Dental Medicaid


Wi-counties-for-Medicaid-pilot---2015

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.

Background

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.

Dental Medicaid Spening

 Medicaid - 2

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Moving Forward

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.

The WDA hosted educational meetings in each of the four pilot counties to help dentists (members and nonmembers) and their dental teams understand pilot details, including how to sign up to be a MA provider, where to obtain a pilot program fee schedule and who to contact for assistance once participating in the pilot program. DHS representatives also participate in each of these meetings.  Total attendance at these four meetings was over 100 dentists and team members.

WDA is working with other stakeholders on laying the groundwork for an expansion of the pilot. Legislation that would allow DHS to expand the pilot to any county where there is significant need has been introduced by:

Rep. Kathy Bernier (R-Chippewa Falls) https://docs.legis.wisconsin.gov/2017/proposals/reg/asm/bill/ab627

Rep. Joe Sanfelippo (R-New Berlin) https://docs.legis.wisconsin.gov/2017/legislators/assembly/1606

Rep. Deb Kolste (R-Janesville) https://docs.legis.wisconsin.gov/2017/legislators/assembly/1576

Sen.Terry Moulton (R-Chippewa Falls) https://docs.legis.wisconsin.gov/2017/legislators/senate/1518

Sen. Leah Vukmir (R-Brookfield) https://docs.legis.wisconsin.gov/2017/legislators/senate/1530

Sen. LaTonya Johnson (D-Milwaukee) https://docs.legis.wisconsin.gov/2017/legislators/senate/1643

The bill, AB 627 (https://docs.legis.wisconsin.gov/2017/proposals/reg/asm/bill/ab627) has been sent to the Assembly Committee on Health and will receive a public hearing on Nov. 29 at 10 a.m.

 

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.

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Other resources:

  • 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]

Support for Dental MA Pilot

FAQs

How do the new enhanced Medicaid rates compare to commercial insurance companies?

Although we cannot get into details of any specific insurance plan, if you review the enhanced rates for the pilot to one of your contracted insurance plans, you will see they are quite comparable. The WDA thinks it’s important to note that with pilot reimbursement rates that fall similarly in line with commercial contracted rates, becoming a Certified Medicaid Provider should be easier to incorporate into your practice just like any other plan.

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?

Yes, you would then have to abide by this new regulation IF, and only IF, the patient asks for a language translator then you must accommodate the request. However, the ADA and the WDA have worked to make this requirement as easy to implement as reasonably possible. You can find additional information on 1557 via the ADA website at http://success.ada.org/en/regulatory-legal/section-1557 or call the WDA Madison office for assistance as well at 888-538-8932

Is the process of filing claims and getting paid by Medicaid still as cumbersome as it has been in the past?

Since the state developed ForwardHealth and the Medicaid portal, the process of becoming a Certified Medicaid provider and filing claims became more seamless. Everything you need to know about being a Medicaid provider, claims, coverage benefits and reimbursements is all located online and in one place now. The creation of the Dental Unit has also made things easier when you need assistance and call provider relations since you will be able to speak with someone who understands the dental world. All handbooks, fee schedules and claims info can be found online at www.forwardhealth.wi.gov

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?

Yes. You can treat any Medicaid patient from any county in Wisconsin and the state must still pay you the enhanced rate since your practice is inside a pilot county. This is also one data parameter that we requested to be tracked since it will be good to know how far Medicaid recipients will travel to obtain the oral health care they need. If the pilot counties have more providers in them that take Medicaid, we foresee more people traveling to one of those counties for care.

Is there any mandate for the state to collect data on the pilot counties and make that public?

Although our original proposal dictated what data parameters to collect and when, the Governor did veto that out of the bill. However, the Department of Health Services, Oral Health Program obtained grant funding from HRSA to do data collection on the pilot. DHS will be contracting with UW Population Health Institute to collect and publish data on the pilot. The WDA will continue to work closely with DHS staff on what parameters should be collected and will also publish the data when available.

Do the HMOs have to pay the dentists the enhanced rates too or is that adjusted differently?

Yes, the HMOs in Racine county must pay the dentists the same enhanced rate that any fee-for-service provider outside of Racine county (and in a pilot county) would get as well. Please contact the HMO you are contracted with to see how this is passed onto the dentist.

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?

No, it does not mean you must open your doors to every Medicaid patient that calls your office. You can still limit your participation however you wish as long as you are not discriminating against any of the protected classes. You can also contact the dental unit at ForwardHealth and ask that they take your name off the list of providers that is online so the calls don’t keep coming in. They can be reached at 1-800-947-9627 Option #4.

What happens when the state runs out of money that is allocated to the pilot? Do the enhanced rates just stop then?

It is our hopes that the state does in fact run out of the $13.7 million allocated because that would mean more children are being seen, more emergency adults are being seen and more dentists are signing up to be Certified Medicaid Providers. The state cannot stop reimbursing at the enhanced rates even if the money runs out. They will need to find the money to continue the enhanced payments in the pilot counties.

 

If I have multiple practices, one in a pilot county and one outside the pilot county, do both offices get the enhanced reimbursement rate since the offices have the same doctors who are Certified Medicaid Providers?

No. Only the office within the pilot county will get the enhanced rate. The office outside of the pilot county will still get the usual reimbursement rate. If you have two (or more) offices, one in the pilot county and one outside the pilot county, you need to contact ForwardHealth Dental Unit and speak with a representative so that they can register your office that is in the pilot county so that you obtain the enhanced reimbursement rate when services are provided there. The enhanced rate is based off the place of service where treatment is provided. The dental unit will work with you to make sure the correct offices are getting the correct reimbursement rate. You can contact them at 1-800-947-9627 Option #4 and let them know your situation.

If I am already a Medicaid Provider must I do something different to get these enhanced reimbursement rates since I am in one of the pilot counties?

No. If you are already enrolled as a Certified Medicaid Provider with the state, then you do not need to do anything to obtain the enhanced rates. Submit your dental claims as usual.

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