Medicaid/CHIP Reform Issues

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The federal and state programs aimed at providing health insurance to low-income children are Medicaid and the state Children’s Health Insurance Program (CHIP). AAPD Advocacy supports programs that provide adequate dental benefits, including maintenance of the Medicaid EPSDT (Early, Periodic Screening, Diagnosis and Treatment coverage for children) benefit and market-based payment rates in order to maximize patient and provider participation and thereby alleviate oral disease among millions of children. The U.S. Surgeon General reported that 80 percent of all dental disease occurs in only 25 percent of U.S. children. These children are more likely to live in low-income and/or minority families and not only have increased dental disease, but more extensive disease and more treatment for pain. An estimated 4 to 5 million children currently are in acute dental need.

 


AAPD Member O-Ed Included in The Hill

AAPD member Dr. Jessica Meeske authored an op-ed, "How Medicaid Audits Hurt Children In My Home State," published recently in The Hill.

In the op-ed, Dr. Meeske shared her experience with the Recovery Audit Contractor (RAC) program and noted that it prevents low-income families and children from receiving dental care through Medicaid in Nebraska. She referenced specific Nebraska RAC audit examples to reinforce her stance. Dr. Meeske balanced her piece by noting provider manuals in Nebraska give dentists discretion to determine frequency of treatment and noted low-income patients, particularly children, are at higher risk and may need care more often than every six months.

To read the full op-ed, please click here.

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CMS Releases New Briefs on Early Childhood Tooth Decay

As part of its Oral Health Initiative, CMS released three new issue briefs on reducing early childhood tooth decay. These tools were developed to help state Medicaid programs improve the delivery of dental and oral health services, particularly in terms of redesigning the approach to early childhood caries (EEC) for a greater emphasis on prevention rather than on treatment.

The first brief, "An Overview for State Policymakers," discusses how Medicaid and CHIP play key roles in health system redesign to promote healthier populations and lower per capita costs. The second, "Leading Steps for State Policymakers," discusses how numerous children in Medicaid and CHIP do not receive appropriate preventive and management services, and as a result, cases of ECC worsen until costly hospital-based restoration or surgical removal of decayed teeth is unavoidable. The third brief, "Strategies for State Medicaid and CHIP Dental Program Managers," covers program and policy strategies to promote ECC prevention and management, such as emphasizing prevention, educating and engaging parents, and promoting risk assessments and individualized care plans for high-risk children.

 


CHIP Increases Children’s Access to Dental Care

More than 8 in 10 children enrolled in CHIP had a preventive dental visit in the past year, according to a July article for the Georgetown University Center for Children and Families. Based on an analysis of data from a 2012 survey of parents of CHIP enrollees in 10 states, CHIP-enrolled children were more likely to have a dental home and dental coverage than children enrolled in private insurance. Read the full article.

 


Medicaid Market for Dental Care Poised for Major Growth in Many States. Health Policy Institute, American Dental Association, December 2014

Due to the Affordable Care Act, the Medicaid market for dental care will grow significantly in many states, even those electing not to expand Medicaid eligibility. This research measures the growth in the Medicaid market by comparing the potential increase in the number of adults and children with Medicaid dental benefits to pre-Medicaid expansion levels in select states. According to the report, the average increase in the potential number of children gaining dental benefits through Medicaid across all 50 states and the District of Columbia is 15.9 percent, ranging from 3.7 percent in D.C. to 40.6 percent in Nevada.

Download the report.

 


A Ten-Year, State-by-State, Analysis of Medicaid Fee-for-Service Reimbursement Rates for Dental Care Services. Health Policy Institute, American Dental Association, October 2014

This research brief calculates Medicaid fee-for-service reimbursement rates for dental care services relative to typical commercial dental insurance charges and analyzes the changes in pediatric Medicaid FFS reimbursement between 2003 and 2013 in all states and the District of Columbia. In 2013, the average Medicaid FFS reimbursement rate was 49 percent of commercial dental insurance charges for pediatric dental services. From 2003 to 2013, Medicaid FFS reimbursement relative to commercial dental insurance charges fell in 39 states and rose in 7 states and the District of Columbia. The available evidence strongly suggests that increasing Medicaid reimbursement rates for dental care services, in conjunction with other reforms, increases provider participation and access to dental care for Medicaid enrollees.

Download the report.

 


The Impact of Medicaid Reform on Children’s Dental Care Utilization in Connecticut, Maryland, and Texas. Health Services Research, April 2014

This brief discusses the impact of Medicaid reforms on access to dental care among Medicaid-eligible children, particularly the increases in Medicaid dental fees in Connecticut, Maryland, and Texas. Based on data from the 2007 and 2011–2012 National Survey of Children’s Health, preventive dental care utilization increased among Medicaid-eligible children in Connecticut and Texas compared to Medicaid-ineligible children and all children from a group of control states. In addition, unmet dental need declined among Medicaid-eligible children in Texas. The research suggests that increasing Medicaid dental fees closer to private insurance fee levels has a significant impact on dental care utilization and unmet dental need among Medicaid-eligible children.

Download the report.

 


AAPD Coding and Insurance Manual 2015 Now Available

The AAPD Coding and Insurance Manual 2015 gives pediatric dental staff a resource to code and document services accurately for claim submissions and dental records. Relying on old information often leads to unexpected claim denials and reimbursement delays. Dental procedure codes in practice management systems or dental benefit plans may be incomplete and hamper efforts to receive reimbursement. The AAPD Coding and Insurance Manual 2015 is the most up-to-date dental coding resource for pediatric dentists. It also fills in coding gaps and reduces ambiguity. Designed for daily use in every pediatric dental practice, this comprehensive resource provides a detailed go-to place for staff by providing answers to many of their questions. 

Purchase a copy now.

 


Second Opinion: Gorillas in the Dental Operatory, ACA and Medicaid. Dr.Bicuspid.com, March 2013

Dr. Paul Casamassimo provided a Second Opinion that appeared on Dr.Bicuspid.com addressing the ongoing financial and cultural challenges associated with Medicaid as it relates to the implementation of the Affordable Care Act (ACA). According to Casamassimo, "Often, criticism is exchanged between the dental profession and child advocates about Medicaid reimbursement and dentists' willingness to care for Medicaid-supported children at reimbursements well below their typical fees. However, the reality of the inadequacy of Medicaid reimbursement as it relates to safety-net dental programs caring for the poor brings this inequity into clearer focus. Today, across the U.S., safety-net dental programs are failing or at risk because the cost of providing dental care has increased while Medicaid reimbursement has not."

Read the article.

 


The Impact of Increased Medicaid Reimbursement in Connecticut. Connecticut Health Foundation, February 2013 

In Connecticut, similar to many other states, children on Medicaid could not easily access dental health services. Few dentists participated in the program with many providers citing low reimbursement rates and cumbersome program administration. Based on a 2008 lawsuit settlement agreement, program administration improved and reimbursement rates increased, moving closer to private insurance rates. A project funded by the Connecticut Health Foundation examined Medicaid data between 2006 and 2011 to determine the effect of the increased Medicaid reimbursement on access to care and provider participation. The findings showed strong increased participation by private providers and a resulting increase in care for children on Medicaid. 

Read the full report.

 


Centers for Medicare and Medicaid Services (CMS) Provide Resources on Medicaid Program Integrity

The AAPD and CMS have partnered in the past to provide members with webinars that provide a comprehensive overview of Medicaid program integrity, common compliance vulnerabilities, and benefits derived from developing or improving a compliance program. The AAPD has also worked closely with CMS and the ADA on compliance issues to help ensure that provider audits are fair and reasonable. CMS has now created an informative website on CMS Medicaid Program Integrity. The site provides educational resources for providers, beneficiaries, managed care plans and other stakeholders and promotes best practices and awareness of Medicaid fraud, waste and abuse. 

Follow this link to learn more about the website.

 


Additional Resources

October 2014:  CHCS Report on Medicaid Dental MCO Contracting Strategies for Children's Oral Health

October 2014:  GWU Report on Medicaid Dental Trends from CMS-416 Data, 2000-2012

2012: ADA Report on Dental Medicaid

AAPD ACA Basics 

CDC State-Based Programs and Reports 

Centers for Medicare and Medicaid Services

Covering Kids and Families

Kaiser Commission on Medicaid and Uninsured

Medicaid/SCHIP Dental Program Representatives