WHO PAYS FOR THE MYSMILEBUDDY PROGRAM and HOW?

Licensees can deliver preventive dental services to families using the MySmileBuddy Program:

1. at their own cost

2. through reimbursement by Medicaid/CHIP

3. through reimbursement by private insurance

4. through third party grant or program funding.

How the MySmileBuddy Program is financed will vary by the type of organization that utilizes the Program. However, most organizations described below would benefit from having Medicaid pay providers for preventive services using the MySmileBuddy Program. For this reason, we have detailed a number of options and opportunities available to Medicaid to pay for licensees of the MySmileBuddy Program.

Public insurance

Both Medicaid and the Children’s Health Insurance Program (CHIP) are required by law to pay for comprehensive dental services provided to beneficiaries under age 21 years. Medicaid provides child beneficiaries with a unique health benefit called EPSDT (Early and Periodic Screening, Diagnostic, and Treatment services) that requires states to provide access to any amount of any service that is “medically necessary” for children whether or not the state’s Medicaid program covers that service. CHIP provides coverage for any dental services “necessary to prevent disease and promote oral health” as well as to “restore oral structures to health and function and treat emergency conditions.” States have multiple options (described below) to pay CHWs to deliver preventive services in home and community sites including paying CHWs to act as MySmileBuddy Program Coachers.

Private insurance

Like public insurers that administer state insurance programs, private insurers that administer employer-sponsored-insurance plans (ESI) have multiple options for paying for preventive services using the MySmileBuddy Program. Unlike public insurers, however, private insurers have more autonomy and opportunity to experiment locally, regionally, statewide or nationally in paying coaches to deliver the Program or to put the MySmileBuddy App directly into the hands of beneficiaries.

Health Departments

Local and state health departments can utilize the MySmileBuddy Program as a community-based public health intervention to advance oral health equity and to improve population oral health by targeted child populations at highest risk for tooth decay. At their own expense, dental public health departments can license the MySmileBuddy Program and engage community health workers (their own or CHWs employed by community-based organizations/CBOs) to deliver the Program. Alternatively, in many states services delivered by Health Department-employed CHWs can be reimbursed by Medicaid. Health Departments can also secure grants or partner with private funders (like dental insurers) to fund CHWs to counsel families using the MySmileBuddy Program.

Federally Qualified Health Centers (FQHCs) and “Look-Alike” Health Centers

These health centers provide a wide range of health services to low-income and socially disadvantaged populations including children at highest risk for tooth decay. By federal law, they must provide at least limited preventive dental services but may provide more comprehensive dental care (as do 82% of FQHCs). Required dental services for all patients that the MySmileBuddy Program supports are “recommendations for preventive intervention” and
“oral hygiene instruction and related oral health education.” Many federally qualified health centers employ health educators, care coordinators, medical social workers, nutritionists and other health counselors who can utilize the MySmileBuddy Program with families of children identified to be experiencing dental problems. The Prospective Payment System that funds these health centers provides a single negotiated per-visit payment for all qualified services delivered during a visit including preventive dental counseling using the MySmileBuddy Program.  FQHCs can also pursue the option of “alternative payment methodologies” as long as such “APMs” reimburse at least as much as the PPS system would allow.

School Based Health Centers (SBHCs)

Whether or not SBHCs provide clinical dental services (18% do), they can utilize the MySmileBuddy Program to counsel families on the prevention, home-management, and ultimate suppression of tooth decay in their children – either by having parents use the MySmileBuddy App on their own or by matching parents with CHWs as MySmileBuddy Coaches. According to the Government Accountability Office (GAO), principal sources of financing for SBHCs “are state, local, and private funds” as well as some federal program funds. Such core funding can be utilized to license the MySmileBuddy Program. 

Dental Service Organizations/Dental Management Organizations (DSOs/DMOs)

Both types of organizations provide business and administrative support services for dental practices but not clinical services per se. Under DSO arrangements, dentists typically retain practice ownership while selling their practices to DMOs. DMOs secure large numbers of dental offices either by purchasing multiple practices (aggregation model) or by growing large multi-site practices (expansion model). Both types of organizations can provide shared resources (e.g. marketing, billing, and human resources), management support (e.g. hiring and training staff), marketing support, and access to capital for improvements and expansions. These organizations can also help individual practices (members) distinguish themselves from other dental practices for market advantage through marketing and branding and through provision of unique services. The American Dental Association Health Policy Institute reports steady growth of DMO/DSO-affiliated practices reaching 13% of US dentists in 2023. DSOs and DMOs can license the MySmileBuddy Program and distribute it to their member practices at their own expense as part of their marketing and practice support functions. 

Community Based Organizations (CBOs)

CBOs provide a range of educational, social, and health services and “are [typically] supported by a patchwork of grants, donations, and government contracts that rarely cover actual program costs, and often operate on a short-term basis.” CBOs can direct these various funding sources to sponsor MySmileBuddy Program licenses and integrate oral health counseling into their existing service programs. Alternatively, they can bill Medicaid in states that have made such payments possible under one of the above-listed authorities.

Early Childhood Support Program

Multiple programs that support early childhood development, education, and health including Head Start/Early Head Start, WIC, MIECHV, and preschool education programs typically target families of young children at high risk for tooth decay. Like CBOs, these programs can use their own funds, grants, contracts, and donations and, where possible, can bill Medicaid for oral health preventive services.

Philanthropic Grant Makers

Non-profit grant makers committed to prevention, oral health equity, population oral health, medical-dental integration, and dental workforce expansions can sponsor use of the MySmileBuddy Program by Health Departments, FQHCs, SBHCs, DMOs/DSOs, and Early Childhood Support Programs. They may elect to do so either by creating a specific grant program or strategic initiative that targets children’s oral health or by honoring requests for funding from these organizations.  In 2019, Grant Makers in Health and the Funders Oral Health Policy Group developed “a framework to fund oral health programming or support oral health efforts in their primary areas of influence” that placed oral health in the “larger context of health equity” and “community-centered strategies.”

Parents

The MySmileBuddy App is available as a freestanding parent version (uncoached) that is available for purchase on web.