skip over navigation

Medicaid Contract Purchasing Specifications

Purchasing Specifications For Pediatric Dental and Oral Health Service Benefits
March, 2000

Table of Contents

§101. In General
§102. Scope of Benefit
§103. Preventive Services
§104. Treatment and Restorative Services
§105.Radiographic, Laboratory and Other Diagnostic Services
§106. Prescription Drugs
§107. Guidelines
§108. Coverage Determinations
§109. Definitions
§110. Compliance Measures

Note on symbols that appear alongside sample purchasing specifications: In order to provide additional guidance to Medicaid purchasers, these sample purchasing specifications contain applicable symbols that are designed to identify the basis (or bases) for the sample specification. The meaning of each symbol is as follows1:

L: The provision is based in whole or in part on federal Medicaid law, as articulated in the Medicaid statute, a federal regulation, or other written HCFA policy such as an Action Transmittal, State Medicaid Directors Letter, Regional Office Memorandum, or other formal HCFA transmittal. Just because an item is marked "L" does not mean that the service or activity is mandatory either for state agencies or for managed care contractors. Where the legal basis in question identifies a required service or activity, a footnote will so indicate. Law-related provisions that relate to optional services and activities also will be identified in a footnote. "L" is also used to indicate provisions that are based on and may incorporate non-Medicaid laws such as those relating to court-ordered treatment services.

G: The provision is based on whole or in part on formal guidelines issued by, or under the auspices of, a government agency (e.g., Centers for Disease Control and Prevention, 1998, MMWR 1998; 47 (No. RR-1), a professional society, or a formally convened, impartial deliberative body (e.g., the Institute of Medicine).

K: The provision is based in whole or in part on the best judgment and opinions of persons knowledgeable in a particular area of health care practice, health care delivery, or health services organization and management. This symbol is used to signify sample specifications that do not reflect a formal legal policy or that are not part of a formal practice guideline but that are recommended for consideration because they reflect good practice in the opinion of experts.

Part 1. Pediatric Dental And Oral Health Services Benefits

§101. In General

(a) Contractor Duties -- Contractor shall, for each enrollee who is under age 21, cover and furnish, or arrange for the furnishing of, dental and oral health services enumerated in this Part in accordance with:

    (1) guidelines and recommendations relating to dental and oral health preventive,. treatment and restorative services that are enumerated in §107 (and any subsequent editions of such guidelines and recommendations);

    (2) accepted standards of practice by dentists and other dental and health care professionals acting within the scope of state law; and

    (3) coverage determination standards and procedures described in §108.

§102. Scope of Benefit

(a) Pediatric Dental and Oral Health Services -- Pediatric dental and oral health services are: 6

    (1) preventive dental and oral health services enumerated in §103;

    (2) treatment and restorative dental and oral health services enumerated in §104;

    (3) radiographic, laboratory and other diagnostic services enumerated in §105; and

    (4) prescription drugs enumerated in §106.

§103. Preventive Services

L,G (a) In General -- Preventive oral and dental health services are the following items and services delivered in accordance with subsection(b) of this Section:

    (1) education on measures to promote an enrollee's dental and oral health and prevent dental and oral disease; 7

    (2) dental and oral health assessments; 8

    (3) referrals to dentists; 9

    (4) examinations of the teeth and oral cavity; 10

    (5) fluoride therapies which shall include: 11

      (A) application of topical fluoride; and

      (B) dietary fluoride supplements enumerated in §106;

    (6) application of dental sealants;

    (7) dental prophylactic services;12 and

    (8) space maintainers.

L (b) Delivery of preventive services. In delivering the preventive services described in subsection (a) of this Section, Contractor shall ensure that:

    L,G (1) the education services described in paragraph (a)(1):

      G (A) are provided to an enrollee and to the enrollee's family or care giver as part of: 13

      (1) dental and oral health assessments described in paragraph (a)(2);

      (2) examinations of the teeth and oral cavity described in paragraph (a)(4); or

      (3) treatment and restorative services described in §104; and

      G (B) address use of fluoride toothpaste, sealants, tooth cleaning, fluoride supplementation, and other topics appropriate for the age of the enrollee.14

    L (2) dental and oral health assessments described in paragraph (a)(2) are furnished by an enrollee's primary care provider as part of EPSDT initial and periodic well-child screens;

    L (3) referrals to dentists described in paragraph (a)(3) are provided; 15

      (A) in accordance with the schedule for periodic EPSDT dental and oral health screens as set out in [drafter insert citation to state medical assistance plan]; and

      (B) at other times as indicated by one or more dental or oral health risk factors identified by a primary care provider;

    L,G (4) examinations of the teeth and oral cavity described in paragraph (a)(4) are:

      L (A) performed by dentists;

      G (B) include a medical and dental history to determine the presence of oral and dental health risk factors;

      L (C) furnished in accordance with the schedule for periodic EPSDT dental and oral health screens as set out in [drafter insert citation to state medical assistance plan];

      L (D) at other times as indicated one or more risk factors identified by the treating dentist;

    G (5) application of topical fluoride described in subparagraph (a)(5)(A) is provided: 16

    [Alternative A]

      (A) annually or more frequently, as indicated in the judgment of the treating dentist, other dental professional, or primary care provider; except

      (B) in the case of a child with active caries, semi-annually or more frequently as indicated in the judgment of the treating dentist, other dental professional, or primary care provider; and as recommended by the manufacturer of the fluoride product;

    [Alternative B]

      (A) semi-annually or more frequently, as indicated in the judgment of the treating dentist, other dental professional, or primary care provider;

    G (6) application of dental sealants described in subparagraph (a)(6) is provided for pits and fissures of:17

      (A) an enrollee's first and second permanent molars that are free of restorations and non-incipient caries; and

      (B) other teeth, as indicated in the judgment of the treating dentist, other dental professional, or primary care provider

    G (7) dental prophylactic services described in subparagraph (a)(7) shall be furnished: 18

      (A) [drafter insert frequency of visits for routine dental prophylactic services]; or

      (B) at the frequency that is indicated in the judgment of the treating dentist, other dental professional or primary care provider; and

    G (8) space maintainers described in subparagraph (a)(8) shall be furnished to prevent space closure following an enrollee's premature loss of primary teeth.

§104. Treatment and Restorative Services

L,K (a) In General -- Dental and oral health treatment and restorative services are the following items and services delivered in accordance with subsection (b) of this subsection:

    (1) radiographic, laboratory and other diagnostic services enumerated in §105;

    (2) restorative services (fillings and prefabricated crowns);

    (3) orthodontic services;

    (4) endodontic services (pulpotomy, root canal therapy and/or apicoectomy and apexification);

    (5) dental and oral surgery;

    (6) periodontic services;

    (7) prosthodontic services;

    (8) oral patholoy services;

    (9) anesthesia services;

    (10) prescribed drugs enumerated in §106;

    K (11) consultations by treating dentists (including dental and oral health specialists and subspecialists) with the physician(s) who are clinically responsible for enrollees with complex medical conditions, chronic conditions, or disabilities that require specialized dental and oral health care; and (11) other services that are covered services under Section 1396d(a) of the Social Security Act.19

L,G (b) Delivery of Treatment and Restorative Services -- In providing treatment and restorative services covered under subsection (a) of this Section, Contractor shall ensure that:

    L (1) the services enumerated in subsection (a) are provided for relief of pain; resolution of infection; restoration of teeth; and maintenance of dental function and oral health of an enrollee;

    G (2) restorative services enumerated in paragraph (a)(2) are provided for restoration of an enrollee's:

      (A) permanent teeth; and

      (B) primary teeth not nearing exfoliation;

    G (3) orthodontic services enumerated in paragraph (a)(3) are provided for:

      (A) an enrollee diagnosed with severe, handicapping malocclusion or other congenital or developmental anomaly or injury resulting in malalignment or severe handicapping malocclusion of teeth; or 20

      (B) following repair of an enrollee's cleft palate;

    G,K(4) anesthesia services enumerated in paragraph (a)(8) are provided in the course of treatment and restorative services enumerated in subsection (a):21

      (A) as local anesthesia; or

      K (B) as sedation or general anesthesia, when indicated in the opinion of the treating dentist;

    K (5) consultations enumerated in paragraph (a)(10) are provided for enrollees with complex chronic conditions or disabilities that require specialized dental and oral health care; and

    G,K (6) In the case of an enrollee diagnosed with an illness, disability or condition or receiving a medical treatment(s) that constitutes one or more risk factors for dental or oral disease as defined in §109, Contractor shall ensure that 22

      (1) dental and oral health services are provided, as indicated by the enrollee's illness, disability, condition or medical treatment:

      (A) as inpatient services and in other appropriate settings; and

      (B) under general anesthetic or with other procedures.

§105. Radiographic, Laboratory and Other Diagnostic Services

L (a) In General -- Radiographic, laboratory and other diagnostic services are the following services delivered in accordance with subsection (b) of this Section:

    (1) radiographs;

    (2) laboratory tests; and

    (3) other diagnostic procedures.

G (b) Delivery of Radiographic, Laboratory and Other Diagnostic Services -- In providing radiographic, laboratory and other diagnostic services covered under subsection (a) of this Section, Contractor shall ensure that:

    (1) radiographs are furnished:

      (A) when indicated, in the judgment of the enrollee's treating dentist, by the enrollee's history and dental and oral examination; and

      (B) in accordance with appropriate clinical guidelines; 23

    (2) laboratory tests and other diagnostic procedures are furnished when indicated, in the judgment of the treating dentist, by the enrollee's history and dental and oral examination.

§106. Pharmaceuticals

L,G (a) In General -- Pharmaceuticals that are covered under §103(a)(5)(B) (relating to preventive services) and §104 (relating to treatment and restorative services) are the following pharmaceuticals delivered in accordance with subsection (b) of this Section:

    (1) dietary fluoride supplements; and

    (2) drugs prescribed for prevention or management of an enrollee's dental or oral disease, condition or injury.

G (b) Delivery of Pharmaceuticals -- In providing pharmaceuticals covered under subsection (a) of this Section, Contractor shall ensure that:

    G (1) dietary fluoride supplements are provided when prescribed for enrollees ages six months to sixteen years:

      (A) in accordance with applicable guidelines and recommendations 24

      (B) by the enrollees' primary care practitioner or treating dentist; and

    G (2) drugs for prevention or management of an enrollee's dental or oral disease, condition or injury are prescribed:

      (A) in conjunction with treatment and restorative services enumerated in §104

      (B) by the enrollee's treating dentist.

G§107. Guidelines 25

(a) American Academy of Pediatric Dentistry. Journal of the American Academy of Pediatric Dentistry, Special Issue Reference Manual 1998-99. 20(6).

(b) Casamassimo P. Bright Futures in Practice: Oral Health. Arlington, Virginia: National Center for Education in Maternal and Child Health, 1996.

(c) U.S. Preventive Services Task Force. Guide to Clinical Preventive Services, 2nd ed. Alexandria, Virginia: International Medical Publishing, 1996.

(d) American Dental Association, Council on Access, Prevention and Interprofessional Relations (CAPIR). Caries Diagnosis and Risk Assessment: A Review of Preventive Strategies and Management. J Am Dent Assoc 1995;126:1s-24S.

(e) Workshop on Guidelines for Sealant Use: Recommendations. J Pub Health Dent 1995; 55:263-273.

(f) New fluoride guidelines proposed. J Am Dent Assoc 1994: 125:366.

(g) American Academy of Pediatrics. Fluoride supplementation for children: interim policy recommendations. Pediatrics 1995; 95:777.

(h) U.S. Food and Drug Administration. The selection of patients for X-ray examination: dental radiographic examinations. Rockville, MD.: 1998; HSD Publication Number 88-8273.

(i) American Dental Association, Council on Dental Materials, Instruments and Equipment. Recommendations on radiographic practices: an update, 1988. J Amer Dent Assoc 1989; 118:115-117.

§108. Coverage Determinations

L,K (a) Use of Prior Authorization Procedures for Certain Services -- Contractor shall not impose any requirement for prior authorization or a "medical necessity" coverage determination for:

    K(1) referral by an enrollee's primary care provider for an enrollee visit to a dental provider or dental specialist provider for services described in §103 (relating to preventive services) or §104a1(a)(1) and (2) (relating to radiographs, laboratory tests and other diagnostic procedures and to restorative services); or

    L (2) services enumerated in §104 when furnished for symptomatic relief and stabilization of emergency dental conditions.

K (b) Determinations of Medical Necessity -- In making coverage determinations with respect to the medical necessity of services enumerated in §104(a)(3)-(11) (relating to treatment or restoration) for purposes of authorizing such services for an enrollee (including the medical necessity of such services which an individual is receiving at the time of enrollment as described in §202(a), Contractor shall:

    (1) utilize appropriate clinical guidelines; 26

    (2) take into account:

      (A) the judgment of the treating dentist; and

      (B) the condition of the individual enrollee; and

    (3) not deny coverage on the grounds that such services are available at a discount or free of charge through a publicly-assisted provider as defined in §109.

§109. Definitions

(a) Dental or oral disease or condition -- a disease or condition of the oral cavity, including but not limited to: dental caries; gingivitis; periodontitis; oral and pharyngeal cancer; salivary and oral mucosal conditions; malocclusion; congenital anomaly; injury or trauma to oral facial structures; and any other dental or oral disease or condition including manifestation of systemic disease and effect of certain medications and other medical treatments.

(b) Emergency dental condition27 -- a dental or oral condition that requires immediate services for relief of symptoms and stabilization of the condition; such conditions include severe pain; hemorrhage; acute infection; traumatic injury to the teeth and surrounding tissue; or unusual swelling of the face or gums.

L (c) EPSDT -- the Medicaid Early and Periodic Screening, Diagnostic and Treatment program, which is a specific set of benefits set forth in 42 U.S.C. §§1396d(a)(4)(B), 1396d(r)d and implementing regulations and guidelines, to which all Medicaid beneficiaries under age 21 are entitled.

(d) Low fluoride water supply -- a water supply with less than 0.7 parts per million (ppm) fluoride as determined by [drafter insert the name of the state agency with authority to evaluate the quality of a community's water supply, including its fluoride content].

(e) Poor personal oral hygiene -- oral hygiene practices that offer less than optimal prevention of dental caries or oral disease, as determined by professional standards of practice and the opinion of a health professional competent to assess oral hygiene practices.

(f) Publicly assisted health care provider -- a provider that:

    (1) is a public or private non-profit agency or entity;

    (2) furnishes services enumerated in §103 either free-of-charge or on the basis of a discounted schedule of charges adjusted for family income; and

    (3) receives funding under any federal, state or local program or under a privately-sponsored program to furnish free or subsidized health care to low income, medically underserved or other specified populations. Such providers include: local public health agencies; school-based health services; clinics of dental schools and dental and oral surgery residency programs; Ryan White CARE Act grantees; Federally Qualified Health Centers; Rural Health Centers; Health Centers for the Homeless; Migrant Health Centers; and other community-based ambulatory care providers.

(g) Risk factors for dental or oral disease or condition -- the presence of one or more of the following: history of dental caries; poor personal or family oral hygiene; use of a low fluoride water supply; absence of regular source of dental care; congenital oral facial anomalies; abnormal tooth morphology; certain medical conditions including diabetes mellitus, HIV infection, pregnancy and xerostomia; use of certain medications and other medical treatments including chemotherapy, radiation of the head or neck, and frequently used sugared medications; physical or mental disability; residence in an institution; use of tobacco; high alcohol intake; or addiction disorder.

(h) Urgent dental condition 28-- a dental or oral condition that require services within for relief of symptoms and stabilization of the condition within a reasonable period of time, as determined by the treating dentist, other dental professional, primary care provider or a triage nurse who is trained in dental care and oral health care. Such conditions may include minor tooth fracture; an oral tissue lesion that is visible to the enrollee (or enrollee's family or caregiver); and lost restoration.

§110. Compliance Measures

K (a) Availability to Purchaser of Certain Documents -- Upon request, Contractor shall make available to Purchaser the most recent version of each of the following documents:

    (1) copies of all manuals, memoranda, and other documents that are distributed to network providers (including dentists and other dental professionals, primary health care providers, providers furnishing pregnancy related care, and adult and pediatric specialists furnishing care for persons with illnesses and conditions which place them at risk for dental or oral diseases) and that describe the benefits provided under this section, the standards used to make coverage determinations, the conditions under which prior authorization for covered services must be obtained, and the evidence that must be submitted to the Contractor with respect to a coverage determination.

    (2) copies of all educational materials prepared for families that explain risk factors for dental and oral disease and steps for preventing and ameliorating dental and oral disease and promoting dental and oral health as well as a written explanation of the procedures that contractor uses to distribute such materials and provide education to enrollees and their families or other caregivers; and

    (3) copies of all coverage manuals and plan descriptions furnished to enrollees that describe services covered under this Part, as well as applicable limitations (including prior authorization and medical necessity requirements).

Endnotes

  1. Commentary: Under federal Medicaid law, a state's Medicaid plan must include "dental services" as one element of the mandatory Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit for Medicaid beneficiaries under age 21. The EPSDT dental benefit consists of dental "screening services," at "intervals that meet reasonable standards of...dental practice, as determined by the State after consultation with recognized dental organizations involved in child health care." (42 U.S.C. §1396d(r)(1)(A),(3)(A)(i)), and also "at such other intervals, indicated as medically necessary, to determine the existence of a suspected illness or condition." In addition to the screenings, the EPSDT dental benefit also includes dental services "which shall at a minimum include relief of pain and infections, restoration of teeth, and maintenance of dental health." (42 U.S.C. §1396(r)(3)(A)(ii),(B)) Health Care Financing Administration (HCFA) guidance further described covered EPSDT dental services as "emergency and preventive services and therapeutic services for dental disease which, if left untreated, may become acute dental problems or may cause ireversible damage to the teeth or supporting structures." Health Care Financing Administration (HCFA) State Medicaid Manual, §5124B.2.b.) The EPSDT benefit also specifically includes "health education (including anticipatory guidance)," which must be provided in the context of dental as well as medical assessments ("screens") and which must be provided both to parents (or guardians) and children. (42 U.S.C. §1396d(r)(1),(B),(v), Health Care Financing Administration (HCFA) State Medicaid Manual, §5124B.2.b.) As with the EPSDT benefit generally, any "mandatory" or "optional" Medicaid service must be covered for an individual child if the dental screen or another provider encounter ("interperiodic screen") indicates that the service is "necessary...to correct or ameliorate a defect or condition" discovered during the screen or other encounter. (42 U.S.C. §1396d(r)(5)). A "mandatory" Medicaid service is one that a state Medicaid plan must include, at least for categorically eligible individuals. Mandatory Medicaid services that might be needed include certain types of services and providers that may provide preventive, diagnostic and or treatment services for routine or complex dental and oral health care. Such benefits include inpatient and outpatient hospital services, laboratory and X-ray services; rural health clinic services, Federally-qualified health center services, physician services and "medical and surgical services furnished by a dentist... to the extent that such services may be performed under State law either by a doctor of medicine or by a doctor of dental surgery or dental medicine...;" and clinic services. (42 U.S.C. §1396d(a)(1), (2)(A)-(C), (3), (5)(B), and (9). An "optional" Medicaid service is one that a state need not include in its state plan; however, it would be considered mandatory under EPSDT for an individual child or adolescent, if found to be "necessary" as described above. Optional Medicaid services include prescribed drugs. (42 U.S.C. §1396d(a)(12)) Regulations implementing dental and oral health care as an EPSDT service are found at 42 C.F.R. §§ 440.40(b), 440.50 et seq.; and 441.56(b)(vi). In addition, detailed guidance is provided at §§5110, 5122.C, 5123.2, 5240 and 5310 of the Health Care Financing Administration's State Medicaid Manual.

  2. Commentary: Health education is a required element of EPSDT screens, including dental screens. For applicable law, see preceding Commentary.

  3. Commentary: HCFA guidance anticipates both an oral health screening as part of a child's physical examination by a primary care provider and also a professional dental examination by a dentist ("an oral screening may be part of a physical examination [but] it does not substitute for examination through direct referral to a dentist." HCFA State Medicaid Manual, §5124G.

  4. Commentary: See preceding Commentary.

  5. Commentary: See Commentary 8.

  6. Commentary: The fluoride therapies described in this paragraph are considered to be important adjuncts to daily use of fluoridated toothpaste and a fluoridated water supply, taking into account risk of caries in a population. For applicable guidelines, See 107(g).

  7. Commentary: Prophylactic services include tooth scaling and, for young children (generally less than 10 years of age) with minimal formation of calculus, tootbrush prophylaxis as an educational tool. For applicable guideline, see §107(a).

  8. Commentary: See Commentary 7.

  9. Commentary: Experts in dental and oral health recommend that children's teeth be cleaned daily from the time that they erupt in the mouth; that parents and guardians consult with a dentist or other health care provider before using a fluoridated toothpaste with a child under age two; and that parental supervision of toothbrushing and other measures to minimize the amount of fluoridated toothpaste swallowed be followed for children under age six. Topics for age-appropriate education of pediatric (including adolescent) and anticipatory guidance of parents or guardians of a child are described in the guidelines at §107

  10. Commentary: Under HCFA guidance, "[a] direct dental referral is required for every child in accordance with a state's periodicity schedule and at other intervals as medically necessary." The state's periodicity schedule "must be established after consultation with recognized dental organizations involved in child health care." The guidance distinguishes the dental periodicity schedule from that for physical health and observes that "where any screening, even as early as a neonatal examination, indicates that dental services are needed at an earlier age, states must provide dental services." HCFA State Medicaid Manual §5123.1.G.

  11. Commentary: Indications for fluoride therapy will vary with a child's medical and dental history, risk of caries, the fluoride level of the available water supply, frequency of the child's use of fluoride dentifrice, and other factors. Because of this variability, two alternative schedules for topical fluoride administration are provided. A minimum, annual level of therapy may be indicated for several reasons. First, available data show that low-income children are at higher risk of untreated caries and that a low percentage nationally of Medicaid-eligible children receive any preventive dental service annually. Second, the frequent disruptions in Medicaid eligiblity that many low-income families experience heighten the importance of preventive measures during periods when these children have Medicaid coverage for dental and oral health care. Finally, the the marginal cost of fluoride therapy as part of a periodic dental visit is low and there are no current data on the frequency with which low-income children use fluoride dentifrice. Alternative A reflects a minimum fluoride therapy level but provides also for more frequent applications of topical fluoride for children with active caries. The American Academy of Pediatric Dentistry recommends that topical fluoride be furnished at least semi-annually. The CAPIR Council, American Dental Association, has suggested that topical fluoride be furnished at least semi-annually for all children living in areas served by low-fluoride water supplies and for children with active caries living in areas served by fluoridated community water systems. Alternative B reflects this recommendation.

  12. Commentary: HCFA guidance provides for coverage of [p]rofessional application of dental sealants when appropriate to prevent pit and fissure caries." HCFA State Medicaid Manual, §4123.2.G. At the time these specifications were drafted, the Task Force on Community Preventive Services was completing its review of the evidence of effectiveness of school-based and school-linked sealant delivery programs in preventing dental caries.

  13. Commentary: AAPD recommends that dental prophylactic services be furnished at least semi-annually. For applicable guidelines, see §107(a).

  14. Commentary: For applicable guidelines, addressing specialized dental and oral health services for children with special health care needs and for hospitalization and use of general anesthesia for pediatric dental services, see §107(a). For applicable Medicaid law, see Commentary 6.

  15. Commentary: Purchasers may wish to consider specifying an objective severity index for use in identifying children without cleft palate for whom orthodontic services are appropriate. See: American Association of Orthodontics. Proceedings of the Orthodontic Indices Consensus Conference, 1993; Parker WS. The HLD (CalMod) index and the index question. American Journal of Orthodontics and Dentofacial Orthopedics, 1998; 114 (2):134-41.

  16. Commentary: For applicable guidelines, addressing specialized dental and oral health services for children with special health care needs and for hospitalization and use of general anesthesia for pediatric dental services, see §107(b).

  17. Commentary: This provision addresses the specialized dental and oral health needs of enrollees under treatment for chronic and acute medical conditions (e.g., HIV infection, cancer) and/or with behavioral disorders, developmental disability or other conditions that require specialized dental and oral health interventions. At least one state Medicaid agency (Connecticut) has recognized the specialized needs by providing in its managed care contract for coverage of oral and dental health services in an enrollee's home and for patient "management" in connection with dental services for enrollees with developmental disability. Rosenbaum et al., Negotiating the New Health Care System: A Nationwide Study of Medicaid Managed Care Contracts (2nd ed., 1998). For applicable guidelines, addressing specialized dental and oral health services for children with special health care needs and for hospitalization and use of general anesthesia for pediatric dental services, see §107(b).

  18. Commentary: For applicable guidelines, see §107(i) and (j).

  19. Commentary: For applicable guidelines, see §107(f), (g), and (h).
  20. Commentary: Purchasers may wish to consider the chapter on oral health promotion in the evidence-based Guide to Community Preventive Services, for which publication was expected in mid-2001. This publication is a companion volume to the 1996 U.S. Public Health Service publication, Guide to Clinical Preventive Services; the forthcoming Preventive Services guide is designed to articulate evidence-based public health practices for such defined populations as communities and members of insured (managed care) health coverage plans. Before publication, information on the status and content of the report may be found at http://www.thecommunityguide.org and also in the publication: Task Force on Community Preventive Services. Introducing the Guide to Community Preventive Services: Methods, First Recommendations and Expert Commentary. Am J Prev Med 2000;18(1s):1-42. At the time these specifications were drafted, a Guide chapter on oral health promotion, addressing the following topics, was under development: school-based sealant delivery programs; community water fluoridation; school-based fluoride delivery programs; provider and public education; oral hygiene education and supervised practice; oral examination for early detection of oro-pharyngeal cancer, and combined approaches.
  21. Commentary: For applicable guidelines, see §107.
  22. Commentary: This language may be used to supplement the Medicaid definition of "emergency medical condition" (emphasis added) in order to ensure that certain conditions of the mouth and teeth and supporting structures are not excluded from emergency care. The federal statutory definition of emergency medical condition for Medicaid enrollees in managed care, which this language may supplement, is:

    "a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

      (1) the placement of the child's health (or with respect to a pregnant adolescent, the health of the adolescent or her unborn child) in serious jeopardy;

      (2) serious impairment of the child's bodily functions; or

      (3) serious dysfunction of any bodily organ part." 42 U.S.C. §1396u-2b(2)(C)

  23. Commentary: Drafter may wish to specify a maximum time within which an enrollee must be seen for an urgent condition. Maximum waiting times for urgent dental care services in Medicaid managed care range from 24 hours to 3 days among 19 states participating in a 1998 survey. Dental Care Medicaid Managed Care: Report from a 19 State Survey. National Academy for State Health Policy (November, 1998).