Caries Prevention Services* Reimbursement Table
Medicaid Reimbursement for Primary Care Caries Prevention Services
This summary reflects results obtained from a survey of the 50 States and Washington, DC performed by Amos Deinard, MD, MPH on behalf ofthe American Academy of Pediatrics Oral Health Initiative, Medicaid/CHIP Dental Association and Chris Cantrell, et al. of the National Academy for State Health Policy.
StateName / Providers Currently Reimbursed
$/Service(s)* / Procedure Code(s) Used* / Age Limit for Service(s) / # Varnish Applications Reimbursed Annually / Training Required? Yes/No If yes, please specify training expectation / Delegation Allowed **
(e.g., RN, LPN, CMA, MA) please specify / Payors (Fee For Service, Managed Care Organizations (please specify) / Does the payment come from the medical or dental Medicaid/
CHIP dollar (please specify) / In what year did Medicaid begin to reimburse? / Was it necessary to get legislative approval to reimburse medical providers? / Comments
Alabama / MD, NP
$18.00 (OE/AG)
$15.00 (FV) / D-0145
D-1206 / 6-36 mos
(moderate high risk) / 3/yr; between 6-35 months / Yes (RA, AG, DH & FV) / LPN
RN / Single / Medical / 2009 / No
Alaska / MD, DO
$56.70 (OE)
28.00 (FV)
NP, PA
$48.20 (OE)
$23.80 (FV) / D-0145
D-1206 / <3 yrs (OE)
None (FV) / 2/yr (OE)
4/yr (FV) / Yes / No / Fee for service / Medical Medicaid and CHIP dollar / 7/1/2010 / No
Arizona / None / 3 yrs / Reimbursement legislated but not yet funded
Arkansas / None
California / MD, NP
FFS-$18.00
MCO- $0.00-$27.00
(FV) / D-1203 / <6 yrs / 3 / No, but encouraged / CMA
LPN
RN / Multiple / Medical / 2006 / No
Colorado / Dental and Medical
$15.07 (FV)
$28.62 (OE)
$20.49 (OE) / D-1206
D-0145
D-0120 / Under 5 / 4 / Yes for medical / Limited / Fee for service / Dental / SFY2009 / Entailed fiscal note
Conn. / MD
NP
PA
$20.00 (FV)
$25.60 (OE) / D-1206
D-0145 / First 40
months
(3rd birthday well-child visit) / With each well-child visit (per HEDIS) / Continuing ED CME course developed by Dental School / CMA
LPN
RN / Multiple
DC / None
Delaware / None
Florida / MD
PA
ARNP
$27.00
(FV/AG) / 99499 with modifier SC / 6-48 mos / 4 / Training not required. U of FL Gator Kids Healthy Smiles Program provides training if requested by provider. / CNA
LPN
RNA
RN / Fee for service and managed care organizations / Medical / 2008 / No
Georgia / MDs
NPs
Dentists
$17.59 (FV) / D-1206 / 6 months / Twice per year / None required / Yes, MD can delegate to staff but must bill under MD / Fee for service
Managed care organizations / Both – Depending on Provider rendering service / 2009 / No
Hawaii / None / Single
Idaho / MD
NP
PA
$13.58 (MD)(FV)
$11.54 (NP, PA)(FV) / D-1203 / 0-21 yrs / 2 / Public Health District
Dental Program / CMA
LPN
RN / PAHP -Fee for service / Medical - / 2003 / NO
Illinois / MD
APN
FQHC
Out Patient Hospital Clinic
$26.00 (FV) / D-1203 and
plans to add
D-1206 / Under age 3 with 4 erupted teeth / 3 / Coordinated by Illinois Chapter – AAP (ICAAP) and provided by practicing pediatric dentists. Upon completion of training and certification, providers send their certificate to state. Then they can submit claims for FV service. / Yes
RN, LPN, CMA and MA / Fee for service / Medical / 2006 / No, but administra-
tive rule had to be changed / Began as a pilot program only in Cook County and metro counties and in FQHCs. The program is being expanded statewide. Training requirements still in effect.
Indiana / None
Iowa / MD
NP
PA
$13.82 (FV) / D-1206 / 0-36 mos / 3 / Training by I-Smile (Oral Health Bureau). / CMA
LPN
RN / Fee for service / Medicaid medical as a physician cost / 2001 / No / Application of fluoride varnish is within the scope of practice for Iowa physicians. Although not required, we chose use our rules making process to allow for public comment.
Kansas / MD
NP
PA
PHN
$17.00 (FV) / D-1203 / None / 3 (MD) +
3 (DDS)
(total 6/yr) / No, though
Bureau of Oral Health will provide training to any medical practitioner that
requests it. Online training also available. / CMA
LPN
RN / Fee for service
Kentucky / MD
$15.00 (FV) / D-1206 / 1 – 5 yrs / Once every 90 days.
(maximum of 2 times in a 12-month period.) / On-line / CMA
LPN
RN / Multiple / Not specified / 2008 / No
Louisiana / None
Maine / MD
NP
PA
$12.00 (FV) / D-1206 / Under 21 yrs. / 3 / Not required / LPN, CMA and RN, MD. / Fee for service / Medicaid / September 2008 / No
Maryland / MD
NP
$24.92 (FV) / D-1206 / 9 mo – 3 yrs / 4 - the child can also receive 2 FV applications from a dentist / Yes - training by Office of Oral Health / LPN
RN
PA
CMA
(anyone allowed to give an immuni-zation) / Fee for service / Medicaid/CHIP Dental budget / 2009 / No – regulatory change only / The program has worked very well – already have about 20,000 medical claims for FV
Mass. / MD
NP
PA
RN
LPN
$26.00 (FV) / D-1206 / < 21 but recommended for under age 3 / No limit; recommended not to exceed one application every 180 days / Online; group or office visit / MD
NP
PA
RN
LPN
MA (effective this Fall 2010) / Multiple / Payments are made through the medical side if the claims are billed by the medical side / 2008 / No / Through the EPSDT Periodicity Schedule, a dental assessment and referral screening are completed that includes exam, guidance, risk assessment and recommendation to seek dental care. All other columns address fluoride varnish only.
Michigan / MD
NP
$9.00 (FV) / D-1206 / <3 yrs / 4 times/y / Online / LPN
PA
RN / Both fee for service and managed care organizations / Payment is from the physician (medical) and Managed Care budgets / 2008 / NO
Minnesota / MD
NP
PA
PHN
FFS - $14.00 (FV) MCO – variable
($14.00 -$20.00) (FV) / D-1206 / 0-20 yrs / 3-6 months / University of Minnesota’s “Dental Health Screening and Fluoride Varnish Application”, available online. / CMA
LPN
RN / FFS &
MCO / Medicaid funds. / 2003 / No
Mississippi / $22.42 (FV)
$33.04 (OE) / D-1206
D-0145 / <3 yrs / 2/fiscal year / Online recommended / Yes – regular physician and nurse practice standards apply / Fee for service / Medical / 2010 / No
Missouri / MD
NP
$13.56 (FV) / D-1206 / <6 yrs / 2 times/rolling year / Department of Health and Senior Services, Division of Community and Public Health / None / Fee for service / Medical / 2008 / NO
Montana / $19.65 (FV)
$22.93 (OE) / D-1206
D-0120 / 0-20 / Up to 6 / Preferred / MD’s/DDS
DDS only / Fee for service
Nebraska / MD
$10.00 (FV) / D-1206 or
D1203 / 12 years and younger / 3 times in a 12 month period / Fee for service / April 20, 2009 / Has to have DX V07.31
Payment is $9.00 for D1203 and $10 for D1206
Nevada / MD
NP
PA
PHN
$53.30 (FV) / D-1206 / 0 - 20 yrs / Every 6 months / On-line / LPN
RN
PA / Multiple / Dental / 2002
New Hampshire / None / Reimbursement legislated but not yet funded
New Jersey / $15.00(FV)-(MCO1);
$25.00 (FV)- (MCO2) / D1206 / 0-6.99yrs (MCO1); through age 20 (MCO2) / 4
MD's 2X per year, DDS additional 2X per year / Yes, CE class state board approved
Some basic training / NP, PA
Consistent with NJ Board of Medicine / Horizon NJ Health and Americhoice are the only managed care organizations currently reimbursing / Comes from MCO medical dollar
From dental dollars / Medicaid does not reimburse
2007 / No / State FFS does not reimburse MCOs nor does it participate
New Mexico / MD
$15.00 (FV) / D-1206 / 0-3 yrs / 6 treatments total up to age 3 / No, but is recommended / Yes / 3 of the 4 MCOs are reimbursing PCPs statewide. One managed care organization reimburses PCPS in Chaves County, NM only
New York / MD
NP
$30.00 (FV) / D-1206 / 0-7 yrs / 4 / Recommended, not required / Yes.
Claims must be submitted through the MD, NP or DDS / Both / Medicaid / 2009 / No
N. Carolina / MD
NP
$16.04 (FV)
$36.35 (OE) / D-1206
D-0145 / 41 mos / 60 days
(Max 6) / Into the Mouths of Babes / LPN
PA
RN / Fee for service / Medical / 2000 / No
N. Dakota / MD
NP
PA
PHN
$21.84 (FV) / D-1206
V 20.2 / 0-21 yrs / 2 / Training approved by Board of Dental Examiners / CMA
LPN
RN / Fee for service / Dental Medicaid / 2007 / Yes
Ohio / MD
NP
$15.00 (FV) / D-1203 / < 3 yrs / Once every 180 days / On-line / LPN
RN / Fee for service
managed care organizations
Oklahoma / None
Oregon / MD
NP
PA
$13.65 (FV) / D-1206
V07.31 / 6 yrs. and younger / 2 times every 12 months, but
up to 4 for high-risk conditions or oral health factors / No / Yes, as allowed by scope of practice / Fee for service / Medical / 2000 / No
Pennsylvania / MD
CRNP
$18.00 (FV) / D1206 / 4 yrs and younger / 4 / Yes, Completion of “Oral Health Risk Assessment Training for Pediatricians and Other Child Health Professionals” CME course available online @ aap.org / Yes; CRNP, PA, RN. / Fee for service and managed care organizations / Medical (Physician and Dentist professional services are both paid from Outpatient Allocation funds.) / 2010 / No
Rhode Island / MCOs
$18.00-$33.00 (FV) / D-1206 / Varies based on MCO / 2 / Varies based on MCO / Yes / Three RIte Care managed care organizations / Medical / 2009 / No
S. Carolina / MD, DO
$16.90 (FV) / D-1206
FQHC***
RHC**** / 0-3 yrs / 2 per year as part of EPSDT examination / Yes, online
CE certificate in provider’s file x / RN, LPN,
CNA,CMA, MA or any other office staff member / Fee for service / Dental / 2007 / No
S. Dakota / MD
NP
PA
PHN
$18.00 (FV) / D-1206
V20.2 / Max. age 5 / 3 / Fee for service / Both, depends upon child’s eligibility / 2006 or before / No
Tennessee / None
Texas / MD
NP
PA
$34.16 (FV) / 99429 (OE) billed with U5 modifier along with ICD-9
EPSDT code (99381, 99382, 99391, 99392) / 6-35 mo / 6 over age range / In person and online Texas course / CMA
LPN
RN / Fee for service,
managed care organizations / Medical Medicaid funding / Sept 2008 / This was part of a strategic initiative that secured Governor and Legislative Budget Board approval
Utah / MD
NP
PA
PHN
$15.00 (FV) / EP modifier added to age-appropriate ICD-9 EPSDT code / 0-4 yrs / At each well-child exam / AAP course online / CMA
LPN
RN / Fee for service and
managed care organizations / Medicaid / 2007 / No / All MCOs included by 1/1/09
Vermont / MD
$39.00
(AG
OE
RA) / D-0145 / 2 yrs. old and younger / D1206 FV started 06/21/10, age 0-5 (under 6) / On line (AAP course) or hands-on (one-hour) / D-0145-No / Fee for service / D-0145 in January,
2008 / No
Virginia / MD
NP
PHN
$20.79 (FV) / D-1206 / Under 3 yrs. / 2 / Yes – training is done by the Virginia Health Department / Physicians, Nurse Practitioners, Health Departments, CHIP of Roanoke and Rural Health Clinics are set up to bill for this service. / Fee for Service and all managed care organizations / Medical Medicaid and CHIP / 2006 / No
Washington / MD
DO
ARNP
PA
PHN
$13.25 (FV)
$29.46 (OE)
$27.58 (FOHE) / D-1203
D-0120
D-9999 / < 5 yrs
(FOHE & OE)
< 20 yrs. (FV) / 2 times in 12 month period age 6 to 20 / Course / CMA
LPN
RN / Fee for service
managed care organizations (Medicaid and Washington Dental Service/Delta Dental) / Dental / 1998 for FV
2008 (for other 2 services) / No
West Virginia / None
Wisconsin / Physician
NP
PA
$12.89 (FV)
Also, oral assessment plus referral to a dentist beginning at 1 years of age covered as part of comprehensive EPSDT screening. / Either D1203 or
D1206 / Two per 12-month period, per provider. Up to four per 12-month period, per provider, for cases of demonstrated high need, or for permanently disabled members. / Training materials available through ForwardHealth Portal at / Topical applications of fluoride may be provided by nurses employed at certified HealthCheck nursing agencies. / FFS for most of state; managed care organizations for the Milwaukee area / Dental / Feb. 26, 2004 / Unknown
Wyoming / MD
$35.00 (FV) / D-1206 / 0-3 yrs / 3 / Wyoming Health Department staff dentist / CMA
LPN
RN / Fee for service
*FV = Fluoride Varnish Application
*OE = Oral Exam
*AG = Anticipatory Guidance
*RA = Risk Assessment
*DH = Recommendation for dental home by age 1
** Though the task may be delegated, the assumption is that billing for the procedure will be under the responsible provider’s name (MD, NP, PA)
*** FQHC = Reimbursement to be included in the all-inclusive HCPCS (T1015) encounter code T1015 paid to the FQHC
**** RHCs = Claims submitted for fee-for-service reimbursement in addition to the HCPCS (T1015) on CMS1500 form
x Online training required: Open Wide: Oral Health Training for Health Professionals. Access at the National Maternal and Child Oral Health Resource Center: Oral Health Risk Assessment: Training for Pediatricians and other Child Health Professionals. Access at the American Academy of Pediatrics: 10/8/2018