Frequently Asked
Questions

A: A FQHC Look-alike is an organization that meets all of the eligibility requirements to receive a PHS Section 330 grant, but does not receive grant funding.

Q: Are Health Center dental providers licensed?

A: Yes. Health Center dental providers must meet the criteria for licensure in the state where the Health Center is located.

Q: Are there location requirements for Health Centers?

A: It depends. Each Health Center that receives PHS 330 grant funding must meet the requirements of that grant. Health Centers must serve a Medically Underserved Area (MUA) or Medically Underserved Population (MUP). To determine if your area qualifies, you can search the MUA/MUP database at http://bhpr.hrsa.gov/shortage/muaguide.htm. Migrant Health Centers, Health Care for the Homeless and Public Housing Primary Care Programs do not need to meet the MUA/MUP restriction. Health Centers maybe located in both rural and urban areas.

Q: Is a sliding fee scale discount required?

A: Yes, Health Centers must use a sliding fee scale for all services included in their scope of project for patients between 100%-200% of the Federal Poverty Level (FPL). A sliding fee discount cannot be applied to anyone above 200% of the FPL or below 100% of the FPL. The sliding fee scale includes discounts based on patient family size and income in accordance with federal poverty guidelines. Health Centers must be open to all, regardless of their ability to pay. If you provide services outside of your scope of project, you must bill separately, but are not required to slide the fee.

Q: Are Health Centers “free clinics?”

A: No. Health Centers do not provide free care to patients. Health Centers are required to serve all people regardless of their ability to pay. When a patient falls below 100% of the poverty guidelines, a nominal fee or no fee is charged. Most Health Centers have a nominal payment that is expected from the patient, regardless of the percentage of sliding fee discount for which one qualifies. If a patient cannot afford to pay even the nominal fee, the Health Center may not refuse to provide services.

Q: What should the reporting structure be at my Health Center?

A:  NNOHA recommends that Dental Directors report directly to the Executive Director.

Q: How much time should Dental Directors spend on administrative vs. clinical duties?

A: There are many variables that may add to or take from administrative time or clerical duties, because some corporate administrators take more or less of this burden. A rule of thumb is that most programs with four to seven professional providers require at least one fifth of the Dental Director’s time for administrative duties.  A business manager and a lead dental assistant can handle many of the clerical duties, such as scheduling staff, ordering supplies, payroll, monitoring time off, running production and producing other reports.  If the Dental Director has to do any of these functions, it adds to the needed administrative time. 

Q: How involved should I be in the budget?

A: The Dental Director is ultimately responsible for preparing and advocating for the dental budget.  The CFO, HR department and staff can greatly contribute, but the Dental Director must understand the budget and provide the direction.  CFOs know far more accounting methods and can guide you, but they are not dentists; the Dental Director has the best vantage point to understand the department’s needs.

NNOHA strongly recommends that the Dental Director be at the table when corporate budget decisions are made. If the Dental Director cannot create the budget, he or she needs to be very familiar with it, as this is one of many tools needed to run the program effectively. NNOHA recommends that Dental Directors review Chapter 3, Financials, at http://tinyurl.com/OMHCOHP.

Q: Does a Health Center’s fee schedule and sliding fee scale for dental services have to be the same as that used for medical services?

A: No.

Q: Can a Health Center implement a different nominal fee for dental services from that charged for medical services?

A: Yes. The Health Center management team, in conjunction with the Health Center’s Board of Directors, can determine what nominal fee makes the most sense for each department (e.g., medical, dental, behavioral health).

Q: Should some portion of a Health Center’s Federal (Section 330) grant be allocated to dental services?

A: Yes.  330 funds are not provided for “medical” or “dental.”  They are provided to support the provision of all services rendered within the Health Center’s scope of project to underserved clients who are at or below 200 percent of the federal poverty level.  The funds are to be used to supplement the nominal fee charged to patients at or below 100 percent of poverty, and the schedule of discounts charged to patients between 101 - 200 percent of poverty.

Q: If my Health Center doesn’t receive any 330 funds targeted for dental services, can’t we do whatever we want in regards to services?

A: No. It is not uncommon to think that because a center does not have 330 funds targeted to dental that they don’t have to abide by scope of project & scope of practice regulations; however, 330 funds are supporting the entire Health Center, regardless of whether a portion of the funds were awarded to target specific services.

Q: What are the average and starting salaries of staff dentists, dental hygienists and Dental Directors at Health Centers?

A: Based upon surveys done in 2009 by NNOHA in partnership with Texas A&M’s Baylor College of Dentistry, the average salaries for staff dentists are $110K-$125K. The average salaries for hygienists are $50K-$60K. More information on adequate salary and benefits will be included in the subsequent Workforce & Staffing chapter of this manual.

Q: Are dental hygienists financially viable providers?

A: Dental hygienists are an integral part of the oral health team, and for the purposes of this chapter, we examine only the financial aspects.  Historically, dental hygiene programs have been net revenue producers: the revenue they generated exceeded the costs of running the program.  And if nothing else, these programs precluded having to use a dentist’s time to do work a dental hygienist could perform at a lower cost.  What has changed, and continues to change, is what dental hygienists are legally allowed to do.  Health Center dental hygienists should work to the full scope of practice allowed in their particular state. Note that dental hygienists are reimbursed differently by Medicaid in different states: http://www.adha.org/governmental_affairs/downloads/medicaid.pdf

Q: How do you establish starting salaries?

A: Reasonable salaries are determined by several factors. “It is important to know the market in which you are competing for staff, and to determine what you can afford to pay and sustain relative to the market. Higher compensation generally will attract more experienced people who may be more productive.”[1] To get some ideas, you may check regional salary surveys (http://www.dentalclinicmanual.com/chapt3/section_01/topic_16/wages.html). In addition to experience, you have to account for benefits you are including in the package. It should be noted that salaries could be about 60-70 % of your overall budget.  

Q: How do I set up a schedule of discounts?

A: First, make sure the overall fee schedule is consistent with locally prevailing rates and covers the reasonable costs of operation.  e.g.: Do not charge $60 per extraction as a full fee when the market rate is $125.  Then, set the sliding fee scale for patients with annual incomes between 101-200% of the federal poverty level appropriately, such as 25 percent of a $125 fee, instead of 50 percent of a $60 fee.  This way you won’t devalue the services provided, and if someone has insurance, you will collect the actual charge of providing care. Set a nominal fee that does not create a barrier to care for patients with incomes at or below 100% of the federal poverty level. Update your fee schedule, sliding fee scale, and nominal fee annually.

Q: Can you limit your program for Medicaid-only patients?

A: No. Health Center programs may not limit access to their services based on ability to pay, financial status, or payor source. Health Centers may give priorities to populations of focus such as pregnant women or children, which in turn could affect payor mix, but only if the Health Center needs assessment clearly demonstrates a need for these populations.

Q: Can I get paid on a fee-for-service basis for Medicaid dental services? 

A: Each state has different nuances in dealing with the PPS rate.  Contacting your State Medicaid Office is the best way to get your answer. Find a list of state contacts at http://www.medicaiddental.org/index.html.

Q: How do I provide service to everyone without regard for payment and still be able to operate my program?

A: Not all programs can have the "ideal" patient mix and must maintain a close eye on their bottom line.  Each program needs to analyze their sources of revenue and develop strategies to maximize collections from all sources. Although Health Centers are not permitted to deny services based on a patient's inability to pay, no one states that the need for payment should be totally disregarded.  If a program does not generate and collect sufficient revenue, it may cease to be sustainable.  No margin...no mission! Patients should be encouraged to pay what they can at the time of service and efforts should be taken to collect the balance.  Remember, the chances of collecting the fees generated by your providers diminish significantly once the patient has left your office, and selecting the right individuals for collecting this payment is crucial.  More information is included in the section of this chapter entitled "The Balancing Act."

Q: Do Health Center oral health programs create unfair competition with private practice?

A: Health Center oral health programs may indeed be “in competition” with private practice dentists in some cases. As in real estate, location is everything. In a rural area, the Health Center oral health program may be the only dental provider in the area and there is no competition. In other locations, the Health Center may be the only dental provider in the area that accepts government sponsored insurance plans, such as Medicaid.  Again, there may be little to no competition for patients covered by those particular plans.

Certainly, in some areas where private practice providers accept government sponsored insurance plans, there may be competition between private practices and Health Centers. In those instances, private practices and Health Centers compete for patients based on traditional criteria, such as accessibility, office appearance, staff friendliness and perceived quality of care.

Generally, Health Center oral health programs are not in competition with private practice for indigent patients.  As mentioned previously, 200 percent of the 2009 federal poverty level is an annual income of $21,660 for an individual. Individual indigent patients with incomes of $21,660 a year or less will most likely not be able to afford full-fee dental care and will most likely not be covered for dental services by commercial health insurance.

Q: Do Health Center oral health programs have an unfair advantage because “they are funded by the government?”

A: The idea that clinics somehow have an unfair advantage because “they are funded by the government” is not true.  As has been seen, the amount of a Health Center’s total 330 grant allocated to the oral health program covers only a portion of total expenses.  

Section 330 grants are intended to support costs of care provided to low-income and indigent patients, typically defined as at or below 200% of the federal poverty level.  Therefore, as stated above, Section 330 grant funds are not helping Health Centers compete for patients seen by private practices—insured patients and self-pay patients with resources.

Health Centers may also serve as a referral base to private practice.  NNOHA encourages private practice providers to serve Medicaid and uninsured patients and encourages its members to partner with their private practice counterparts to benefit the health of their communities.

Q: If a new patient who is pregnant comes into the clinic and refuses x-rays for fear of harming the baby, but she is in pain, what should I do?

A:  Do not treat this patient without an x-ray. It is beneath the standard of care to provide treatment without proper diagnostic information. Explain about the safety of x-rays and the need to have them for proper diagnosis and treatment.  The California Dental Association Foundation released, Oral Health During Pregnancy and Early Childhood:  Evidence-Based Guidelines for Health Professionals in 2010. It can be downloaded from:  www.cdafoundation.org/guidelines.

Q: Should we take full-mouth x-rays on all non-emergent, new patients?  

A: Take the necessary x-rays that enable you make a complete and comprehensive diagnosis and treatment plan.  Panoramic and bite-wings would suffice the definition of FMX. The ADA has developed guidelines on the type and frequency of x-rays suggested throughout the life cycle: The use of dental radiographs: Update and recommendations. It can be downloaded from: www.ada.org/sections/professionalResources/pdfs/report_radiography.pdf

Q: Are part-time dentists covered by FTCA?

A: Part-time dentists who are employees of the Health Center (i.e., receive a W-2 form) are covered.  Part-time dentists who are contractors are not covered unless they are contracted for at least 32.5 hours per week.

Q: Are volunteers covered by FTCA?

A: Volunteers are not covered by FTCA at the time of this writing. 

Q: Are visits made to a patient’s home covered under our “scope”?

A: Both the site and service must be covered under the organization's scope of project to be covered and considered under “scope”[2]. "Home visits" may be added to a Health Center’s scope of project. A Health Center need not add each patient’s individual home as a site (they likely would not qualify as sites).

Q: A patient desires a fixed bridge but does not want a full exam or any other treatment due to financial concerns. Should I make the bridge?

A: You cannot provide treatment without first conducting the appropriate exams. This is beneath the standard of care.

Q: What if I work for an organization that does not do quadrant dentistry, but encourages providers to spread out treatment into multiple appointments?

A: NNOHA recommends quadrant dentistry should be practiced whenever possible. Although there are scenarios and patients where different treatment sequences are advised, splitting treatment out into multiple visits for non-clinical reasons is unethical and not consistent with the standard of care. This may also violate encounter-based billing rules.

(Updated: December 12, 2011)