Dental Medicaid Act

Summary

An Act establishing dental services for adults in the Medicaid program.

Dental Medicaid Act

PROVIDING DENTAL SERVICES FOR ADULTS IN MEDICAID

(A) The general assembly hereby finds that:

  • Research has shown that untreated oral health conditions negatively affect a person’s overall health and that gum disease has been linked to diabetes, heart disease, strokes, kidney disease, Alzheimer’s disease, and even mental illness;
  • Regular dental care and prevention are the most cost-effective methods available to prevent minor oral conditions from developing into more complex oral and physical health conditions that would eventually require emergency and palliative care;
  • One in four adults has untreated tooth decay. Early detection and access to preventive and restorative treatments for oral health conditions can be up to ten times less expensive than treating those same conditions in an emergency setting.
  • Research has also shown that good oral health improves Medicaid beneficiaries’ ability to obtain and keep employment. Employed adults lose more than one hundred and sixty-four million hours of work each year due to dental problems.
  • Children are more likely to receive regular dental services if their parents have access to dental services; and
  • Therefore, the general assembly declares that in order to improve overall health, promote savings in Medicaid programs, and prevent future health conditions caused by oral health problems, it is in the best interest of the state to establish a permanent oral health benefit for adults in the Medicaid program.

 

(B) State Medicaid Department Requirements

(1) [Insert pertinent state Medicaid department] shall design and implement a dental benefit for adults using a collaborative stakeholder process to consider the components of the benefit, including but not limited to the cost, best practices, the effect on health outcomes, client experience, service delivery models, and maximum efficiencies in the administration of the benefit.

(a) Stakeholders shall include:

(i) A consumer representative who is currently, or has within the past 5 years been, enrolled in Medicaid;

(ii) Appropriate representation of dental benefits companies operating in the state;

(iii) A representative of the disability rights community;

(iv) A representative of the state dental association or society;

(v) A representative of the state hospital association;

(vi) The Governor or his/her designated representative;

(vii) The Secretary of Health or his/her designated representative;

(viii) The Commissioner of Insurance or his/her designated representative;

(ix) Such stakeholders as the [Insert pertinent state Medicaid department] may deem necessary and appropriate

(2) Benefits shall include services that:

(a) Provide emergency care [as defined elsewhere]

(b) Eliminate active dental decay

(c) Bring periodontal condition to a healthy maintenance state

(d) Provide preventive dental services including examinations, necessary x-rays or other imaging, prophylaxis, topical fluoride, oral hygiene instruction, behavior management and smoking cessation counseling, and other services as determined by the commissioner

(e) Provide restorative treatment to restore tooth form and function

(f) Provide medically necessary oral and maxillofacial care

(g) Provide removable prosthodontics to replace missing teeth subject to medical necessity

(3) [Insert pertinent state Medicaid department] shall design the dental benefit for adults in compliance with Section 1902(a)(30)(A) of the Social Security Act using a benchmark on which to establish a dental services fee schedule. To establish a reasonable fee schedule, provider payment levels will be increased on an annual basis by an economic index reflecting overall inflation as well as inflation in practice expenses of the particular provider category involved to the extent data is available.

(4) [Insert pertinent state Medicaid department] shall seek all federal authorizations necessary to provide the adult dental benefit.

 

FOR STATES ESTABLISHING MANAGE CARE CONTRACTS FOR THE ADULT DENTAL PROGRAM – ACCOUNTABILITY MEASURESFOR CONSIDERATION

(A) If State Selects MCO to Manage Adult Dental Medicaid

(a) Prohibit MCO from requiring Medicaid participating dentists to join some or all commercial  MCO products

(b) MCO must reimburse providers at a level that is at least equal to the rate paid by the state’s dental fee-for-service plan

(c) State must retain policy-setting power

(B) Setting Benchmark Measurements for MCO

(a) Establish a time limit for review (i.e. 4-5 years) to measure utilization; compare utilization to a beanchmark (i.e. national average) to measure success or failure of MCO

(C) Corrective Action Plan

(a) If MCO falls below benchmark by a certain amount (i.e. 10 percentage points), MCO must submit corrective action plan describing how the entity intends to increase dental utilization to meet the performance benchmark