1. Texas Medicaid Medical and Dental Information Series 1 Module 2 Version 1.2 (6/22/2010) 2/22/2013

2. Medicaid Curriculum Overview Module 1: General Structure of the Texas Medicaid System Module 2: Understanding Medicaid Clients and Health Literacy Module 3: Texas Health Steps Module 4: Navigating Insurance and Managed Care Module 5: Interfacing with Medicaid as a Provider Module 6: Special Medicaid Programs Module 7: Special Medical Issues Module 8: Special Dental Issues 2 Module 2

3. Understanding Medicaid Clients and Health Literacy 3

4. Module 2: Objectives After completing this module, you should be able to: Explain how poverty is defined and measured in the U.S. List at least three characteristics of children living in poverty Contrast the terms generational poverty and situational poverty List at least five barriers to health care caused by poverty List at least three ways that emergency department usage is affected by poverty and unemployment Define health literacy and its effect on health and provision of health care List Texas Medicaid initiatives to address adverse effects of poverty and disability 4 Module 2

5. Module 2: Identifying Patterns This module attempts to describe poverty in terms of the patterns observed in the research literature– but all patterns have exceptions. Patterns involve broad generalizations about large groups of people. The goal of this presentation is to describe poverty, its barriers and its health implications to help providers improve their patient care– not to create or perpetuate stereotypes. 5 Module 2

6. True or False? Test Your Knowledge about Texas Medicaid: In 2011, nearly 1 in 20 people and 1 in 15 children lived in poverty. The federal government requires that state Medicaid programs set service eligibility at 100% of the FPL. A family in generational Poverty is one that has been in poverty for two or more generations. Nationally, a 1% decrease in the employment rate adds about 1 million new enrollees to Medicaid & CHIP. Only about 12% of adults have a health literacy level that could be considered proficient. 6 Module 2

7. REVIEW: What is Medicaid? 7 Medicaid is a federal health care program that is jointly funded by federal and state money. Medicaid is jointly funded by the state and federal governments: About one-third funded by the State of Texas About two-thirds funded by the Federal Government In December 2011, about 1 in 7 Texans relied on Medicaid for health insurance or long-term services (3.7 million of the 25.9 million). Medicaid was created through Title XIX of the 1965 Social Security Act, and established in Texas in 1967. In Texas, Medicaid is administered by the Texas Health and Human Services Commission (HHSC). Medicaid is an entitlement program, which means: The number of eligible people who can enroll cannot be limited. Any services covered under the program must be paid. Module 2

8. REVIEW: Who can receive Full Medicaid Benefits? Categories of Eligibility Families and Children Based on income level, depending on age, or pregnancy Cash Assistance Recipients Based on receipt of Temporary Assistance for Needy Families (TANF) or Supplementary Security Income (SSI) Aged and Disabled Individuals Based on income, age, and physical and/or mental disability Some Dual Eligible Individuals: Qualified Medicare Beneficiaries Based on age, income, and disability status Module 2 8

9. REVIEW: Who can receive Limited Medicaid Benefits? Categories of Eligibility Some Dual Eligible Individuals: In the Qualified Medicare Beneficiary, Specified Low-Income Medicare Beneficiary, Qualified Individuals, and the Qualified Disabled Working Individuals Programs, Medicaid pays for some or all of Medicare premiums Based on income, assets, age, and/or disability Non-Citizens Undocumented persons who are not eligible for Medicaid based on citizenship status may receive emergency services Qualified Legal Permanent Residents are eligible for limited Medicaid services Special programs for women (e.g., family planning services, cervical and breast cancer coverage, community attendant services) Available to women and based on income level and age Module 2 9

10. REVIEW: What Does Medicaid Cover? Long-term services for elderly and disabled clients Mental health and substance abuse treatment Acute and preventive health care for all ages Physician visits Inpatient and outpatient services Pharmacy, lab, and radiology costs 10 Module 2 Dental services for patients under the age of 21 Preventive Therapeutic

11. At any one time, how many individuals are enrolled in Medicaid? About 3.54 million 11 Module 2 REVIEW: How Many People Does Texas Medicaid Serve?

12. REVIEW: Texas Medicaid Recipients State Fiscal Year 2011 12 FemaleMale 0-56-1415-2021-6465+ HispanicCaucasianAfrican- American Other Unduplicated Clients SFY 2011 = 4,567,077 Module 2

13. REVIEW: Who is Eligible for Medicaid Benefits? Medicaid primarily serves: Low-income families Foster children Pregnant women The elderly People with disabilities Babies born to mothers receiving benefits at time of delivery (Services available for one year) 13 Module 2

14. Medicaid and Poverty 14 Module 2 A family crisis such as death, disability or divorce that leads to loss of income Loss of a job or other economic distress Long-term poverty that persists for more than one generation A family crisis such as death, disability or divorce that leads to loss of income Loss of a job or other economic distress Long-term poverty that persists for more than one generation Medicaid serves primarily low-income or disabled families and individuals– those likely to be in poverty. Why might a family or individual qualify for Medicaid? What is poverty? What is the link between poverty and health care? How does health literacy affect health care? What Texas Medicaid programs help reduce health disparities caused by poverty or disability? What is poverty? What is the link between poverty and health care? How does health literacy affect health care? What Texas Medicaid programs help reduce health disparities caused by poverty or disability? This module focuses on helping providers understand some of the challenges faced by their Medicaid clients that lead to health disparities:

15. Why Is It Important to Learn About Poverty? Poverty and Health Research points to a strong negative relationship between Income and Health Status: As income declines, health status also declines 15 Module 2

16. Why Is It Important to Learn About Poverty? Poverty and Dental Care 16 Module 2

17. Why Is It Important to Learn About Poverty? Poverty and Cultural Competency Health providers and organizations that are culturally competent demonstrate the ability to recognize role of cultural diversity— including values, traditions and language preferences—in making positive health outcomes. Linking poverty to culture is controversial, especially explanations that blame victims of poverty or that cast doubt on the values or morals of the poor, but recent scholarship recognizes a link between culture and persistent poverty. The characteristics of socioeconomic status—income level, educational attainment, and employment position—often also affect traditions and language preferences. Thus, understanding the effect of socioeconomic status and poverty on health is a first step in achieving competency regarding the culture of poverty. 17 Module 2

18. Understanding Medicaid Clients What is poverty? Definitions & measurements Children living in poverty Poverty across the US & Texas Generational vs. Situational poverty 18 Module 2

19. How Poverty is Defined and Measured in the U.S. The Census Bureau uses a set of money income, or poverty thresholds (or Federal Poverty Level, FPL) that vary by family size and composition (but not by region of the country) to determine who is in poverty. If a family's total income is less than 100% FPL, then that family and every individual in it is considered poor or in poverty. Families with incomes between 100-200% FPL are considered to be low income. In 2011, the FPL is $22,350 per year for a family of 4, or $1863 per month. 19 Module 2

20. 20 Module 2 In 2011, there were over 311 million people in the United States In 2011, more than 46 million of these people lived in poverty (a 15-year high) 1 in 7 people overall 1 in 5 children

21. 21 Module 2 In 2011, more than 46 million of these people lived in poverty (a 15-year high) 1 in 7 people overall 1 in 5 children

22. Children Living in Poverty Compared with children in higher income families, poor children are more likely than non-poor children to: Be in single-parent families Have parents with low educational attainment Live in areas called “food deserts” with limited access to fresh groceries and healthy food Be exposed to chronic stress that is linked to chronic disease Suffer developmental delays Give birth during the teen years Be in poor or fair health 20002009% Change Low Income26,784,24431,298,59017% Poor11,502,06715,325,97433% The percentage of children living in low-income and poor families has increased since 2000: 22 Module 2

23. Federal Poverty Level (FPL) 23 Module 2 Total Number of People Living in Poverty based on Household Income (In Thousands), 2009 Persons in Family or Household Annual Pre-Tax Income 48 Contiguous States and Washington DC 1$11,170 215,130 319,090 423,050 527,010 630,970 734,930 838,890 > 8Add $3,960 for each additional person Texas 4.26 million 2012-13 US Poverty Guidelines

24. Poverty in Texas Texas (2010-2011) vs. US (2011 ) 24 Module 2

25. Generational Poverty vs. Situational Poverty 25 Module 2 Generational Poverty Situational Poverty Poverty that persists for two or more generations Generational Poverty has its own: Culture Hidden Rules Belief Systems Approach to Language Poverty that persists for two or more generations Generational Poverty has its own: Culture Hidden Rules Belief Systems Approach to Language Poverty that caused by circumstance (such as death, illness, divorce) and has a duration of one generation or less Situational Poverty maintains an orientation toward middle class codes and mores. Poverty that caused by circumstance (such as death, illness, divorce) and has a duration of one generation or less Situational Poverty maintains an orientation toward middle class codes and mores.

26. Understanding Medicaid Clients 26 Module 2 Income & Medicaid eligibility Health implications of poverty Effects of unemployment & income fluctuations Impact on emergency department (ED) use What is the link between poverty and health care?

27. FPL and Social Services The Department of Health and Human Services develops and publishes the Poverty Guidelines, which are updated annually and form the basis for eligibility for Medicaid and other programs. The federal government sets minimum FPL criteria for eligibility to federally funded programs, but states can set higher FPL eligibility to cover a broader range of income levels. Program eligibility is often expressed as a percentage of the FPL. The higher the percentage, the greater the income limit, or more generous the benefit. 27 Module 2 Children 6-18: up to 100% FPL, or up to $23,050/year for a family of 4 Elderly and Disabled: 75% FPL or $11,348/year for a family of 2 Examples of Texas Medicaid Eligibility by FPL Pregnant Women: up to 185% FPL, or up to $35,316/year for a family of 3

28. 28 Module 2 Federal Poverty Levels in Use Medicaid Eligibility in Texas, 2012 FPL = Federal Poverty Level FBR = Federal Benefit Rate * SSI is awarded to individuals and couples only

29. Income Guidelines 29 Module 2 www.chipmedicaid.com

30. 30 Module 2 www.chipmedicaid.com

31. Common Medicaid Myths National Center for Children in Poverty data for Texas, 2008: 38% of children in poor families (<100% FPL) have at least one parent who is employed full- time, year-round 33% of children in poor families have at least one parent who is employed either part-year or part-time 30% of children in poor families do not have an employed parent In contrast, 88% of children in families that are not poor have at least one parent who is employed full-time, year-round National Center for Children in Poverty data for Texas, 2008: 38% of children in poor families (<100% FPL) have at least one parent who is employed full- time, year-round 33% of children in poor families have at least one parent who is employed either part-year or part-time 30% of children in poor families do not have an employed parent In contrast, 88% of children in families that are not poor have at least one parent who is employed full-time, year-round 31 Module 2Myth Most Medicaid-eligible children have parents who are unemployed.Myth Fact Medicaid primarily serves the working poor—families with at least one parent who works full or part-time but with a family income less than 100% FPL and no other source of insurance.Fact

32. Health Implications of Poverty: Barriers to Care Money to pay for co-payments, medications or other health costs Inadequate or unreliable transportation Low educational levels Food insecurity Low literacy levels or limited understanding of English Poor health literacy Conflicting priorities and needs 32 Module 2

33. The Face of Poverty: Implications for a family’s health Rhonda is a 31-year-old single mother of Tamika (14) and Andre (10) living in Dallas. Rhonda lives in a low income housing development, near her mother and older brother, who is mentally handicapped. Rhonda’s job in a call center earns $332 per week, but offers no benefits. She also receives $40 per week in child support from Andre’s father, who lives in Louisiana. Her total monthly pre-tax income is $1488 (93.5% FPL) or $17,856 per year. Rhonda’s mother has Type 2 diabetes and hypertension. Her father, a lifelong smoker, died of lung cancer 5 years ago. Rhonda limits her own smoking to a half-pack of cigarettes a day. 33 Module 2

34. The Face of Poverty: Rhonda’s Family According to the National Center for Children in Poverty, as a single mother with 2 children in Dallas, Rhonda could expect the following monthly expenses, even to be considered low- income (132% FPL): 34 Module 2

35. Linking Financial Status and Health Care 35 Module 2

36. Health Implications of Poverty for Children Physician Care 36 Module 2

37. Health Implications of Poverty for Children Overweight and Obesity 37 Module 2

38. Health Implications of Poverty for Children Dental Care 38 Module 2

39. The Face of Poverty: Implications for a family’s health Provider’s Concerns Rhonda’s Concerns Juggling competing demands in an extended family despite limited resources: Keeping her kids fed Paying her bills Keeping her car running Getting to work on time Helping her extended family Juggling competing demands in an extended family despite limited resources: Keeping her kids fed Paying her bills Keeping her car running Getting to work on time Helping her extended family 39 Module 2 Bringing in a copy of the kids’ shot records Setting a quit date for smoking Keeping appointments for dental referrals Getting regular exercise and avoiding junk food Filling and taking prescriptions Bringing in a copy of the kids’ shot records Setting a quit date for smoking Keeping appointments for dental referrals Getting regular exercise and avoiding junk food Filling and taking prescriptions

40. Effects of Unemployment and Income Fluctuations 40 Module 2

41. Linking Financial Status and Health Care 41 Module 2 Percent of workers who become uninsured (6+ months) after leaving a job, among workers previously insured through their employer

42. Effect of Employment Rate on Medicaid & CHIP 42 Module 2 National Employment Rate Medicaid and CHIP Enrollment 1% 1 Million

43. Effects of Poverty, Unemployment & Uninsurance on ED Usage Key Findings from a 2009 Kaiser Family Foundation study of Emergency Departments (EDs): ED capacity is strained and almost all EDs report rising volume. Many EDs observe a new “recession” population of those who have lost jobs and insurance or those who can’t afford deductibles or cost-sharing costs in the doctor’s office. EDs are seeing more insured patients who come because they cannot obtain timely or affordable primary care in the community. Both insured and uninsured patients are refusing medically recommended care because of cost. 43 Module 2 ED physicians see anxiety and depression among patients who lost their jobs. The inability to arrange for follow-up care for uninsured patients is a huge problem, which impacts how ED physicians practice and how patients fare.

44. Characteristics of ED Users By Insurance Status 44 Module 2

45. Characteristics of ED Users By Chronic Condition 45 Module 2

46. Characteristics of ED users By Reason for Visit 46 Module 2

47. The Link Between Poverty and Health Care: Barriers Caused by Patient and Provider Knowledge & Attitudes 47 Module 2 Provider Quotes “I can’t get the mother to turn the TV off and bring her kid in to get a checkup.” “My patients don’t want to pay the $5 co-pay, so they come to the ED and wait 6 hours to be seen for a cold.” Provider Quotes “I can’t get the mother to turn the TV off and bring her kid in to get a checkup.” “My patients don’t want to pay the $5 co-pay, so they come to the ED and wait 6 hours to be seen for a cold.” Patient Quotes “I didn’t know people went to the doctor. I thought everyone went to the emergency room.” “I never saw a dentist. Didn’t even know you were supposed to until you needed false teeth.” Patient Quotes “I didn’t know people went to the doctor. I thought everyone went to the emergency room.” “I never saw a dentist. Didn’t even know you were supposed to until you needed false teeth.”

48. Addressing the Link Between Poverty and Health Care A strong and positive provider-patient relationship has a positive and significant effect on treatment adherence and outcome Conflicting norms and behaviors among patients and providers of different social groups may create barriers to effective communication or positive relationships Suggestions for providers: Recognize norms as adaptive and socially constructed, and avoid assigning positive or negative value Do not assume that someone will see how their choices today will affect their health tomorrow. Learn more about the effects on health of poverty, unemployment and uninsurance Get to know your patients. Understanding their perspective can improve the services you provide. 48 Module 2

49. Health Literacy 49 Module 2 Definition & importance of health literacy Measurement and extent of health literacy Addressing health literacy in health care settings How does health literacy affect health care?

50. What Is Health Literacy? Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Health literacy is dependent on both individual and systemic factors: 1. Communication skills of lay people (such as patients) and professionals (such as health care providers) 2. Knowledge of lay people and professionals of health topics 3. Culture 4. Demands of the healthcare and public health systems 5. Demands of the situation/context Module 2 50

51. Health Literacy: A National Priority American Dental Association: American Medical Association: 51 Module 2 Limited health literacy is a potential barrier to effective prevention, diagnosis and treatment of oral disease.

52. Why Is Health Literacy Important? Health literacy affects people’s ability to: Navigate the healthcare system, including locating providers and services and keeping appointments Fill out forms and give informed consent Share personal and health information with providers Engage in self-care and chronic disease management Adopt health-promoting behaviors, such as exercising and eating a healthy diet Act on health-related news and announcements Costs of Low Health Literacy: Poor health outcomes Increased health care costs through higher utilization of hospitalization and emergency services Reduced quality of care Treatment non- adherence and medication errors Poor health behavior choices Costs of Low Health Literacy: Poor health outcomes Increased health care costs through higher utilization of hospitalization and emergency services Reduced quality of care Treatment non- adherence and medication errors Poor health behavior choices 52 Module 2

53. Common Reasons for Poor Health Literacy Lack of educational opportunity Poor English-language skills Low reading levels Reading abilities are typically 3 to 5 grade levels below the last year of school completed (i.e. a high school graduate likely reads at a 7th or 8th grade level). Learning disabilities Cognitive decline Poor health 53 To accomplish health tasks, patients may need to be: Visually literate (able to understand and read graphs and charts) Computer literate (able to operate a computer) Information literate (able to obtain and apply relevant information) Numerically or computationally literate (ability to calculate or reason numerically) To accomplish health tasks, patients may need to be: Visually literate (able to understand and read graphs and charts) Computer literate (able to operate a computer) Information literate (able to obtain and apply relevant information) Numerically or computationally literate (ability to calculate or reason numerically) Module 2

54. Health Literacy and Shame People with limited health literacy often report feeling a sense of shame about their skill level. Individuals with poor literacy skills are often uncomfortable about being unable to read well, and they develop strategies to compensate. Possible indicators of low health literacy: Excuses for not reading: “I forgot my glasses.” Lots of papers folded up in purse/pocket Lack of follow-through with tests or appointments Few questions or only simple questions Difficulty explaining medical concerns or how to take medications 54 Module 2

55. Measuring Health Literacy 2003 National Assessment of Adult Literacy (NAAL) Survey Literacy Levels Proficient: Can perform complex and challenging literacy activities. Intermediate: Can perform moderately challenging literacy activities. Basic: Can perform simple everyday literacy activities. Below Basic: Can perform no more than the most simple and concrete literacy activities. Nonliterate in English: Unable to complete a minimum number of screening tasks or could not be tested because did not speak English or Spanish. 55 Module 2 Literacy Scales Prose (reading comprehension) Document (finding & using information) Quantitative (performing computations) Prose (reading comprehension) Document (finding & using information) Quantitative (performing computations) Health Care Domains Clinical Prevention Navigation of the health care system Clinical Prevention Navigation of the health care system

56. Difficulty of Selected Health Literacy Tasks Proficient 310-500 Intermediate 226-309 Basic 185-225 Below Basic 0-184 Average Score 245 Circle the date of a medical appointment on a hospital appointment slip. (101) Give two reasons a person should be tested for a specific disease, based on information in a clearly written pamphlet. (202) Determine what time a person can take a prescription medication, based on information on the drug label that relates the timing of medication to eating. (253) Calculate an employee’s share of health insurance costs for a year, using a table. (382) Use a BMI index to determine a healthy weight range for a person of a specific height (290) Module 2 56

57. Percentage of Adults in Each Literacy Level 57 Module 2

58. Percentage of Adults in the Below Basic Literacy Level 58 Module 2

59. Poverty, Insurance Coverage and Health Literacy 59 Module 2 Poverty Threshold Average Health Literacy Score Below 100% FPL205 100-125% FPL222 126-150% FPL224 151-175% FPL231 Above 175% FPL261 Insurance Type Average Health Literacy Score Employer-Provided259 Military248 Privately Purchased243 Medicare216 Medicaid212 No Insurance220 Adults at poverty levels 100-125% FPL scored in the Below Basic levels of health literacy. Average health literacy levels for those above 175% FPL was in the Intermediate range. Among adults who received Medicare or Medicaid, 27% and 30%, respectively, had Below Basic health literacy. Among adults who had employer-provided, military, or privately purchased insurance, the percentages with Below Basic health literacy were 7%, 12% and 13%, respectively.

60. Addressing Low Health Literacy Using Plain Language Strategies to improve patient comprehension: Limit the amount of information provided at each visit Begin with the most important information “Slow down” Avoid jargon Provide patient education materials at the appropriate reading level Use pictures or modules to explain important concepts Use the “show-me” or “teach-back” methods Encourage questions 60 Module 2

61. Addressing Low Health Literacy Testing for Understanding Suggestions for providers: Use a medically trained interpreter if necessary: Ensure that all language access services, including translation, use plain language For those who do not speak English, plain English alone will not be enough to ensure understanding Ask open-ended questions: Elicit cultural beliefs and attitudes: “Tell me about the problem and what may have caused it.” Check for understanding: Use the “teach-back” method: Have the person restate the information in his or her own words. 61 Module 2

62. Medicaid Programs 62 Module 2 Case Management Outreach & Informing Transportation Assistance Ensuring accommodations for the disabled What Texas Medicaid programs help reduce health disparities caused by poverty or disability?

63. Case Management Case Management for Children and Pregnant Women (CPW) provides services to children with a health condition/health risk, birth through 20 years of age and to high-risk pregnant women of all ages, in order to help them gain access to medical, social, educational and other health-related services Dependent upon a client’s needs, a CPW case manager may complete a variety of tasks that include the following: Linking a client to community resources Coordinating medical services and supplies Locating mental health services Assisting with medical transportation problems Referring a client to waiver programs, ECI and other resources Advocating for a client at school meetings 63 Module 2

64. Outreach and Informing Program The Outreach and Informing Program provides outreach, informing, and support services to THSteps recipients. The Outreach & Informing program seeks to improve patients’ interactions with providers through: Helping patients and families locate a provider Scheduling appointments Providing information for patients on the importance of checkups Performing outreach after missed appointments 64 Module 2 Eligible recipients: Children birth through age 20 who are newly-certified or recertified for Medicaid (including parents/caretakers required to have a Health Care Orientation) Children birth through age 20 years who are due or overdue for a medical or dental checkup Pregnant women in the fourth month of pregnancy Special outreach groups who are at high risk for health problems (e.g., children of migrant farm workers) Eligible recipients: Children birth through age 20 who are newly-certified or recertified for Medicaid (including parents/caretakers required to have a Health Care Orientation) Children birth through age 20 years who are due or overdue for a medical or dental checkup Pregnant women in the fourth month of pregnancy Special outreach groups who are at high risk for health problems (e.g., children of migrant farm workers)

65. Medicaid Transportation Program Provides free rides for Texas Health Steps and other Medicaid eligible patients Helps clients miss fewer appointments Allows scheduling of multiple appointments at one time Results in fewer no-shows 65 THREE WAYS TO GET TO THE DOCTOR Module 2

66. Americans with Disabilities Act (ADA) ADA: Title III: The term "disability" means, with respect to an individual: (A) a physical or mental impairment that substantially limits one or more major life activities of such individual; (B) a record of such an impairment; or (C) being regarded as having such an impairment. “No individual shall be discriminated against on the basis of disability in the full and equal enjoyment of the goods, services, facilities, privileges, advantages, or accommodations of any place of public accommodation by any person who owns, leases (or leases to), or operates a place of public accommodation.” Professional offices of a health care providers and hospitals are included under the definition of “place[s] of public accommodation 66 Module 2

67. Americans with Disabilities Act Requirements Title VI of the Civil Rights Act requires health providers give their limited-English-proficient patients meaningful access to their services, which may entail offering translation services People with disabilities must be able to access an office building and suite. Barriers to access must be removed if alterations are “readily achievable” Providers have a duty to provide effective communication, including services for vision- or hearing-impaired patients, such as: Qualified readers, Braille or large print materials Sign language interpreter, written forms and information sheets, or exchange of written notes for non-complex situations 67 Module 2

68. True or False? Test Your Knowledge about Texas Medicaid: In 2011, nearly 1 in 20 people and 1 in 20 children lived in poverty. The federal government requires that state Medicaid programs set service eligibility at 100% of the FPL. A family in generational poverty is one that has been in poverty for two or more generations. Nationally, a 1% decrease in the employment rate adds about 1 million new enrollees to Medicaid & CHIP Only about 12% of adults have a health literacy level that could be considered proficient. 68 Module 2

69. Medicaid Resources Texas Health & Human Services Commission www.hhsc.state.tx.us/medicaid www.hhsc.state.tx.us/medicaid Texas Medicaid & Healthcare Partnership www.tmhp.com www.tmhp.com Texas Health Steps www.dshs.state.tx.us/thsteps/providers.shtm www.dshs.state.tx.us/dental/thsteps_dental.shtm www.dshs.state.tx.us/thsteps/default.shtm www.dshs.state.tx.us/thsteps/providers.shtm www.dshs.state.tx.us/dental/thsteps_dental.shtm www.dshs.state.tx.us/thsteps/default.shtm CHIP/Children’s Medicaid www.chipmedicaid.org www.chipmedicaid.org 69 Module 2

70. This Texas Medicaid curriculum was prepared by Betsy Goebel Jones, EdD Project Director Tim Hayes, MAM Project Designer Authors: Module 2 Betsy Goebel Jones, EdD David Trotter, MA Department of Family & Community Medicine 70 Module 2