Florida’s experiences with the use of mobile dental vans in the provision of school-based dental care have been both negative and positive. The negative experience produced-not-so-glamorous headlines in the newspaper, negativity towards Medicaid from dental providers, and negative dental care for Medicaid children. From information provided to Medicaid via various sources plus paid-claims data, it became apparent that Medicaid was being billed for a multitude of services that were not necessarily essential. Through the support of the Florida Dental Association and the Florida Board of Dentistry, Medicaid implemented policy to curtail the activities of the entrepreneurial mobile providers. At the same time, Medicaid worked to maintain the same level of access to care.

Some of the negative aspects of Florida's initial mobile van experience included the following:

• Mobile units solicited at housing projects when they were not stationed at schools. This pattern of practice occurred across the state.
• Mobile units rovided diagnostic and preventive services, but minimal therapeutic treatment. Several instances were reported where a mobile unit had provided diagnostic and/or preventive services to the same child on two to three occasions, months apart, while grossly carious teeth were ignored.
• Parents/guardians falsely believed their children were receiving essential services.
• No continuity of care of care was provided. The mobile units followed a nomadic routine.
• Mobile units provided no access to after-hours care or follow-up emergency services even though these services were called for in the Florida Dental Practice Act. The vans were seldom in same location/city more than 12 hours.

Medicaid received reports of questionable radiography techniques, suspect supervision of questionably trained auxiliary staff, reports of disarrayed and dirty facilities, questionable sterilization techniques and questionable medical necessity of various services that were billed.

• Complaints were also received about abusive billing practices.
• Schools reported, after the fact, that mobile units were highly disruptive to the school routine and would prefer they not have access to their schools.

In response, the state developed an alternative approach to mobile dental units. "Florida’s Solution" had the following characteristics:

• The state implemented a policy that allowed mobile units only if owned by, operated by, or having a contractual agreement with a County Health Department (CHD) or a Federally Qualified Health Center (FQHC) for provision of Medicaid children’s services.
• The above policy was placed into Florida's Administrative Code prior to implementation.
• Use of mobile units for adult Medicaid dental care was permitted only at nursing home facilities.
• Medicaid concluded that there would be more control over the billing with the CHDs and FQHCs being the controlling factors. This stems from the fact that CHDs and FQHCs are reimbursed through encounter rates, based on cost reports, with the CHD and FQHC submitting claims for reimbursement.
• The state implemented edits into the claims adjudication system to limit prophys, fluoride treatments, OHI, and BW x-rays to once per six months.
• The state also placed restrictive language affecting the mobile units into statute in June 2001.
• The state also added state-approved dental educational institutions (dental schools) as entities allowed to own, operate or contract with a mobile unit.
• For Medicaid purposes, the use of a mobile unit or portable equipment are one and the same.

Positive Mobile School-Based Experiences

• Duval County Health Department (Jacksonville metro area)
• The CHD owns a mobile unit.
• Screens 2nd and 7th graders at schools.
• Refers children needing treatment back to CHD or to the child’s dentist of record in the community.

• Palm Beach County Health Department
• Presently using portable equipment
• Screens 2nd graders at schools and applies sealants to 1st permanent molars.
• Quantum Foundation reimburses CHD for non-Medicaid; Medicaid reimburses for Medicaid.
• Quantum Foundation grant for mobile unit.
• Plan to expand program to include 6th graders.

• Monroe County Pilot Project
• Monroe County includes the Keys (a chain of islands stretching over 200 miles)
• No Medicaid providers in the county.
• Medicaid transportation costs more than the costs of dental treatment.
• Pilot project to examine and provide preventive services including sealants to 2ndand 6thgraders at one school.
• To expand to other schools if successful at first school.
• Cooperative effort of Monroe CHD, the school system, a Rural Health Network, and Miami Children’s Hospital Dental Department.
• Miami Children’s has a contract with CHD for provision of dental services.
• CHD reimburses Miami Children’s for all services, billing Medicaid for Medicaid recipients and private insurance for those with insurance.
• Portable dental equipment and supplies bought by CHD through the rural health network and will remain the property of CHD at conclusion of project.
• Children identified as needing treatment were transported to Miami Children’s as a group.

• Florida Panhandle Project
• Cooperative efforts of a Rural Health Network, five CHDs, Head Start, and the county school boards.
• Will be using a mobile unit – expect delivery in late January 2002.
• Rural Health Network bought the mobile unit via a grant.
• The five CHDs have a contract among themselves with one CHD being the lead for administrative and billing purposes. Their inter-CHD contract deals with manpower, monetary, and administrative issues.
• Hiring two dentists, who will rotate between the mobile unit and a land-based dental clinic at one of the CHDs.
• Plan to serve pre-school through third grade low income children in the five county area. Are to provide exams, x-rays, sealants and minor treatments on the mobile unit.
• Involved community dental practitioners from the beginning – have agreements with local practitioners for referral of children for treatment that cannot be performed on the van.

Summary provided by:
Millard Howard, DDS
Dental Program Manager
Florida Medicaid
Phone: 850-922-7328
Fax: 850-922-7303
howardm@fdhc.state.fl.us