Seal America, The Prevention Invention
Seal America, The Prevention Invention

Step 5
Funding

To operate effectively, school-based dental sealant programs need adequate funding. Programs must capture reimbursements whenever possible and must also secure external funding. The school-based dental sealant program director needs to determine whether the program can be reimbursed for certain services and to create an infrastructure to document, bill, and reconcile billings.

To ensure that funding can be secured and reimbursements maximized, school-based dental sealant programs should start small and expand over time. As programs become more efficient and established, funders are more likely to invest generously.

Obtaining Initial Funding

Preparing to Secure Funding

Although it may seem reasonable to determine whether funds are available to set up and support a school-based dental sealant program before embarking on the process of planning a program, in most instances this is not possible. Rather, program administrators must be far enough along in the planning process to demonstrate to potential funders the feasibility and value of the program. The keys to acquiring funding are as follows:

  • Stating a problem or demonstrating a need convincingly (e.g., demonstrating untreated tooth decay among children from families with low incomes, demonstrating lack of access to care, using data to support statements).
  • Explaining how a proposed solution will reduce disparities and meet Healthy People 2020 objectives and MCHB performance measures.
  • Providing measurable objectives (e.g., how many students will benefit from dental sealants in this program in a given year) to monitor and demonstrate the program’s impact.
  • Presenting a business plan that demonstrates an understanding of the expenses and revenues associated with the school-based dental sealant program and communicates to potential funders that the program will be sustainable. (e.g., providing a previous track record or a budget plan to sustain the program).
  • Providing realistic capital and operating budgets (e.g., the cost of equipment, supplies, and staff) with supporting narrative.
  • Supplying evidence of support for the program from key members of the community (e.g., letters from the dental society, school administrators, the teacher's association, child-advocacy groups).

Before seeking funding, therefore, program administrators must

However, while planning a program, it is useful to make informal contacts with representatives of potential funders to gauge their interest. These representatives may help school-based dental sealant program administrators focus on an aspect of the program that is in line with a particular funder’s mission. For example, one foundation might be interested in prevention and would provide funds for dental sealants, while another may be more interested in funding the referral and follow-up component of the program.

MCH Block Grant Funding

Funding for State Health Departments. Some state and local school-based dental sealant programs have received funding through the federal MCH Block Grant awarded to state health departments. As part of the MCHB Block Grant application, every 5 years states are required to conduct a statewide needs assessment that includes an oral health needs assessment as a required component. State health department personnel interested in acquiring funds to support school-based dental sealant programs should offer to help with the department’s oral health needs assessment and MCH Block Grant application to help ensure that funds for dental sealant programs are incorporated in the application. For assistance in preparing needs assessments, see Step 1, Designing the Program in Assessing Oral Health Needs: ASTDD Seven-Step Model, rev ed.

Funding for County and Local Health Department and Nonprofit Agencies. Staff of county and local health departments and nonprofit agencies interested in acquiring funds to operate or support school-based dental sealant programs should contact the oral health director in their state health department to determine whether public funds are available for school-based dental sealant programs and to request assistance in identifying and acquiring those funds. Where there is no state oral health director, staff should contact the MCH director at the state health department and offer to help prepare the oral health needs assessment. This may place the health department or agency in an advantageous position to acquire a portion of the state’s MCH Block Grant award to fund a school-based dental sealant program. If dental sealants are not a component of a state MCH program, the local or county health department or nonprofit agency should urge state officials to include dental sealants in the program in the future. A helpful document is Strategies to Improve Health by Integrating Oral Health and Maternal and Child Health Programs.

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Other Funding Options

Funding from Nonprofit Agencies. In addition to securing funds from MCH Block Grants, there are other options for obtaining funding. Nonprofit agencies in the community, such as United Way, may be willing to provide staff or funding to start a school-based dental sealant program.

Funding from City Councils, Companies, Service Groups, or Foundations. If a school-based dental sealant program has the active support of community groups, county commissioners might be convinced that the project is worthy of financial support. Local companies, Rotary Clubs, Kiwanis, and other service groups may be willing to provide funding. Directories of foundations can be found in public libraries and on the websites of professional organizations (e.g., the National Association of County and City Health Officials).

Figure 5.1. Foundation Directories Can Help Guide a Search for Funding. Courtesy of the Cincinnati Department of Health.

Characteristics of Successful Grant Applications. Every grant application is different. Some funders may ask for a 3-page proposal and budget, while others may request a detailed 25-page proposal with a problem statement, program description, evaluation, budget, and budget justification. In preparing grant applications, it is essential that the directions concerning length and content be followed exactly. Successful applications are clearly written, well organized, and grammatically correct and include measurable objectives. It is important to present a viable business plan. It may be useful to have a person familiar with grantwriting but unfamiliar with dental sealants read the proposal before it is submitted to make sure it clearly communicates the need, the methodology, and the measurable outcomes of a school-based dental sealant program. For assistance in preparing successful grant applications, see the Foundation Center's free Proposal Writing Short Course. Existing school-based dental sealant programs may be able to provide examples of grant applications that have received funding.

Funding from Multiple Sources. All program dollars do not have to come from one source. Some funders may not be able to support a program entirely but may be willing to provide partial funding. In one city, for example, a local United Way agency funds two dental hygienists for a school-based dental sealant program, and the local health department funds the dental assistants, the supplies and equipment, and the program administrator. While the school-based dental sealant program is consistent with the mission of both the United Way agency and the local health department, neither could have funded the entire program alone.

Sustaining Funding

Once a school-based dental sealant program has obtained initial funding, a regular source of income is needed for operations to continue. Historically, school-based dental sealant programs have received a substantial proportion of funding from program-generated revenue through collections from Medicaid, CHIP, and Medicaid managed care. Some dental sealant programs have received ongoing funding from the school district in which they operate.

Funding from Medicaid and Insurance Companies

School-based dental sealant program administrators need to learn how Medicaid operates in their state to maximize reimbursements. Medicaid reimbursement policies (e.g., replacement dental sealants, teeth eligible for sealing, billing cycles, follow-up assessments) vary from state to state.

Currently, almost all states provide Medicaid reimbursement for dental sealants on a fee-for-service basis to practices and programs with a valid National Provider Identifier. School-based dental sealant program administrators should become familiar with the Medicaid billing process to determine whether the agency providing the dental sealants can bill Medicaid. Program administrators should determine the number of students eligible for Medicaid in the service area to estimate Medicaid revenues and allow for accurate budgeting. To receive adequate and timely reimbursement, school-based dental sealant programs need a competent staff member to oversee billing and collections.

The actual method of billing Medicaid and other insurance companies for reimbursement varies by state and by insurance company. The staff member responsible for billing and collections needs to work closely with the various payors to learn how to maximize collections. He or she also needs to work closely with the dental hygienist and dental assistant and must educate them about the necessity of adhering to state regulations and about the importance of timely and accurate documentation of dental sealants provided.

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Collecting Identification Information for Billing Purposes

Collecting accurate student-identification information is critical to successful billing and collections. Most insurance companies, including Medicaid and CHIP, have assigned an identification number to each participant. Previously this number may have been the person’s social security number, but now it is usually a random identification number. Some programs have had success in collecting Medicaid identification numbers by putting a blank sample Medicaid card on the consent form. Parents then copy their child’s identification number from their Medicaid card onto the consent form. Programs have also used logos from managed care organizations (MCOs) on the consent forms so parents can more easily identify the company that matches their card and can provide accurate identification numbers. Many state Medicaid programs and private MCOs also have web-based programs that can be used to verify Medicaid eligibility. While checking students’ eligibility for Medicaid is time consuming, it can greatly increase program revenue.

Billing for Uninsured Students
Medicaid regulations prohibit programs from billing Medicaid for services if the programs do not bill other insurance plans, However, it is permissible for programs receiving Title V funds and that qualify as Medicaid providers to bill Medicaid and not seek reimbursement for services for students who are not eligible for Medicaid and are uninsured.1

Funding for Outreach
Some school-based dental sealant programs have sought reimbursement for outreach activities using administrative matching funds under Medicaid. There are specific guidelines for the use of these funds.

The Centers for Medicare and Medicaid Services (CMS) has developed the Medicaid School-Based Administrative Claiming Guide2 to inform schools, state Medicaid agencies, and other interested parties about appropriate methods for claiming reimbursement for the costs of Medicaid administrative activities performed in the school setting. Programs not operated by government agencies are not eligible for Medicaid reimbursement.

Administrative activities that are eligible for reimbursement (also known as allowable activities) are categorized by function. Those that pertain to school-based dental sealant programs are

  • Medicaid outreach and public awareness. Activities that inform individuals who are or may be eligible about Medicaid and how to access services.
  • Facilitating Medicaid eligibility determination. Activities that assist individuals in the Medicaid-eligibility-determination process. This does not include actual determination of individual’s eligibility for Medicaid.
  • Program planning, policy development, and interagency coordination related to medical services. Activities for the collaborative development of programs with other agencies that ensure the delivery of Medicaid-covered medical, dental, and mental health services to Medicaid beneficiaries.
  • Referral, coordination, and monitoring of Medicaid services. Activities for developing appropriate referral sources for program-specific services at local health departments and for monitoring the delivery of Medicaid services within local health departments. These activities are also used for coordinating programs and services at local health departments.
  • Medicaid-specific training on outreach eligibility and services. Activities for coordinating, conducting, or participating in training events and seminars for staff who provide outreach services related to the benefits of the Medicaid program, including how to assist families in accessing Medicaid services and how to more effectively refer individuals for services.
  • Arranging for Medicaid-related transportation. Activities for assisting individuals in obtaining transportation for Medicaid-covered services.
  • Arranging for provision of Medicaid-related translation services. Activities for arranging or providing translation services or developing translation materials that assist individuals with accessing and understanding necessary care or treatment covered by Medicaid.

CMS’s guide provides more detail about each of these categories. It is strongly recommended that school-based dental sealant program staff seek assistance from the state Medicaid agency before proceeding with any of the methods for claiming reimbursements that are discussed in the guide.

State Medicaid Programs Converted to Managed Care

A number of states have converted Medicaid programs to a managed care format. Under such models, state Medicaid programs contract with private MCOs to provide oral health services. The MCOs in turn contract with individuals or agencies to provide oral health care. Some of these MCOs reimburse oral health professionals on a capitation basis, and others pay fee-for-service.

In instances where fee-for-service reimbursement is an option under a Medicaid managed care plan, the school-based dental sealant program should consider participating with as many MCOs in a service area as possible. If reimbursement by MCOs is capitated, school-based dental sealant programs may not be eligible for Medicaid reimbursement. School-based dental sealant program administrators might consider approaching state Medicaid programs directly to contract for the provision of dental sealants on a fee-for-service basis.

Funding from School Districts

If a school-based dental sealant program is a joint partnership with the local health agency, then the school district may be willing to provide funding to sustain the program. Engaging in discussions with the school district finance department and the school board may help with developing a budget line-item for needs assessment or staffing.

References

  1. Centers for Medicare and Medicaid Services. 2005. Early and Periodic Screening, Diagnosis, and Treatment of Individuals Under the Age 21—Section 5000. In State Medicaid Manual. Baltimore, MD: Centers for Medicare and Medicaid Services. http://www.cms.hhs.gov/Manuals/PBM/itemdetail.asp?filterType=none&filter
    ByDID=- 99&sortByDID=1&sortOrder=ascending&itemID=CMS021927
    .
  2. Centers for Medicare and Medicaid Services. 2003. Medicaid School-Based Administrative Claiming Guide. Baltimore, MD: Centers for Medicare and Medicaid Services. http://www.cms.hhs.gov/MedicaidBudgetExpendSystem/Downloads/
    Schoolhealthsvcs.pdf
    .

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