE) announced it will approve waivers for any state that is unable to assess their students through standardized tests and report cards for the remainder of the school year due to the ongoing COVID-19 emergency. This change was implemented to protect student’s health and safety. DOE has approved these waivers in several states, including Arkansas, Colorado, Florida, Georgia, Indiana, Michigan, Oklahoma, Pennsylvania, Tennessee, and Washington State, and more states are considering this option.
- Virginia and Kansas have already announced their schools will be closed for the remainder of the school year, and other states may also close schools.
Food: Assuring access to healthy food, a critical determinant of health, is a challenge during a pandemic. States have determined that grocery stores are essential businesses, and food store workers are considered part of the critical infrastructure. To ensure underserved individuals maintain their ability to access healthy food in a safe way consistent with CDC guidelines, states are implementing various strategies. Additionally, the largest anti-hunger federal initiative is the Supplemental Nutrition Assistance Program (SNAP), and to ensure continuation of SNAP funding, the CARES Act (Title VI Division B) directs $15.8 billion to remain available until Sept. 30, 2021. Of this amount, $15.5 billion must remain in a contingency reserve until the secretary deems the funds necessary. The CARES Act (Title VI Division B also appropriates $8.8 billion to Child Nutrition Programs, also available until Sept. 30, 2021. Several state and strategies to ensure at-risk populations have access to nutrition are listed.
- Providing meal delivery services:
- The school lunch program is the second-biggest anti-hunger initiative after SNAP. To ensure students who receive free or reduced-price lunches at schools do not go hungry while state-mandated school shutdowns are in place, at least 25 states were approved for US Department of Agriculture (USDA) waivers that authorize school meal distribution. Maryland and Florida have developed websites with interactive maps of the states’ locations for grab-and-go meals. Cities and counties are working in collaboration with states to ensure all students are able to get their meals, even if they are living with at-risk relatives. Loudoun County in Virginia, Wayne Township in Indiana, and Cambridge, Massachusetts are all using school buses to deliver meals to those students.
- Arizona, California, Ohio, and Texas governors all directed their National Guard units to be on alert to aid in food delivery for vulnerable populations, including elderly individuals.
- The CARES Act (Title VI Division B) appropriates $100 million for the USDA Food Distribution Program directly to Native American reservations.
- Arizona and Iowa’s approved 1135 waivers for Medicaid Emergency Authority both expand eligibility for home-delivered meals. Arizona’s waiver expands access to all eligible populations, and Iowa’s waiver expands eligibility to non-waiver members who are home-bound and waiver members even if the waiver does not have meals as an allowable service.
- Modifying restaurant services:
- Most states (42 states and Washington, DC as of March 25) have halted “dine-in” options for restaurants and bars to slow and limit the spread of the coronavirus. For example, the Colorado Department of Public Health, like many other states, issued a public health order to close bars, restaurants, and other establishments though they are still permitted to provide delivery service, window service, and drive-through services with precautions.
Transportation: Access to transportation services is an important determinant of health, but to aid in social distancing and limit spread, states are recommending people limit their use of public transportation by working remotely and using telemedicine services to reduce unnecessary travel so that public transportation can be safer for those who depend on it, such as transit operators, essential health care workers, and grocery store employees. The CARES act (Title XII) also appropriates $25 billion in funding, available until expended, to support this the infrastructure of operating expenses for transit agencies related to the response of to the coronavirus public health emergency.
- Modifying public transportation services:
- Relaxing telehealth requirements
- States are rapidly relaxing telehealth requirements to address coronavirus symptoms. For example, the Massachusetts Department of Public Health issued guidance that all insurers are required to cover medically necessary telehealth services in the same manner they cover in-person services. Texas and Michigan have issued guidance that allows providers to establish patient-physician relationships via telemedicine, including phone calls. Other states, including Louisiana and West Virginia, are relaxing Medicaid requirements to allow emergency and non-emergency evaluation visits to be conducted via telemedicine. These changes are vital to ensure that everyone in the state can still access health services while taking precautions against unnecessary potential viral spread.
- The CARES Act (Part II Sec. 4213) reauthorizes Health Resources and Services Administration’s (HRSA) grant programs that promote telehealth services, which offers flexibility for Medicare patients at risk of contracting COVID-19, and aids in screening patients avoiding their exposure to others.
- The CARES Act (Part II Sec. 4214) also reauthorizes HRSA grant programs that strengthen rural community health through quality improvement, increased access to care, and improvement in coordination to care. This is especially important because rural residents are disproportionately older and more likely to have a chronic disease, which increases their risk for coronavirus.
Employment benefits: Many states, including Maryland, New Jersey, and North Carolina, have implemented telework policies and are encouraging all employers to allow telework opportunities to aid in social distancing. However, many state employees, including sanitation workers, health workers, and retail workers do not have the ability to work remotely, and require protection and benefits to ensure they stay healthy and able to do their jobs. Many retail workers are part-time hourly employees and do not have access to sick leave so states are taking initiatives to create equitable policies for their more vulnerable residents who are providing critical services during this pandemic. The federal government is following states’ lead in developing policies to support individuals with benefits and supports that are essential to respond to the pandemic.
- Classifying emergency workers:
- Minnesota and Vermont have classified grocery store workers and food distribution workers as essential personnel. This change classifies grocery and food distribution workers as first responders, critical to their states’ response to coronavirus. This classification qualifies them for special child care provisions. This is especially important because these workers tend to be paid hourly, and often do not have access to comprehensive benefits.
- The CARES Act (Title VIII) proposes an additional $3.5 billion in funding to states and territories, available through Sept. 31, 2021, through the Child Care and Development Block Grant to provide childcare assistance to low-income families. The funds may also be used for continued payment and assistance to child care providers to health care employees, emergency responders, sanitation workers, and other employees deemed essential to the response to coronavirus.
- Paid sick leave:
- Several states have paid sick leave policies in place. When Colorado declared a state of emergency on March 10, 2020, the declaration allowed workers in certain covered industries, including hospitality, food services, child care, education, transportation, and home health, up to four days of sick leave when experiencing flu-like symptoms and awaiting test results for COVID-19.
- The CARES Act (Subtitle C Sec. 3602) authorizes paid sick leave benefits for employers with employees who are sick or seeking care for coronavirus or need to take leave to care for quarantined individuals, including their children. The payments are capped at $511 per day per employee who is sick or seeking care, and $200 a day for employees who are caring for a sick family member.
- Unemployment benefits:
- States are creating unemployment compensation benefit plans. For example, Alabama and Pennsylvania have implemented a policy to allow individuals who are employed but unable to work because of COVID-19 to file for unemployment benefits.
- The CARES ACT (Title II Sec. 2102) creates a temporary Pandemic Unemployment Assistance program to provide payment to individuals who are not eligible for traditional unemployment benefits (e.g., self-employed, independent contractors, those with limited work history, and others) and are unable to work as a direct result of the coronavirus public health emergency for reasons including:
- They are seeking a COVID-19 diagnosis;
- Are providing care for someone sick with COVID-19;
- Are providing care to a child or someone in their household who is unable to attend school or another facility that has been closed because of c COVID-19;
- Are unable to get to work because of a COVID-19-related quarantine. Individuals who have the ability to telework with pay or are receiving paid sick leave or other paid leave benefits do not qualify for these funds.
- These funds are available to those who experienced unemployment, partial unemployment, or inability to work from Jan. 27 through Dec. 31, 2020.
State policymakers have led the way in taking aggressive steps to address the impact and stop the spread of COVID-19. They have recognized that vulnerable populations need special attention and protections and have launched efforts to address a myriad of health-related social needs. The federal government is adding needed support through the CARES Act, which will allow states to invest in their residents’ social and medical needs. Many of these efforts are stop-gap measures in a time of crises and raise questions about how policies will continue to address the health and social disparities that the crisis exacerbates after the immediate emergency period is over.
In a Washington Post op-ed, Richard Besser, president of the Robert Wood Johnson Foundation, notes, “Every long-term solution must be viewed through the health equity lens, for if they are not, we’ll be setting the stage for our next public health failure.” States are working hard to address both health and health-related social needs emerging from COVID-19, and the National Academy for State Health Policy will continue to track implementation of state’s critical policies to assist states with replication.
Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the foundation.
As states grapple with the impact of the opioid crisis and the acute treatment needs of people with substance use disorders (SUD), the next policy challenge is how to support this group of individuals in their long-term recovery. This daylong preconference offers state policymakers the opportunity to learn about emerging policy issues and other states’ experiences developing and implementing policies that support and sustain long-term SUD recovery. Participants can learn how states:
- Can build recovery-oriented systems of care for people with SUD;
- Implement policies and programs that address the social health needs that can impact long-term recovery; and
- Use cross-agency strategies to build and sustain effective services and systems.
State policymakers from across the nation will present best practices and innovations on an array of topics, including supportive housing and employment, long-term medical care for those in recovery, leveraging data to better understand the opioid crisis in rural communities, and tackling the issues of social isolation and re-entry after incarceration and treatment.
Supported through a cooperative agreement with the Health Resources and Services Administration (HRSA) U.S. Department of Health and Human Services (HHS).