Though largely preventable, tooth decay (caries) is the most common chronic disease in US children, affecting approximately 23 percent of children ages 2 to 5.[1],[2] Texas’s First Dental Home and its enhanced bundled payment has increased access to preventive dental service and improved the oral health of Medicaid-enrolled children ages 6 to 35 months.

Providing children with access to routine oral health services has the potential to prevent dental caries, reduce emergency dental visits, and promote overall health, resulting in significant cost savings for states. States are required to provide dental services to Medicaid-enrolled children under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. While it is recommended that all children receive an initial dental visit in their first year of life, less than 10 percent of Medicaid-enrolled children under age 3 receive preventive dental services.[3] This case study explores how Texas is improving oral health access for these very young children.

Importance of Oral Health in Very Young Children

Early childhood caries (ECC) is characterized by the presence of at least one decayed, missing, or filled primary tooth surface in a child younger than age 6.[4] Among children in this age group, nearly one-quarter have ECC,[5] with 10 percent untreated.[6]

In addition to causing pain and discomfort, dental caries, including ECC, can affect young children’s quality of life and overall development, including reduced intake of food, lower weight, and increased school absences.[7] High incidences of untreated dental caries are also associated with increased risk of hospitalizations and emergency dental visits, resulting in significant costs to state Medicaid programs.[8],[9] One report examining Medicaid-enrolled children under age 6 in Iowa found that children treated for ECC in a hospital or ambulatory setting accounted for 25 to 45 percent of total dental costs.[10]

Children who have their first preventive dental visit by age 1 are more likely to have subsequent preventive visits and lower dental-related costs.[11] Given the importance of early access to routine, preventive oral health services among young children, several leading national pediatric medical and dental organizations recommend that all children receive an initial dental visit during the first year of life.[12],[13],[14] Yet, only 9 percent of Medicaid-enrolled children under age 3 received a preventive dental service over a one-year period, compared to 84 percent of children in the same age group who received a well-child visit.[15],[16]

As states explore opportunities to improve access to oral health services, there is growing interest in strengthening routine access to oral health services among young children.

Texas First Dental Home

Implemented in 2008 by the Texas Health and Human Services Commission (HHSC) – the state’s Medicaid program – to increase children’s access to preventive services under the EPSDT benefit, the First Dental Home (FDH) is a legislatively supported, Medicaid dental initiative designed to improve the oral health of Medicaid-enrolled children, ages 6-35 month, through the following actions:

• Initiate early preventive dental services (including for those children without erupted teeth);
• Provide communication and education to parents and caregivers promoting the importance of children’s oral health; and
• Establish dental homes for children beginning at 6 months of age or as early as possible upon enrollment in Medicaid. [17]

Children participating in FDHs are eligible for a maximum of 10 visits between 6 to 35 months of age, with at least 60 days between visits. This requirement allows for a child to begin FDH visits at six months of age with a recall schedule of every three months (for those children at moderate-to-high risk for developing severe ECC) until their third birthday.[18] In addition to completing an oral health questionnaire, a dental risk assessment questionnaire, and a comprehensive oral evaluation during the initial visit, FDH visits include:

• Texas Health Steps Caries Risk Assessment Tool;
• Dental prophylaxis;
• Oral hygiene instructions for the child’s primary caregiver;
• Application of topical fluoride varnish;
• Dental anticipatory guidance, including nutritional counseling and oral developmental milestones; and
• Establishment of a dental recall schedule.[19]

Due to the importance of caregiver participation and understanding of their children’s oral health, HHSC requires at least one parent or caregiver to be present with the child during the entire FDH visit.[20] An evaluation of FDH found that participation in the program increased caregivers’ oral health knowledge and some of their oral health practices to improve their children’s oral health.[21]

First Dental Home Bundled Reimbursement and Provider Enrollment

The Current Dental Terminology (CDT) code D0145 is used at an enhanced reimbursement rate of $142.07 for all FDH visits. For the purposes of FDH billing, D0145 is considered an all-inclusive (or bundled) code required for all diagnostic and preventive services rendered under FDH, including those not traditionally reimbursed for routine preventive services, such as oral hygiene instruction and nutritional counseling.[22],[23] Dentists cannot bill for any other exam, prophy, or fluoride codes for a FDH visit.[24]

Eligible providers (e.g., pediatric and general dentists) must become FDH providers to claim reimbursement using the enhanced bundled CDT code. In addition to being trained and certified by the Texas Health Steps Program, the state’s EPSDT program, dentists must have a National Provider Indicator number (NPI) and an individual Texas Provider Indicator (TPI) number of each practice location.[25] Within the first 12 months of the program’s implementation, 815 dentists became FDH providers, 674 of whom billed for services.[26]

Texas is a state with dental benefits carved-out of its medical managed care program to three dental maintenance organizations (DMOs). Collectively, these DMOs help to manage the dental care needs of the state’s Medicaid members, including participation in FDH. Under this arrangement, HHSC outlines FDH-specific contract requirements, which stipulate that each DMO must:

• Implement a process to detect under-utilization of FDH services;
• Verify a providers’ qualifications to submit claims for FDH services; and
• Publish provider directories and note which providers are FDH providers.

In addition to these contract requirements, HHSC has a dental Pay-for-Quality (P4Q) program to further strengthen oral health utilization. Under Texas’s dental P4Q program, 1.5 percent of each DMO’s capitation is at risk of recoupment for specific performance measures (e.g., the percentage of enrolled children who receive a comprehensive or periodic oral evaluation in a reporting year) if a DMO’s performance declines beyond a defined threshold. Conversely, if a DMO’s performance improves beyond the threshold, the DMO can earn incentive payments.[27] To help bolster its performance, at least one DMO implemented value-added services for members participating in FDH, including a free dental care kit and gift card upon completion of a FDH visit.[28] As a result of limited data due to COVID-19 from which to assess quality measures, HHSC has temporarily suspended its dental P4Q program, including performance measures under FDH.[29]

Texas’s multipronged efforts to increase access to preventive oral health services for Medicaid enrolled children 6 to 35 months of age under the EPSDT benefit have resulted in increased utilization, even exceeding the rate of dental care use among commercially insured children in some years.[30],[31] Based on available dental performance measures collected by HHSC, participation in FDH has steadily increased with approximately 71 percent of children 6 to 35 months of age receiving at least one FDH visit in FY 19.[32] Based on claims data collected from 2005-2011, there was an estimated cost savings of $12.9 million (or $269.01 per member per year) among children 3 to 6 years of age receiving routine preventive dental services. The savings per member is driven, in part, by reductions in oral health utilization and treatment expenditures.[33] The goal of FDH services is to aid in the additional reduction of treatment expenditures.[34]

Due to the impact of COVID-19 on access to preventive services,[35] utilization of FDH was down 90 percent at the start of the public health emergency. By summer 2020, use of FDH services was at 80 percent compared to the previous year, with access rates slowly returning to normal.

Conclusion

To improve the oral health of Medicaid-enrolled children ages 6 to 35 months, Texas’s First Dental Home successfully implemented an enhanced bundled payment, caregiver engagement strategies, and provider-specific requirements to increase access to preventive oral health services for very young children under the EPSDT benefit. Texas’s approach is one that other state Medicaid programs can adapt as they explore strategies to improve the oral health of very young children and promote access to an initial dental visit during the first year of life.

Acknowledgements: This case study is a publication of the National Academy for State Health Policy (NASHP). This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under the Supporting Maternal and Child Health Innovation in States Grant No. U1XMC31658; $398,953. The information, content, and conclusions are those of the authors’ and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the US government.

Notes

[1] “Hygiene-related Diseases, Dental Caries,” U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, September 2016. https://www.cdc.gov/healthywater/hygiene/disease/dental_caries.html

[2] “Dental Caries in Primary Teeth,” U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, September 2019. https://www.cdc.gov/oralhealth/publications/OHSR-2019-dental-caries-primary-teeth.html – :~:text=The prevalence of untreated tooth,-poor, and poor children.

[3] “Utilization of Dental Services Among Medicaid Enrolled Children,” U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, October 2012. https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MedicaidDataSourcesGenInfo/Downloads/MAX_IB9_DentalCare.pdf

[4] “Statement on Early Childhood Caries,” American Dental Association, 2000. https://www.ada.org/en/about-the-ada/ada-positions-policies-and-statements/statement-on-early-childhood-caries

[5] U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, “Dental Caries in Primary Teeth,”

[6] “Dental Caries and Sealant Prevalence in Adolescents in the United States, 2011-2011, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, March 2015. https://www.cdc.gov/nchs/products/databriefs/db191.htm#:~:text=Dental%20caries%20among%20children%20aged,31%25)%20aged%202%E2%80%938

[7]Sheiham, A., “Dental caries affects body weight, growth, and quality of life in pre-school children,” British Dental Journal, November 2006. https://www.nature.com/articles/4814259 – :~:text=First, untreated caries and associated,foods because eating is painful.&text=Second, severe caries can affect,irritability and disturbed sleeping habits

[8] “The Importance of the Age One Dental Visit,” Pediatric Oral Health Research & Policy Center, 2019. https://www.aapd.org/globalassets/media/policy-center/year1visit.pdf

[9] “Allareddy, V., et al., “Hospital-based emergency department visits involving dental conditions: profile and predictors of poor outcomes and resource utilization,” Journal of the American Dental Association, April 2014. https://pubmed.ncbi.nlm.nih.gov/24686965/

[10] “Kanellis, M., et al., “ Medicaid Costs Associated with the Hospitalization of Young Children for Restorative Dental Treatment under General Anesthesia,” Journal of Public Health Dentistry, May 2007. https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1752-7325.2000.tb03288.x?sid=nlm%3Apubmed

[11] Savage, M., et al., “Early Preventive Dental Visits: Effects of Subsequent Utilization and Costs,” Journal of the American Academy of Pediatrics, October 2004. https://pediatrics.aappublications.org/content/114/4/e418.long

[12] “Recommendations for preventive pediatric health care,” Journal of the American Academy of Pediatrics, March 2000. https://pediatrics.aappublications.org/content/105/3/645

[13] American Dental Association, “Statement on Early Childhood Caries.” [14] “First Oral Health Assessment Policy,” American Association of Public Health Dentistry, May 4, 2004. https://www.aaphd.org/oral-health-assessment-policy

[15] Centers for Medicare and Medicaid Services, “Utilization of Dental Services Among Medicaid Enrolled Children.”

[16] “Utilization of Well-Child Care Among Medicaid Enrolled Children,” U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, October 2012. https://www.cms.gov/research-statistics-data-and-systems/computer-data-and-systems/medicaiddatasourcesgeninfo/downloads/max_ib10_wellchild.pdf

[17] “First Dental Home: Section 1: Overview of the First Dental Home Initiative,” Texas Health and Human Services, Texas Health Steps. https://www.txhealthsteps.com/static/warehouse/1076-2010-Jun-8-7c06br1a1rkyar7csn96/section_1.html

[18] “First Dental Home: Section 3: Scheduling, Treatment Planning, Documentation, and Billing,” Texas Health and Human Services, Texas Health Steps. https://www.txhealthsteps.com/static/warehouse/1076-2010-Jun-8-7c06br1a1rkyar7csn96/section_3.html

[19] “First Dental Home,” Texas Health and Human Services. https://hhs.texas.gov/doing-business-hhs/provider-portals/health-services-providers/texas-health-steps/dental-providers/first-dental-home

[20] Texas Health and Human Services, Texas Health Steps, “First Dental Home: Section 1: Overview of the First Dental Home Initiative.”

[21] Mccann, Ann., & Schneiderman, E., “Does the Texas First Dental Home Program Improve Parental Oral Care Knowledge and Practices,” Journal of Pediatric Dentistry, March 2017. https://www.researchgate.net/profile/Ann_Mccann/publication/319040790_Does_the_Texas_First_Dental_Home_Program_Improve_Parental_Oral_Care_Knowledge_and_Practices/links/5e496c8f299bf1cdb930f08e/Does-the-Texas-First-Dental-Home-Program-Improve-Parental-Oral-Care-Knowledge-and-Practices.pdf

[22] Texas Health and Human Services, Texas Health Steps, “First Dental Home: Section 3: Scheduling, Treatment Planning, Documentation, and Billing.”

[23] Use of CDT code D0145 in other state Medicaid programs is typically limited to an oral evaluation and counseling with the primary caregiver.

[24] Texas Health and Human Services, “First Dental Home.”

[25] Ibid.

[26] “State of Texas Medicaid Dental Review,” U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, October 2010. https://www.mchoralhealth.org/PDFs/CMSReview_TX.pdf

[27] “Pay-for-Quality Program,” Texas Health and Human Services. https://hhs.texas.gov/about-hhs/process-improvement/improving-services-texans/medicaid-chip-quality-efficiency-improvement/pay-quality-p4q-program – :~:text=Medical Pay-for-Quality Program,performance on certain quality measures.&text=The redesigned medic.

[28] “DentaQuest Provider Office Reference Manual: TX HHSC Dental Services,” DentaQuest, October 2020. https://dentaquest.com/getattachment/State-Plans/Regions/texas/Dentists-Page/Provider-Resources/TX_ORM.pdf/

[29] National Academy for State Health Policy, Early and Periodic Screening, Diagnostic and Treatment Network Call, “How States Can Promote Children’s Oral Health.”

[30] Nasseh, K., et al., “ Dental Care Use among Children Varies Widely across States and between Medicaid and Commercial Plans with States,” Health Policy Institute Research Brief, 2014. https://www.semanticscholar.org/paper/Dental-Care-Use-among-Children-Varies-Widely-across-Nasseh-Aravamudhan/763bbe86700c42c0f4b8a5cec50772dc20cda1a7#references

[31] Gupta, N., et al., “Medicaid Fee-for-Service Reimbursement Rates for Child and Adult Dental Care Services for all States, 2016,” American Dental Association, Health Policy Institute, 2017. https://www.ada.org/~/media/ADA/Science and Research/HPI/Files/HPIBrief_0417_1.pdf

[32] “How States Can Promote Children’s Oral Health,” National Academy for State Health Policy, Early and Periodic Screening, Diagnostic and Treatment Network Call, October 2020.

[33] Lee, I., et al., “Estimating the cost savings of preventive dental services delivered to Medicaid-enrolled children in six southeastern states,” Health Services Research, November 2017. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6153169/pdf/HESR-53-3592.pdf

[34] The research study focuses on children outside the age range of those receiving services under the First Dental Home. The study also includes claims data that precede implementation of the First Dental Home.

[35] “CMS Issues Urgent Call to Action Following Drastic Decline in Care for Children in Medicaid and Children’s Health Insurance Program Due to COVID-19 Pandemic,” U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, September 2020. https://www.cms.gov/newsroom/press-releases/cms-issues-urgent-call-action-following-drastic-decline-care-children-medicaid-and-childrens-health