Medicaid covers oral health care for children – a key preventative service that can have lifelong health implications. But that doesn’t mean it’s easy for low-income families in New Jersey to get their kids into a dentist’s chair.
Nearly half of the dental offices listed in Medicaid directories here were unable to schedule an appointment for a toddler, according to a report released Tuesday by the New Jersey Health Care Quality Institute, a nonprofit policy collaborative. More than one-third of the clinics did not take the Medicaid managed care plan that included their office in its online list of providers, the report showed, and others were unreachable. On average, the first available visit for a 2-year-old was a month away.
Health care advocates suggest these “ghost directories” – listing providers who are no longer accepting new patients covered by a specific plan – contribute to the problems identified by the state Department of Health in its first-ever survey of childhood oral health in 2023. Some 36% of third graders in New Jersey had untreated dental disease, compared to the national average of 20%, and decay was found in 24% of participants here in Head Start, a federally funded program to benefit low-income children, twice the national average, according to the Quality Institute report. On any day, 15% of these kids need urgent dental care, it said.
“We see these kids literally every single day,” said Dr. Michal Herman, the chief operating officer at KinderSmile Foundation, which seeks to raise awareness about oral health needs, runs a variety of related education programs and treats low-income patients in Bloomfield, Newark and Trenton. New Jersey also has one of the lowest levels of fluoride-treated water nationwide, at just over 16%, an additive long heralded for helping to prevent tooth decay.
Oral health is not just about nutrition or avoiding tooth decay, which can be debilitating. “It’s eating, it’s playing, it’s learning,” said Herman, a dentist. Missing or decayed teeth can lead to misdiagnosed speech impediments, she added, and result in discrimination as an adult. “It’s such a vicious cycle,” Herman told NJ Spotlight News.
Ghost networks are not a new problem, or unique to New Jersey. Medicaid members have historically struggled with so-called network adequacy, or a disconnect between the benefits they have on paper and accessing actual care. Experts blame a combination of workforce shortages, low reimbursement rates and other factors. For patients, the problem results in wasted time and energy, greater frustration and potentially limits or delays care, which can further harm their health. Others opt to pay out-of-pocket for services that should be covered.
“It’s extensive across the country,” said attorney Steve Cohen, who in October filed a federal class action lawsuit in New York alleging that a Blue Cross insurance plan had violated various consumer protection statutes by publishing inaccurate directories. The claim details the attorneys’ own secret-shopper investigation which revealed 80% of the mental health providers listed in the directory were unable to see a pediatric patient within a reasonable amount of time. The research also informed a U.S. Senate committee hearing on ghost networks in 2023, Cohen told NJ Spotlight News.
Issues with ghost networks are most severe when it comes to mental health providers, Cohen said. “But people volunteer to us that the next worst thing is dental,” he said. The firm is now looking at other practice areas and additional insurance companies, both in New York State and elsewhere, he said. Blue Cross has yet to file a legal response.
KinderSmile’s experience in New Jersey prompted the Quality Institute to examine the dental directories for the five managed care plans offered through NJ Family Care, the state’s Medicaid program, a state and federally funded health insurance program that covers more than 2 million people here, including nearly 817,000 children. Quality Institute representatives called the 824 dental practices listed in the five online directories in July and reached 86% of the offices. New Jersey also covers dental care for adults through Medicaid – one of just a handful of states to offer this benefit – but these providers were not part of the Quality Institute’s study.
Officials at the state Department of Human Services, which oversees Medicaid, and the New Jersey Association of Health Plans, which represents the insurance companies that manage the Family Care health plans, said they are also eager to improve oral health among children and share the goals outlined in the Quality Institute report. The state has taken steps to increase access to care and now requires that more than half of the kids in Medicaid plans get preventative care each year – a target that will increase in years to come.
“The Department believes that robust access to oral health services is an essential part of providing high quality care for NJ FamilyCare members,” communications director Tom Hester Jr. said. “While we have seen gradual progress in access to pediatric dental care in recent years, we recognize that there is still significant room for improvement, and will continue to consider all policy levers to ensure that children covered by NJ FamilyCare receive the oral health services they need. We welcome the input in this report, and will carefully review its findings to inform future action.”
Hester also noted that while the figure is not as high as state officials would like, federal Medicaid data shows that 48% of children in Family Care received a comprehensive dental evaluation in 2022, while the national average was less than 43%. But leaders at the Quality Institute point out that figure masks worrisome details, like the rate among kids age 1-2 years, which is only 22% statewide, and significant variation between the individual managed-care plans. Aetna paid for less than 10% of its members age 1-2 years to receive an evaluation that year, while Fidelis plans reimbursed for these services for four out of five youngsters in that age group, the study showed.
Ward Sanders, president and CEO of the state’s health plans association, said the state also conducts regular spot checks of Family Care directories and can penalize insurance companies for errors. Medical and dental providers are required to update these insurance companies if they move or opt out of a plan, but that system is far from foolproof, he and others said.
These managed care companies “look forward to continuing to work with their provider partners on the shared responsibility of ensuring that network directories are accurate so that our members have appropriate access to preventive dental services,” Sanders said.