May 2019 Volume LIV Number 3


Legislative and Regulatory Update

May 2016 Volume LI Number 3


Legislative and Regulatory Update 

Unless otherwise noted, for further information on any of these issues, please contact Chief Operating Officer and General Counsel C. Scott Litch at (312) 337-2169 or


Federal news

AAPD 2016 Legislative and Regulatory Priorities

These priorities, as developed by the AAPD Council on Government Affairs and approved by the AAPD’s board of trustees, are provided below and are also available on the AAPD website at

Priority: Affordable Care Act (ACA) and Insurance Reform

Goal: Access to Care

Target: Federal Health Care Reform

1. Support corrections to Affordable Care Act (ACA) to:

a) Make pediatric oral health coverage mandatory.

b) Include dental premium cost under calculation of tax subsidy for low income families.

c) Exempt preventive dental services from deductibles in embedded plans and SADPs.

2. Assist ADA in promotion of ERISA reform bill from Congressman Gosar (H.R. 1677), that would require all health plans offering dental benefits to provide uniform coordination of benefits and permit consumers to designate payment of dental benefits to providers who do not participate in the network.

3. Work with ADA and other dental and medical organizations to support a H.R. 3323, the Dental and Optometric Care Access Act, which would apply non-covered services provisions to ERISA plans.

Target: Federal Regulations

1. As the Affordable Care Act (ACA) provision defines pediatric oral health as an essential health benefit (EHB), ensure that implementing regulations require robust coverage consistent with the AAPD Policy on a Model Dental Benefits for Infants, Children, Adolescents, and Individuals with Special Health Care Needs.  Coordinate joint response/comments on proposed regulations with ADA and keep key members of Congress informed.  

Support mandatory purchase (vs. offer) of an appropriately structured embedded or stand-alone dental plan for children inside exchanges, and encourage states to adopt such a requirement as several have already done (Kentucky, Nevada, Washington state).  

Sustain regulatory inclusion of general anesthesia coverage state mandates as EHB in 2017 and beyond (for states that approved such mandates prior to 12-31-11). Monitor types of pediatric oral health insurance offered in state health insurance exchanges as compared with AAPD model benefits.  

Evaluate and respond to key ACA insurance plan issues such as network adequacy, provider fees, family out-of-pocket costs, and the impact of pediatric dental coverage embedded in medical plans.  Communicate recommendations to Center for Consumer Information and Insurance Oversight.

2. Work closely with ADA, state dental associations, and state pediatric dentistry chapters to ensure that state health insurance exchanges appropriately adhere to federal guidelines and regulations concerning insurance plans offering pediatric oral health coverage.  Fully engage state Public Policy Advocates in this effort.

Target: State Legislation and Regulations

1. Continue to provide technical assistance to states for General Anesthesia legislation, highlighting ongoing cost analysis and using TRICARE coverage and success in 33 states to spur momentum.  Evaluate likelihood of states considering future insurance mandates in light of ACA EHB provision.  

Utilizing research and policy center technical brief and working closely with CDBP, educate insurers and insurance regulators on necessity of this benefit and role of pediatric dentists in treating high risk children.

Priority: Medicaid Dental Reform

Goal: Access to Care and Medicaid Dental Reform

Target: Federal Health Care Reform

1. Explore possibility of targeted pediatric oral health bill to address Medicaid dental reform by increasing Medicaid matching payments for states that pursue specific Medicaid dental reforms including reimbursement at competitive market-based rates (per previous proposals such as S. 1522/H.R. 3120).  Protect Medicaid EPSDT guarantee in Medicaid block grant and other cost-savings proposals.

2. Ensure that Medicaid EPSDT regulations continue to promote the dental home and a required examination by a dentist. 

Goal: Medicaid Dental Reform

Target: Federal Regulations

1. Encourage CMS to include pediatric oral health quality measures developed by the Dental Quality Alliance as part of the Medicaid dental program.

Target: State Legislation and Regulations

1. Provide continued technical assistance to state pediatric dentistry chapters for Medicaid dental reform for their efforts with both state legislatures and state dental associations.  

Continue to promote states’ adoption of appropriate dental periodicity schedules consistent with AAPD guidelines, and update research and policy center dental periodicity schedule adoption map on website as appropriate.  

Promote state Medicaid programs’ adoption of pediatric oral health quality measures developed by the Dental Quality Alliance (DQA). 

Continue to inform and educate key constituencies about reforms that work, including MSDA (Medicaid/CHIP State Dental Association), NCSL, NGA etc.

Work with research and policy center and CDBP to respond to Medicaid medical movement to managed care by:

(a) promoting dental managed care hybrid payment models that leave the risk with the plan contractor (or at least share it between the plan and the provider); and 

(b) maintaining accountable dental fee-for-service plans.

2. Ensure that state Medicaid programs conducting provider audits do so in an appropriate and fair manner, adhering to AAPD clinical guidelines and utilizing peer review by pediatric dentists.  Secure appropriate guidance to states from CMS Center for Medicaid and State Operations.

Priority:Workforce Improvements

Goal: Workforce

Target: Federal Appropriations for FY17

1. Seek appropriations for sec. 748 Title VII dental primary care cluster of $35.873 million, with directed funding of not less than $10 million going to pediatric dentistry in recognition of the demand for training grants and the increased need for pediatric dentists to treat newly insured children under the ACA.   Obtain continued support for dental faculty loan repayment, and strongly encourage applications in response to HRSA’s FY 2016 grant announcement.

2. Support efforts of Children’s Hospital Association to obtain full funding of $300 million for Children’s Hospitals GME, and oppose any HRSA efforts to restructure the program and eliminate dental positions from residency count in funding formula.

3. Seek HRSA support to implement AAPD proposal for restructured MCHB program for Leadership in Pediatric Dentistry Education. 

Target: State Legislation and Regulations

1. Promote states’ adoption of expanded duties for dental assistants as recommended in the AAPD’s Policy on Workforce Issues and Delivery of Oral Health Care Services in a Dental Home, and assist state chapters dealing with dental therapist and other mid-level proposals. Provide technical assistance, via research and policy center, to state Public Policy Advocates working in collaboration with state dental associations on this issue.

Priority: Other

Goal: Access to Care

Target: Federal Health Care Reform

1. Work with ADA and other dental and medical organizations to support a simplified process across appropriate governmental agencies to designate individuals with intellectual disabilities as a medically underserved population. 

2. Secure HRSA review and update of dental health professions shortage area (HPSA) criteria, building from unimplemented 2005 UNC/Sheps Center report along with other recommendations.   An improved dental HPSA will provide a more accurate federal assessment of oral health workforce needs.

Target: Federal Regulations

1. Monitor implementation of Head Start Performance Standards proposed in 2015, to ensure appropriate requirements for dental periodicity schedule and establishment of a dental home.

Target: State Legislation and Regulations

1. Provide technical assistance to states seeking legislation for mandatory oral health examinations prior to school matriculation. Seek support of state dental associations and other interested organizations via efforts of state Public Policy Advocates.  

2. Work with ADA, state dental associations, and state pediatric dental units to promote community water fluoridation, and prevent efforts to remove fluoride from currently fluoridated communities.


1 The initial DQA pediatric oral health quality measures tested and adopted in 2013 are as follows:

Evaluating Utilization Use of Services

Preventive Services

Treatment Services

Evaluating Quality of Care Oral Evaluation

Topical Fluoride Intensity

Sealant use in 6-9 years

Sealant use in 10-14 years

Care Continuity

Usual Source of Services

Evaluating Cost Per-Member Per-Month Cost

The DQA was formed by the ADA at the request of CMS.  The AAPD was a founding member and has a representative on the DQA’s Executive Committee. The AAPD Pediatric Oral Health Research and Policy Center maintains an EFDA "tool kit" on its web page.

The AAPD Pediatric Oral Health Research and Policy Center maintains an EFDA "tool kit" on its web page.

3 Note that a tool kit is available on the AAPD research and policy center web page.


AAPD and ADA Urge Improved CMS Oversight of Medicaid Dental Programs

 In early January 2016, the AAPD and ADA sent two comment letters to the Centers for Medicare and Medicaid Services (CMS) concerning the CMS regulation on Medicaid Programs: Methods for Assuring Access to Covered Medicaid Services issued on Nov. 2, 2015 (CMS-2328-FC). The organizations urged that dental services be included in state Access Monitoring Plans that must be submitted to CMS by July 1, 2016. A number of additional recommendations were made related to market-based reimbursements and measuring patient utilization via Dental Quality Alliance measures. Effective CMS oversight of Medicaid is even more important given the 2015 Supreme Court decision denying health care providers the right to sue Medicaid to seek judicial enforcement of the "equal access" provision in the Medicaid law. Copies of the letters are available at:


State News

OIG Report: Most Children with Medicaid in Four State are Not Receiving Required Dental Services; AAPD Spokesperson Quoted in AP Story 

In January 2016 the HHS Office of Inspector General (OIG)released its latest in a series of reports on Medicaid dental programs. This report focused on Medicaid dental claims in four states:  California, Indiana, Louisiana, and Maryland. The study focused on three required dental services – biannual oral exams, dental cleanings, and fluoride treatments – for children continuously enrolled in Medicaid for two years. OIG founds that three out of four children did not receive all required dental services, with one in four failing to see a dentist at all.

The AAPD has been engaged in ongoing discussions with D-HHS OIG concerning their work on Medicaid children’s dental issues, offering our expertise to ensure their analysis is as accurate as possible. OIG deputy regional inspector general Meredith Saife spoke to AAPD’s state Public Policy Advocates during their luncheon 2014 at the 2014 AAPD Annual Session in Boston. AAPD leaders, including current Academic Trustee-at-large Dr. Amr Moursi, had previously met with Ms. Saife and her staff at the OIG regional office in New York City.

The Associated Press covered this OIG report in an online story on Jan. 25, 2016. The article quoted AAPD spokesperson Dr. Amr Moursi of New York University College of Dentistry, who stressed the importance of regular dental care. He stated, "We need to get children who are enrolled and eligible for services to actually get them." The article also featured photos of AAPD member Dr. Juan F. Yepes treating pediatric patients at Riley Hospital in Indianapolis. This story ran on Reuter’s, the Washington Post online, and newspapers across the country.

The four states discussed in the report had adopted the AAPD periodicity schedule requiring exams and cleanings every six months, but Indiana and Louisiana had coverage policies that didn’t allow Medicaid payment for particular services in the established schedule. The coverage policies "were impeding children from getting the services they need and were required to get," according to Meridith Saife, the OIG deputy regional inspector general who worked on the report.

A copy of the OIG report is available at:



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