MEDICAID DENTAL PROGRAM Policy Review

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MEDICAID DENTAL PROGRAMPolicy Review
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What is Medicaid?

• Wyoming Medicaid is a joint federal and state
  government program that pays for medical and
  dental care for low income and medically needy
  individuals and families.
• Wyoming Medicaid benefit expenditures generally
  receive 50 percent Federal match (FMAP).
• Medicaid provides medical assistance for
  low-income and medically vulnerable citizens.
  There are currently four major categories of
  eligibility Children, Pregnant Women, Family
  Care Adults, and Aged, Blind or Disabled (ABD).

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What is the Affordable Care Act (ACA)?

• The Patient Protection and Affordable Care Act
  (PPACA), commonly called the Affordable Care Act
  (ACA) or "Obama Care", is a United States federal
  statute signed into law by President Barack Obama
  on March 23, 2010.
• Under the law, a new Patients Bill of Rights
  gives the American people the stability and
  flexibility they need to make informed choices
  about their health.

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How does the ACA impact Wyoming Medicaid?

• Expands income eligibility for children
• Transitions children from Kid Care CHIP to
  Medicaid
• Implements the Modified Adjusted Gross Income
  (MAGI) eligibility for children, pregnant women
  and family care adults
• Expands the availability of Medicaid benefits to
  former foster care children until age 26

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Medicaid Dental

• Childrens program is mandatory by the federal
  government and covers all services needed to
  prevent and treat dental diseases and restore
  function.
• Adult program is optional and can be limited to
  basic services as determined by each state.
• Expansion of the adult coverage range is optional
  and must be passed by the legislature and
  governor for each state.

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State Duties vs. Fiscal Agent Duties

• The Division of Healthcare Financing administers
  the Medicaid program. They are responsible for
  financial management, developing policy,
  establishing benefit limitations, payment
  methodologies, and fees, and performing
  utilization reviews.

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State Duties vs. Fiscal Agent Duties

• The Fiscal Agent (Xerox Healthcare Solutions)
  processes all claims and adjustments. They also
  answer provider inquiries regarding claims
  status, payments, client eligibility, known third
  party payers and provide onsite visits to train
  and assist your office staff on Medicaid billing
  procedures or to resolve claims payment issues.

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Who reviews dental policies?

• The Medicaid Dental Manager is responsible for
  presenting new policies, codes, and fees to the
  Medicaid Dental Advisory Group (DAG) for
  consideration.
• The DAG is made up of 6 dentists and Department
  of Health and Fiscal Agent employees.
• The DAG collectively reviews new or changes to
  existing policies for compliance with industry
  standards.

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What does the DAG do?

• When would the DAG review a policy?
• New ADA codes
• Provider requested fee increase
• Data shows outliers in billed charges
• Clinical appeals from providers
• The DAG members also provide professional advice
  and expertise on current acceptable dental
  practices.

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Who are the current DAG members?

• Dr. Jay Cole- Pediatric Dentist-Cheyenne
• Dr. Jim Nelson- General Dentist- Worland
• Dr. A. Bryce Castillon- General Dentist- Green
  River
• Dr. Thomas Zumo- General Dentist- Cheyenne
• Dr. Matthew Henry- Pediatric Dentist- Cheyenne
• Dr. Jim Hoag- State Orthodontic Consultant
• Members from the Wyoming Dental Association are
  invited to attend and participate at quarterly
  meetings as representatives of the professional
  association in Wyoming.

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What is Public Health Dental?

• The Oral Health section of Public Health is not
  funded or managed by Medicaid.
• Public Oral Health has many programs that are
  paid for by State general funds to help assist
  uninsured or underinsured dental patients.
• These programs include Senior Dental, Marginal
  Dental, Sealant Program, Cleft Palate Program,
  and part of the Severe Malocclusion Program.

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Who is in charge of Public Oral Health?

• Public Oral Health has a manager, Cassandra
  Walkama RDH, MPH and a dentist, Dr. Edward
  Lawler.
• These programs were previously administered by
  Trish OGrady and Peggy Baluska.
• Public Oral Health also employees 4 Community
  Oral Health Coordinators (public health
  hygienists).

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How many dentists participate with WY Medicaid?

• In 2015, 231 of the 295 licensed, practicing
  dentists in Wyoming are enrolled as Medicaid
  providers
• WY ranks in the top 10 for provider participation
  and fee reimbursement in the nation. 78 of
  licensed dentists are MC providers. The national
  average is (40-50)

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How many Medicaid clients are there?

• As of March 2015 there were
• 46,456 children on MC
• 27,288 adults on MC
• 2,106 nursing home residents on MC
• Of the 46,456 children on MC in 2015, only
  21,838 (47) have been seen for a dental visit
  and only 18,701 (33) have had a prophy

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What are my requirements as a provider?

• Bill claims timely, within 12 months to avoid
  timely filing denials
• Retain adequate records
• Inform clients, in writing, if a service is not
  covered or if the client has used their benefit
  limits
• Report suspected abuse or fraud by another
  provider or eligible client (page 4-5)
• Check client eligibility prior to rendering
  services
• Review and understand all policies contained in
  the provider manual

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What is Program Integrity?

• Medicaid Program Integrity Unit is in place to do
  the following
• Review of claims submitted for payment
• Review of dental records related to covered
  services
• On-site review of dental records and client
  interviews
• Case management oversight
• Recovery of overpayments or payments made in
  error based on policies

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What is expected from Program Integrity?

• Each employee in the provider office are informed
  of Medicaid rules and policies
• Records are kept accurately on each client
• Access to client records as requested
• Access to financial records of reimbursement from
  Medicaid
• Office policies are enforced the same for all
  types of patients EX. Medicaid, Cash pay,
  Traditional insurance

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What is required in the records?

• A patients dental records must contain the
  following information and be typed or legibly
  hand written
• Name on each page of the record
• Diagnosis of disease/conditions and history
• Treatment Plan
• All services rendered with
• gtTooth Numbers
• gtSurfaces
• gtQuantities
• gtMedications and dosages
• gtObserved conditions progress at each visit
• gtTotal treatment minutes if codes are used
  that are
• reimbursed at 15 minute increments

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Severe Malocclusion Program

• The SMP is the orthodontic program for Medicaid
• Clients can be referred to an orthodontist if
  there malocclusion appear to meet the set
  guidelines
• Clients go through an approval process before
  ortho can be started
• Only clients who have poor malocclusions that
  affect function EX. Speaking, Chewing, Breathing,
  will be approved

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