Improving access to oral health care is important for Indigenous populations who face stark inequities in care and outcomes. The United States Government has a legal obligation to provide American Indian and Alaska Native tribes (AI/AN) health care services due to historical policy decisions that limited tribes’ access to resources including health care. In 2021, Oklahoma made significant changes to its Medicaid program including expanding coverage for low-income adults and adding an adult dental benefit. Oklahoma is also likely to transition their Medicaid program from fee-for-service to managed care. These actions, in coordination with a tribal consultation process, have the potential to increase access to oral health care for AI/AN people in the state.
A 2021 report by the U.S. Department of Health and Human Services, Oral Health In America: Advances and Challenges, explains that AI/AN populations face the following barriers to accessing dental care:
- Geographic isolation
- Chronic shortage of dentists within the Indian Health Service (IHS), which creates difficulties in accessing routine and preventive dental care, and
- Underfunding of oral health care services provided through the IHS, resulting in a need to concentrate on providing basic emergency care services.
Indeed, almost half of AI/AN children have untreated dental caries compared to just 17 percent of the general U.S. population in this age group. AI/AN adults also have twice the prevalence of untreated dental caries when compared to the general U.S. population, and are more likely to have severe periodontal disease, missing teeth and oral pain. Additionally, according to 2019 Census data, the AI/AN population continues to have the highest uninsured rate compared to other populations.
This is a part of a series on engagement of tribes in state Medicaid oral health policy. To learn about Arizona’s work, read the other case study.
What is the IHS and How are Services Reimbursed?
- IHS is a health care delivery system that serves 2.6 million AI/AN individuals who belong to 574 federally recognized tribes in 37 states, regardless of insurance status.
- IHS services are delivered through a system of federally run, tribally run, and Urban Indian health programs. Tribes administer Tribal Contract or Compact Health Centers (also known as Tribal 638 Facilities), and the IHS directly administers the remaining programs that tribes have chosen not to run.
- IHS providers are authorized to bill third-party payers and collect reimbursements from third-party payers, including Medicaid (by the Indian Health Care Improvement Act, made permanent by the ACA).
- State expenditures for eligible Medicaid-covered services provided to AI/AN Medicaid beneficiaries by IHS federal or tribally run facilities can be reimbursed at a rate of 100 percent Federal Medical Assistance Percentage (FMAP).
- The American Rescue Plan Act (ARPA) temporarily authorized a 100 percent FMAP for eight fiscal quarters beginning April 1, 2021, for Medicaid services provided by Urban Indian Organizations that have grants or contracts with IHS.
Oral Health Care Access for Tribes in Oklahoma
There are 38 federally recognized tribes in Oklahoma, and AI/AN populations comprise about 9.4 percent of the state’s population. Oklahoma has the second largest AI/AN population in the United States. Data from the IHS Oklahoma City Area (OKC) shows AI/ANs who utilize IHS and tribal health systems received fewer services and had poorer oral health compared to the nation overall as shown in Table 1.
| Table 1: Oral Health Statistics in the IHS Oklahoma City Area (OKC Area) | ||
| OKC Area | Nationwide | |
| Patients receiving dental services in the last 12 months | 31% | 43% |
| Children aged 1-5 years with untreated decay | 18% | 12% |
| Adults ages 35+ with untreated decay | 59% | 27% |
| Source: Oral Health Among Indian Health Service Oklahoma City Area. Native Oral Health Network, 2020. | ||
In Oklahoma, there are more than 50 Indian Health Facilities that include facilities operated by IHS, tribes and urban Indian clinics. The Oklahoma City Area Dental Support Center also provides support, training, and consultation to all dental programs in the IHS Oklahoma City Service Area.
In January 2022, over 200,000 AI/AN people were enrolled in Oklahoma’s Medicaid program, comprising 17 percent of all enrollees. Most Medicaid members (58 percent) are children under age 19. Children enrolled in Medicaid in Oklahoma receive preventive and restorative dental services as part of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. Prior to 2021, Oklahoma’s adult dental benefit covered medically necessary extractions only.
In 2021, the Governor signed Senate Bill 1046, which required the Oklahoma Health Care Authority (OHCA) to expand the Medicaid adult dental benefit to include examinations, x-rays, dental cleanings, fluoride, dental fillings, scaling, root planning and dentures. The legislature also appropriated $16.7 million for the expanded adult dental benefit. The state developed and submitted a state plan amendment (SPA) to expand adult dental services beginning July 1, 2021.
Medicaid Managed Care
In addition to adding a dental benefit, Oklahoma Medicaid is planning to transition to managed care. OHCA formed a state/tribal workgroup that included partners from each of the IHS, tribal and urban providers. The workgroup met three times over the period of a year. As a result, the managed care request for proposals (RFP) includes an entire section dedicated to special considerations for AI/ANs and tribal providers.
In June 2021, the Oklahoma Supreme Court ruled Gov. Stitt and the Oklahoma Health Care Authority did not have authority to move forward with transitioning to managed care without the approval of the legislature. In May 2022, SB 1337 was signed into law, directing the Oklahoma Health Care Authority to transition into a managed care delivery system.
AI/AN individuals will have the option to enroll in SoonerSelect, the state’s managed care program, as states cannot mandate enrollment in managed care for AI/AN. Additionally, IHS/tribal facilities may contract with non-IHS/tribal providers to provide services reimbursable by managed care organizations (MCOs). As shown in Figure 1, AI/AN members who enroll in managed care can receive services from both Indian health care providers (IHCP) and non-ICHP facilities covered at 100 percent FMAP through OHCA. A transition to Medicaid managed care has the potential to significantly increase revenue for services already provided by IHCPs and expand clinical capacity for services.
Oklahoma Medicaid’s Tribal Consultation Policy
Oklahoma maintains ongoing communication with tribes on all health policies. Section 5006 of the American Recovery and Reinvestment Act of 2009 (ARRA) requires states with one or more Indian health programs or urban Indian organizations that provide health care services to establish a process for the state Medicaid agency to seek advice on a regular basis from IHS, tribally operated, and urban programs. States must submit this process as a SPA for approval by the Centers for Medicare and Medicaid Services (CMS). HHS and CMS also have tribal relation policies.
In Oklahoma, both OHCA and the Department of Health engage in tribal consultation. The Office of the Tribal Liaison within the Department of Health was created in 2012 and worked with Oklahoma Medicaid and tribes to communicate changes in health care access with the implementation of the Affordable Care Act.
According to the OHCA’s policy, consultation with sovereign tribal governments will occur prior to any action that will significantly affect sovereign tribal governments. The tribal consultation process includes:
- Identification of the issue(s) that have or may have a substantial impact on tribal governments and/or members
- Determination of the affected/potentially affected tribal governments, populations, health providers, etc.
- Determination of the most appropriate type of consultation, e.g., written communication or meetings
- Notice to the affected/potentially affected tribal governments about the issue and the consultation process using methods such as mailing, broadcast e-mail, and the Oklahoma Register
- Provision of clear instructions from OHCA on the comment submission process and
- Reporting to the affected tribal government(s) about the outcomes and whether the intended results were achieved based on the issue and the extent of consultation.
OHCA went through the tribal consultation process for revising child dental benefits and adding an adult dental benefit in 2021. OHCA releases annual reports on its tribal consultation. The 2021 tribal consultation summary includes:
- Dental revisions. Adds scaling as a new procedure, requires caries risk assessment documentation for prior authorization for crowns and clarifies billing language for administering nitrous oxide.
- Dental services for adults. Adds dental examinations, x-rays, dental cleanings, fluoride, dental fillings, scaling, root planning and dentures for Medicaid adult members.
Conclusion
As a result of historical imbalances, deep inequities exist in oral health care access for AI/AN populations. The IHS also continues to be underfunded with a limited workforce to meet the needs of AI/AN individuals. In fiscal year (FY) 2019, IHS’ per capita expenditure was $4,078 compared to $9,726 for health care spending nationally. Recently, President Biden’s proposed FY2023 budget includes a full mandatory HIS budget for the first time.
In the United States, tribes are sovereign nations, but their members have access to public benefits including Medicaid, and it is critical to include AI/AN communities in health policy decision-making processes. Oklahoma’s recent expansion of Medicaid coverage to low-income adults and addition of adult dental services have the potential to improve access to care for AI/AN populations in the state. OHCA’s well-established tribal consultation policy provides a pathway for meaningful input from tribal nations on Medicaid policy.
Note on language: While the terms “American Indian or Alaska Native”, “tribal populations”, and “Indigenous populations” are used here to describe people with different tribal affiliations, there are limitations to using this terminology interchangeably. When referring to a specific tribe, it is best practice to use their preferred term. This publication uses the term American Indian and Alaska Native (AI/AN), but the author recognizes members may prefer different terms.
Federally Recognized Tribes in Oklahoma
- Absentee-Shawnee Tribe of Indians
- Alabama-Quassarte Tribal Town
- Apache Tribe of Oklahoma
- Caddo Nation of Oklahoma
- Cherokee Nation
- Cheyenne and Arapaho Tribes
- Citizen Potawatomi Nation
- Comanche Nation
- Delaware Nation
- Delaware Tribe of Indians
- Eastern Shawnee Tribe of Oklahoma
- Fort Sill Apache Tribe of Oklahoma
- Iowa Tribe of Oklahoma
- Kaw Nation
- Kialegee Tribal Town
- Kickapoo Tribe of Oklahoma
- Kiowa Indian Tribe of Oklahoma
- Miami Tribe of Oklahoma
- Modoc Tribe of Oklahoma
- Muscogee (Creek) Nation
- Ottawa Tribe of Oklahoma
- Otoe-Missouria Tribe of Indians
- Pawnee Nation of Oklahoma
- Peoria Tribe of Indians of Oklahoma
- Ponca Tribe of Indians of Oklahoma
- Quapaw Tribe of Indians
- Sac & Fox Nation
- Seminole Nation of Oklahoma
- Seneca-Cayuga Nation
- Shawnee Tribe
- The Chickasaw Nation
- The Choctaw Nation of Oklahoma
- The Osage Nation
- Thlopthlocco Tribal Town
- Tonkawa Tribe of Indians of Oklahoma
- United Keetoowah Band of Cherokee Indians in Oklahoma
- Wichita and Affiliated Tribes (Wichita, Keechi, Waco and Tawakonie)
- Wyandotte Nation
Acknowledgements
The authors thank the Oklahoma officials who provided information and feedback for this publication. Additionally, we thank Hemi Tewarson, Carrie Hanlon and the Health Resources and Services Administration officials who provided thoughtful input. This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services under grant number U2MOA394670100, National Organizations of State and Local Officials. This information, content, or conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the US government.
