AAPD and ADA File Joint Comments on CMS Proposed Regulations on Medicaid/CHIP Managed Care Contracts

On July 24, 2015, the American Academy of Pediatric Dentistry (AAPD) and the American Dental Association (ADA) filed joint comments on proposed regulations of the Centers for Medicare and Medicaid Services (CMS) concerning Medicaid and Children’s Health Insurance Program (CHIP) Managed Care contracting and comprehensive quality strategies. This is an important issue because many states are moving to managed care contracts for Medicaid and CHIP services, including dental (although dentists may still be receiving fee for service payments, the insurance company is being paid by the state based on a per enrollee per month figure). In some states there have been concerns with inadequate contracts and oversight, resulting in low provider reimbursements, administrative burdens for providers and inadequate provider networks for program beneficiaries.
Among the key comments in the joint AAPD-ADA letter:
  • AAPD-ADA supported the proposal to require Managed Care Organizations (MCOs), Prepaid Inpatient Health Plans (PIHPs) and Prepaid Ambulatory Health Plans (PAHPs) with Medicaid contracts beginning after January 1, 2017, to utilize a minimum medical loss ratio (MLR) requirement in the development of actuarially sound rates. It was also recommended that CMS should provide a clear definition for plans of what should be included or excluded as administrative costs, and develop standardized reporting requirements.
  • AAPD-ADA supported the proposal that capitation rates should be "sufficient and appropriate for the anticipated service utilization of the populations and services covered under the contract and provide appropriate compensation to the health plans for reasonable non-benefit costs." AAPD-ADA suggested that state programs utilize existing data from commercial dental plans to create utilization benchmark targets for populations enrolled in Medicaid managed care plans. 
  • AAPD-ADA encouraged CMS and state programs to utilize existing research and seek expertise on dental payment rates and the relationship between access to and utilization of dental services in Medicaid
  • AAPD-ADA urged CMS to work with professional societies and multi-stakeholder alliances like the Dental Quality Alliance (DQA) before embarking on any effort to move payment for dental services into the value based model.
  • Noting that the proposed rule requires that States establish time and distance standards for specific network provider types, including pediatric dental services, AAPD-ADA encouraged CMS to define pediatric dental services as requiring a specific provider network composed of pediatric and general dentists and other dental specialists, with unique time and distance standards. It was also noted that AAPD-ADA do not support provider to beneficiary ratios as the sole means of assessing network adequacy. Rather, CMS was encouraged require States to address geographic variations when setting adequacy standards
  • AAPD-ADA noted that the Healthcare Effectiveness Data and Information Set (HEDIS) measure, Annual Dental Visit, is not a sufficient measure to determine beneficiary access to dental services. Instead, it was recommended that programmatic access measures developed by the DQA be used to assess utilization and access. Specifically, CMS was urged to adopt programmatic and plan level measures developed by the DQA based on the measure set titled "Dental Caries in Children: Prevention and Disease Management." 
  • AAPD-ADA supported efforts to require plan accreditation, and urged CMS to pursue standards for readiness assessment of prior to a contract award. A readiness assessment should examine elements such as a plan’s ability to provide dental services to Medicaid enrollees; quality improvement and utilization management function capability; the ability to provide an adequate, accessible network; the technical capacity to process claims; the ability to process grievances and appeals; systems for enrollee support and outreach; and systems for provider network support.
For further information, please contact AAPD Chief Operating Officer and General Counsel C. Scott Litch at slitch@aapd.org.

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