Table 1.

Conceptual framework used to assess conformity of state Medicaid dental provider documents with CMS guidance on the provision of and payment for medically necessary dental services for children and adolescents as required by the EPSDT benefit

CMS May 2018 Informational Bulletin directive a	State document data source	Measure
Specify the periodicity schedule with which preventive and medically necessary restorative services would be provided.	Periodicity schedule	What is the state’s specified periodicity schedule, if any? What is the quality of the periodicity schedule’s statement on flexibility?
Have a mechanism in place to cover medically necessary dental services that exceed the periodicity schedule, recognizing the periodicity schedule as a floor for coverage of dental services rather than a ceiling.	Dental provider manual	Does the dental provider’s manual contain a general statement on flexibility of benefit limits and frequencies? Is there a mechanism described for covered services that are medically necessary?
Ensure that fee schedules and payment policies are aligned with periodicity schedules.	Fee schedule	Does the fee schedule contain a general statement on the flexibility of benefit limits and frequencies? Does the fee schedule allow for payment of each covered service at the same frequencies as are specified in the periodicity schedule?

Abbreviations: CMS, Centers for Medicare & Medicaid Services; EPSDT, Early and Periodic Screening, Diagnostic and Treatment.

^aData source: CMS Informational Bulletin. ¹⁶