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Dental Medicaid Pilot Program
2015 Wisconsin Act 55
The Dental Medicaid Pilot Program will test the positive impact that raising MA reimbursement rates will have on improving access to dental care for low-income patients enrolled in this state program.
The Wisconsin Dental Association has long supported increasing rates for all children’s care and for limited adult emergency care in “pilot” counties with hopes that documented success will naturally lead to an expansion of the number of counties where dental MA rates are increased.
- Wisconsin’s MA reimbursement rates are currently the third lowest in the nation for children’s dental care and fifth lowest in the nation for adult dental care.
- In state fiscal year 2011 (last year for which Department of Health Services has provided dental-specific data), the state spent $7.1 billion on all services provided to its MA recipients. Of that total, only $65 million (less than 1 percent) was spent on dental care.
In early July 2015, Gov. Scott Walker signed into law a dental Medicaid pilot program to test market-based rates in improving access to all dental care services provided to MA-enrolled children and enrolled adults seeking emergency dental care when provided in the four counties of Brown, Marathon, Polk and Racine.
The three fee-for-service counties (Brown, Marathon and Polk) must stay fee-for-service for purposes of this pilot, and the one MA Health Maintenance Organization or HMO county (Racine) must also remain HMO and pay dentists at the same rate as dentists in the fee-for-service counties. Federally Qualified Health Centers are not allowed to bill under this pilot, regardless if they are in the pilot county, because they already receive cost-based reimbursement through a separate mechanism dictated by the federal government.
The WDA has worked closely with DHS on all aspects of pilot implementation. The WDA has provided valuable input on pediatric oral health services and would like to eventually see the number of low-income children receiving dental care each year increase to a rate similar to that of children not on MA.
The WDA was also involved in developing the list of covered adult emergency dental services. It is hoped that the pilot will make it easier for adult MA patients to obtain urgent dental care from dentists, thereby lowering visits to emergency rooms and reducing the number of prescriptions needed for pain and infection which do not solve the underlying oral health issues. If the pilot is sustained over several years, it is hoped MA patients will ultimately experience less dental pain and need fewer higher-cost, restorative procedures, because they will be accessing lower-cost, routine, preventive dental care on a regular basis.
The Dental Medicaid Pilot Program went live on October 1st, 2016 in all four counties.
In February 2019, the UW Population Health Institute released its of the first year (2016-2017) of the program. Key initial findings were:
- A 4% increase in the number of children receiving dental services, from 40% to 44%;
- A 5% increase in the number of adults receiving dental services, from 25% to 30%;
- A 33% increase in the number of dentists enrolled as Medicaid providers in the pilot counties;
- 35% of the new enrollees served over 100 Medicaid patients.
WDA continues to meet regularly with the Department of Health Services and request updated data.
Efforts to remove the pilot program in the 2019-2021 budget were unsuccessful due to WDA advocacy. We continue to push for expansion of the pilot and increased Medcaid rates, as we believe that the state is best served by investing in the current workforce, as opposed to creating new models.
Detailed information regarding enrollment, submission of claims, reimbursement and more can be obtained by visiting the online handbook on the ForwardHealth Portal at www.forwardhealth.wi.gov.
- Targeted Dental Reimbursement Rate Increase page of the portal is available online. To locate the page, MA providers will need to select the provider-specific resources link from the portal home page and then select the more information link under the dentist provider type.
- ForwardHealth Dental Provider Services at 800-947-9627, option #4
- ForwardHealth also sends electronic messaging and updates via portal account messaging. Providers should subscribe to messaging to be notified of new updates and monthly summaries.
WDA members may also contact WDA Dental Practice and Government Relations Associate Dental Practice and Government Relations Associate Erika Valadez for more information at 608-250-3442, toll-free 888-538-8932 or [email protected]
▶ If I become a Certified Medicaid Provider, must I then abide by the new ACA rules for Section 1557 that state I must provider a language translator to Medicaid patients if they ask for one?
▶ Is the process of filing claims and getting paid by Medicaid still as cumbersome as it has been in the past?
▶ If I am a Certified Medicaid Provider and my practice is in one of the pilot counties, can I treat kids and emergency adults from outside the county and still get paid the enhanced rate?
▶ If I sign up to be a Certified Medicaid Provider to participate in this pilot, does that mean I have to take every Medicaid patient that calls my office? How will I control being overwhelmed?
▶ What happens when the state runs out of money that is allocated to the pilot? Do the enhanced rates just stop then?