CMS-10291 Description of Dental Benefits Provided Under Medicaid a

ATTACHMENT A

Description of Dental Benefits Provided Under

Medicaid and the Children’s Health Insurance Program (CHIP)

State: _____________________

Updated: _________________________

Contact Person’s Name and Title May be an employee of the Medicaid/CHIP agency or the dental managed care plan administrator
Name(s) of the Program(s) You Are Reporting On
Telephone Number
E-mail Address

The information collected in this survey will be used to create an online resource for families with children enrolled in Medicaid and CHIP. The Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) included many provisions to improve children’s dental coverage and and families’ access to information about children’s dental services available in Medicaid and CHIP.

In addition to the information already available on the Insure Kids Now website (insurekidsnow.gov) about children’s dental providers who accept Medicaid and CHIP, CHIPRA also requires that the Secretary of Health Human Services post and annually update descriptions of the dental services provided under each state plan for Medicaid and CHIP. The purpose of the attached survey is to collect the information on children’s dental benefits covered in each state that HHS needs to fulfill this requirement.

Please note that the information collected in this survey will be presented in a consumer-friendly format when it is ultimately displayed on the Insure Kids Now website.

About Medicaid and CHIP in Your State

Medicaid

• Under the Medicaid State Plan, dental benefits are provided to eligible individuals under the age of 21 in compliance with the requirements of Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services. 

State Program Name: ____________________

CHIP

• CHIP Medicaid Expansion Program ONLY, i.e., offering complete oral health services under Early and Periodic Screening, Diagnostic and Treatment (EPSDT)

State Program Name: ____________________

• CHIP Stand-Alone/Separate Program ONLY

             State Program Name: ____________________

• Dental Services Provided through State-defined benefit package

• Benchmark Program – Which benchmark: ____________________

• Optional Supplemental Dental Coverage for CHIP eligible children with private or group insurance

• CHIP Medicaid Expansion and Stand-Alone Program (complete relevant information about each program above)

Directions

Please complete the following table for children’s Medicaid and CHIP dental services covered in your state. If the state operates a Medicaid expansion program, it is only necessary to complete the table for Medicaid. States with combination and separate programs should complete the survey twice: once for their Medicaid program and one for their separate CHIP.

Note that oral hygiene instruction is not listed as a service in this list, because it can be part of any dental provider visit and is typically not reimbursed as a separate, unbundled service. However, when the information from this survey is displayed on the Insure Kids Now website, the site will explain that parents can expect that oral hygiene instruction is an included service that children receive in Medicaid and CHIP.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1065. The time required to complete this information collection along with the Children’s Dental Benefits Survey is estimated to average 30 hours annually per response, including the time to review instructions, search existing data resources, gather the data needed, and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to CMS, 7500 Security Boulevard, Attn” PRA Reports Clearance Officer, Mails Stop C4-26-05, Baltimore, Maryland 21244-1850.

Attachment A – page 2