CMS Issues State Letter for Dental Coverage in CHIP

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop S2-26-12
Baltimore, Maryland 21244-1850
Center for Medicaid and State Operations
SHO #09-012
CHIPRA # 7
October 7, 2009

RE: Dental Coverage in CHIP

Dear State Health Official (full letter on the CMS site):
The Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA), Public Law 111-3, reauthorizes the Children’s Health Insurance Program (CHIP) under title XXI of the Social Security Act (the Act). CHIPRA ensures that States are able to continue their existing CHIP programs and provides funding to expand health insurance coverage to additional low-income uninsured children including children already eligible for CHIP or Medicaid but not enrolled. The purpose of this letter is to provide general guidance on some of the provisions in section 501 of CHIPRA, including the dental benefit provisions and the State option to provide dental-only supplemental coverage, pending the issuance of regulations.

Required Dental Services

Section 2103(c)(5) of the Act, as added by section 501 of CHIPRA, requires that “child health assistance provided to a targeted low-income child shall include coverage of dental services necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions.” This requirement applies to all child health assistance coverage described in section 2103 and is effective October 1, 2009.

Medicaid Expansions

States that provide title XXI coverage to children through a Medicaid expansion program are required to provide Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services, as defined in section 1905(r) of the Act. The dental services provided under a Medicaid expansion program through EPSDT will be considered to meet the requirements of this provision.

Separate CHIP Programs

States that provide coverage in a separate CHIP program may choose between two methods of providing the dental services as required by section 2103(c)(5) of the Act. The State may define the services in the dental benefit package and demonstrate that the package includes all of the services required by the statute. In so doing, the State should specify the periodicity schedule with which preventative and restorative services, such as cleanings and fillings, would be provided, as well as whether these services are sufficient to prevent further disease, as required by section 2103(c)(5). This applies to State-defined benefit packages and dental benchmark packages as described below.
Alternatively, the State may provide a dental benefit package that is equivalent to one of the three dental benchmark packages described in the CHIPRA statute. Under the statute, there is no option in new section 2103(c)(5) of the Act for proving actuarial equivalence or modifying the benefit package. States may, however, cover benefits in addition to the dental benchmark plan consistent with the standards in section 2103(c)(5).

In order to fully describe a State dental benefit package under a separate CHIP program, and ensure that the benefits are sufficient to meet the statutory requirements, a State should describe both the types of covered benefits and the covered amount or duration of those benefits. The amount or duration should also be expressed through identification of the periodicity schedule that the State will use in its program. The periodicity schedule sets the frequency by which certain services should be provided and will be covered. We encourage States to rely on nationally recognized standards, including Medicaid dental periodicity guidelines used for children under EPSDT or the guidelines from the American Academy of Pediatric Dentistry (AAPD). The link to AAPD’s periodicity guidelines can be found at: http://www.aapd.org/media/Policies_Guidelines/G_Periodicity.pdf.