Transcription
Statewide Medicaid Managed CareDental Program OverviewOctober 2018
The Dental Component of the StatewideMedicaid Managed Care Program Beginning in December 2018, Medicaid recipients will have anew way of receiving dental services:1. All eligible recipients will be required to select a dental planfor their dental services.2. Each recipient will have a dental plan that will be responsiblefor their dental services.– Recipients will no longer receive dental services through theirhealth plan.– Recipients enrolled in the fee-for-service program will no longerreceive dental services through fee-for-service.2
The Dental Component of the StatewideMedicaid Managed Care Program The purpose of this training is to provide information:– About the services provided by the dental plans– About which recipients must enroll in a dental plan– About the program enhancements in the new dental plans– To providers about interacting with the dental plans3
Evolution of Florida Medicaid Dental Services2014200020162016- Florida Legislaturedirects the Agency to “carveout” dental services fromthe Managed MedicalAssistance plans.2014Phase 1: Statewide MedicaidManaged Care (SMMC):Fully Integrates MedicalCare, Dental, Behavioraland Transportation intoManaged Care (statewide) Fee-for-service dentalservices201020192019Phase 2: Statewide Medicaid ManagedCare: Fully Integrates MedicalCare, Long-Term Care,Behavioral and Transportationinto Managed Care (statewide). No fee-for-service dentalservicesImplementation of dental plans4
What is Changing?2013SMMC ProgramBegins(5 year contracts withplans)2017-2018First Re-procurementof Health Plans;Procurement ofDental PlansTwo Program Components: Managed Medical Assistance(MMA) Program (includesdental services) Long-term Care (LTC) ProgramDecember2018NewContracts(MMA, LTC &Dental) BeginTwo Program Components: Integrated MMA and LTC Dental5
Continued Commitment to Quality All plans under the SMMC program are held to the higheststandards of quality, access, and accountability, including thedental plans.– Quality benchmarks– Provider network standards– Access standards– Compliance levers, including liquidated damages, sanctions– Stakeholder engagement
HEDIS Annual Dental Visit:Major Gains Under Statewide Medicaid Managed CareContinue7
Preventive Dental Services for Children: Major GainsUnder Statewide Medicaid Managed CareEnd of FFY 2014 – SMMC ProgramImplemented*Note: Calendar Year 2014 was a transition year between Florida’s prior managed care delivery system and the SMMC program implementation.8
Dental Plans Commit to Higher PerformancePotentially Preventable Dental Related Events 5% average reduction in Potentially PreventableDental Related Emergency Department Visits(Year 1) 9% average reduction (Year 5)9
Dental Plans Commit to Higher PerformanceImprove Child Access to Dental Care Annual Dental Visit: An average 3% increase yearover-year above the annual target in the ITN Preventive Dental: An average 1% increase yearover-year above the annual target in the ITN10
Dental Plans Commit to Higher PerformanceInitial Oral Health Assessment Oral Health Assessments: Dental plans willcomplete oral health assessments on at least 50%of all children, pregnant women, and enrolleeswith developmental disabilities, within 60 days oftheir enrollment into the plan11
Dental Plans Commit to Higher PerformancePerformance Improvement Projects (PIPs) Dental plans commit to three PIPs:1. Increasing the rate of enrollees accessing preventivedental services2. Reducing potentially preventable dental-relatedEmergency Department visits3. Coordination of transportation services with thehealth plans (this is a joint PIP with the health plans)12
Gains for RecipientsDentalPlansAccess to Care When you Need it:Guaranteed access to after hours and weekend care andteledentistry where available Additional Network Providers: Access to Endodontists andproviders offering sedation as medically necessary Best Benefit Package Ever: Additional benefits at no extra costto the state. Extensive adult dental benefits offered by plans.Model Enrollee Handbook:Information and content has been standardized across allplans’ enrollee handbooks for greater ease of use.13
Gains for ProvidersDentalPlansLess Administrative Burden:High performing providers can bypass prior authorizationLess Administrative Burden:Plans will complete credentialing for network contracts in 60days 14
Gains for Recipients & ProvidersDentalPlansPrompt Authorization of Services:Plans will provide authorization decisions: Within 7 days of receipt of standard request. Within 2 days of an expedited request. Smoother Process for Complaints, Grievances, and Appeals:Plans agreed not to delegate any aspect of the grievancesystem to subcontractors. 15
Stakeholder Engagement Dental plans will:– Participate in Agency dental workgroups– Participate in statewide oral health coalition meetingsfocusing on improving access to services for Medicaidrecipients16
Commitment to Accountability For all of the performance standards in the contract, theAgency can impose penalties and incentives if the standardsare not met, including:– Liquidated damages– Monetary sanctions– Enrollment freeze– Capitation withhold to provide incentives to top performingplans17
Dental Plans will Operate StatewideRegion 2HolmesJacksonNassauGadsdenW altonLeonBayHamiltonMadisonDuvalBakerLibertyRegion 1GulfW l plans willoperate on a statewidebasis. Each dental planwill operate in allregions of the state.Region 4PutnamFlaglerLevyMarionRegion 3VolusiaRegion 7LakeCitrusSeminoleHernandoOrangePascoRegion 5OsceolaPolkRegion 6ManateeHardeeSt. LucieHighlandsSarasotaRegion 1: Escambia, Okaloosa, Santa Rosa, and WaltonRegion 2: Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon,Liberty, Madison, Taylor, Wakulla, and WashingtonRegion 3: Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando,Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, and UnionRegion 4: Baker, Clay, Duval, Flagler, Nassau, St. Johns, and VolusiaRegion 5: Pasco and PinellasRegion 6: Hardee, Highlands, Hillsborough, Manatee, and PolkRegion 7: Brevard, Orange, Osceola, and SeminoleRegion 8: Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and SarasotaRegion 9: Indian River, Martin, Okeechobee, Palm Beach, and St. LucieRegion 10: BrowardRegion 11: Miami-Dade and MonroeDe SotoCharlotteLeeMartinGladesHendryRegion 8Palm BeachBrowardCollierRegion 9Region 10DadeRegion 1118
What Dental Plans will Provide Services? The Agency selected three dental plans to operate statewide:SMMC Participating Dental PlansKnown As:Full Business Name:DentaQuestDentaQuest of FloridaLIBERTYLiberty Dental Plan of FloridaMCNA DentalManaged Care of North America This means that each recipient will have a choice among these threeplans.19
Who is Required to Enroll?20
Who is Required to Enrollin Dental Plans? Dental Plans: Who must enroll?– All recipients who receive MMA services must also choose adental plan.– All recipients who receive their medical services through thefee-for-service system must choose a dental plan, with verylimited exceptions. This includes Medically Needy and iBudget enrollees21
Medically Needy Enrollees Under the Medically Needy program, Floridians who would beeligible for Medicaid except for their income can “spend down” tothe Medicaid limit using qualified medical expenses. Once they spend down (meet their “share of cost”) each month, theyare eligible for Medicaid services until the end of the month.– This includes dental services. Medically Needy recipients who meet their monthly share of costwill be enrolled into a dental plan at the point in the month whenthey meet their share of cost.– Eligibility for dental services through the plans lasts through the end ofthe month once share of cost is met. The Medically Needy recipient will be enrolled into that same planeach month that they meet their share of cost.22
iBudget Enrollees Recipients enrolled in the iBudget waiver for people withdevelopmental and intellectual disabilities will enroll in a dentalplan. All people enrolled in iBudget waiver will receive a letter fromthe Medicaid program listing their dental plan. Contract requirements designed to help people with specialhealth care needs include:– Network requirement for sedation dentistry– Comprehensive assessments– Direct access to a specialist Access to free, robust adult dental expanded benefits Practice acclimation for adults with intellectual disabilitiesoffered as an expanded benefit23
iBudget Enrollees iBudget enrollees receive all services under both the Medicaidstate plan and as outlined in their waiver care plan. State plan and expanded dental benefits will now be receivedthrough the dental plan. Dental plans will provide extensive expanded benefits foradults (age 21 and older) The Agency has established a hierarchy for the responsibilityfor coverage of payment for dental benefits– Dental Plan: State Plan benefits– Dental Plan: Expanded benefits– iBudget Waiver24
iBudget Enrollees1. State PlanDentalServices2. ExpandedBenefit DentalServices3. iBudgetWaiver DentalServices The dental plan covers State Plan dental services. Expanded dental benefits pay after State Plan benefits havebeen exhausted. iBudget waiver covers all remaining dental services (or noncovered State Plan/expanded benefit services) after StatePlan and expanded benefits have been exhausted.25
Nursing Home Residents Nursing home residents who are enrolled in or eligible for theManaged Medical Assistance program currently receive dentalbenefits for adults as outlined in the State Plan. These residents will now be enrolled in a dental plan for thosesame services– These residents will now have access to robust adult dentalexpanded benefits at no cost to the enrollee– Dental providers must be in a dental plan network to bereimbursed by the Medicaid program (through the dental plan)for dental services provided to Medicaid nursing home residents26
Dual Eligibility andDental Plan EnrollmentSome Medicare/Medicaid dual eligibles MAY be required to enroll in a dentalplan, depending on whether they have full Medicaid eligibility (full dual) and theirchoice of Medicare delivery system.Dual Eligibility Group required to enroll inDental?YesNoSometimesFull Duals (QMB Plus)Partial Duals (SLMB, QI1, QMB)Sometimes: If a FULL dual is enrolled in one of thebelow- Are they required to enroll in Dental?YesNoOriginal Medicare (FFS Medicare)Medicare Advantage PlanD-SNPFIDE-SNPFreedom Specialty Plan (C-SNP)27
Who is EXCLUDED from the Dental Plans(May not enroll)? Recipients with a limited Medicaid benefit who do notcurrently receive any State Plan dental benefits, whichincludes:– Partial Dual eligibles (QMB, SLMB, QI1) for whom theState only pays Medicare cost sharing– Presumptively eligible pregnant women– Individuals eligible for emergency services only due toimmigration status– Women who are eligible only for family planning services.28
Who is EXCLUDED from the Dental Plans(May not enroll)? Recipients in institutions or programs where the Agency paysa per diem or all-inclusive rate that includes a component fordental, which includes:– State mental health hospital if under the age of 65– Residential treatment facility– Program of All-Inclusive Care for the Elderly enrollees– Medicaid recipients residing in residential commitmentfacilities operated through the Department of JuvenileJustice or a treatment facility as defined in s. 394.455(47),F.S.29
REMINDER:Recipient Types & Dental Plan SelectionALL recipients must choose:One dental plan in their region30
What Services are Coveredby the Dental Plan? For children: comprehensive dental care, including all medically necessarydental services. For adults: (1) State Plan dental services plus (2) expanded benefits offeredby the dental plans.1. The State Plan dental services for adults are: Dental exams (limited to emergencies and dentures) Dental X-rays (limited) Prosthodontics (dentures) Extractions Sedation Ambulatory Surgical Center or Hospital-based Dental Services providedby a dentist2. Expanded benefit dental services31
Extra Benefits Offeredby the Dental Plans All three dental plans are offering the richest adult dental benefitpackage that Florida Medicaid has ever had.Expanded Dental BenefitsDentaQuestLIBERTYMCNAPreventive Diagnostic Restorative Periodontics Oral and Maxillofacial Surgery Adjunctive General Services Diabetic Testing Practice Acclimation for Adults with Intellectual Disabilities 32
Dental Covered Services: State PlanCoverageServiceDescriptionA review of your tooth, teeth, or mouth by adentistDental ScreeningsA review of your mouth by a dental hygienistInternal pictures of teeth with differentDental X-raysviewsBasic cleanings that may include brushing,Teeth Cleaningsflossing, scrubbing, and polishing teethA medicine put on teeth to make themFluoridestrongerThin, plastic coatings painted into theSealantsgrooves of adult chewing surface teeth tohelp prevent cavitiesEducation on how to brush, floss, and keepOral Health Instructionsyour teeth healthyA way to keep space in the mouth when aSpace Maintainerstooth is taken out or missingFillings and CrownsA dental service to fix or repair teethDental ExamsChildren Adults(ages 0- (ages Prior Authorization20)21 AYesNoN/AYesNoN/AYesNoN/ANote: Additional descriptions of each service and information on the coverage/limitationscan be found in the dental enrollee handbook.33
Dental Covered Services: State PlanCoverageServiceRoot CanalsPeriodonticsDescriptionA dental service to fix the inside part of atooth (nerve)Deep cleanings that may involve both yourteeth and gumsChildren Adults(ages 0- (ages20)21 )YesNoN/AYesNoN/AProsthodonticsDentures or other types of objects to replaceteethYesYesOrthodonticsBraces or other ways to correct teethlocationYesNoExtractionsPrior AuthorizationAsk the dental plan for approvalbefore you go to an appointmentfor these servicesAsk the dental plan for approvalbefore you go to an appointmentfor these servicesN/ATooth removalYesYesA way to provide dental services where aSedationYesYes N/Apatient is asleep or partially asleepDental services that cannot be done in adentist office.Ambulatory SurgicalAsk the dental plan for approvalCenter or HospitalYesYes before you go to an appointmentThese are services that need to be providedbased Dental Services with different equipment and possiblyfor these servicesdifferent providersNote: Additional descriptions of each service and information on the coverage/limitations can be found inthe dental enrollee handbook.34
Dental Plan or Health Plan/FFS:Who covers what? The dental plans will be responsible for coverage of all dentalservices provided by a dentist or dental hygienist. Some services that are considered dental services will still bethe responsibility of the Managed Medical Assistance plan (orthe fee-for-service program if the recipient is not enrolled in anMMA plan) Prescription Drugs and Transportation are covered by theMMA plan or fee-for-service Care will be coordinated by the MMA and dental plansworking togetherNOTE: For Medically Needy and any other recipients who are NOT enrolled in MMA, the Medicaid FFS programwill cover the items listed as “Health Plan Covers”35
Dental Plan or MMA Health Plan/FFS:Who covers what?Type of Dental Service(s)Emergency dental services in a facilityNon-emergency (scheduled) dentalservices in a facilityDental services with sedation in anoffice settingDental services (general or specialty)without sedation in an office setting,County Health Department, orFederally Qualified Health CenterPharmacy (Prescribed Drugs)Dental Plan Covers---Dental services by a dentalproviderDental services by a dentalprovider with a requiredsedation permitMMA Plan/FFS CoversAll emergency dental services andreimbursement to the facilityReimbursement to the facility,anesthesiologist and ancillary servicesAnesthesiologist (MD or ARNP) whenrequired for sedationD-codes when rendered by thedental providerDental services by a dentalDental services provided by a nonproviderdental providerDrugs prescribed by a health careprovider or a dental provider withinscope of practiceTransportation to all dental services--Transportationprovided by the dental or health plan,including expanded dental benefitsNOTE: For Medically Needy, ibudget and other recipients who are NOT enrolled in MMA, the Medicaid FFSprogram will cover the items listed as “Health Plan Covers”---36
Coordination with Health Plans It is critical that there be continual coordination between thehealth and dental plans to ensure enrollees access appropriateand high quality dental care. The following four contractrequirements are designed to ensure constant coordination ofservices and all enrollees’ health:1. Designated Employee: Dental plans will have a designatedemployee to serve as a point of contact for health plans inhelping to resolve operational (i.e., sharing of data/information)and care coordination /issues, and will work directly with theAgency.37
Coordination with Health Plans2. Communication Strategy: Dental plans will work with theAgency and the health plans to foster enhancedcommunication, strategic planning, and collaboration incoordinating benefits.3. Coordination of Benefits Agreement: Dental plans will enterinto a coordination of benefits agreement with the health plansthat includes data sharing and coordination protocols to supportthe provision of dental services.38
Coordination with Health Plans4. New performance measures:– Dental plans must contact each enrollee who went to theEmergency Department within 7 days of discharge andimplement strategies to ensure follow up care is obtained byenrollee.– All dental plans will participate in the Florida HealthInformation Exchange Event Notification Service in order tobe promptly notified when its enrollees access the emergencydepartment.39
How will the Transition to New DentalPlans Impact Recipients? All eligible recipients will be assigned to a dental plan– Can change plans if they choose– May contact Choice Counseling if they wish to make adifferent plan choice.40
When will recipients be notified of thetransition to dental plans? Recipients will receive letter approximately 45 days prior to thetransition date for their region letting them know their dental planassignment and transition date.Phase123Transition RecipientRegionsDateLetter Date12/01/18 ounties9Indian River, Martin, Okeechobee, Palm Beach, St. Lucie10Broward11Miami-Dade, Monroe5Pasco, Pinellas6Hardee, Highlands, Hillsborough, Manatee, Polk7Brevard, Orange, Osceola, Seminole8Charlotte, Collier, DeSoto, Glades, Hendry, Lee, Sarasota1Escambia, Okaloosa, Santa Rosa, Walton2Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Madison, Taylor, Wakulla, Washington3Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter,Suwannee, Union4Baker, Clay, Duval, Flagler, Nassau, St. Johns, Volusia41
Recipient Notification As previously noted, almost all Medicaid recipients must enrollin a dental plan. Each recipient will receive a letter with their dental planassignment. Some recipient letters will also include their MMA and LTCassignment, depending on their eligibility.42
Dental Network Providers To provide Medicaid dental services, providers must beenrolled in one or more dental plan network.– NOTE: All three dental plans participated as subcontractorsunder the MMA program. Providers may already be enrolled. The new dental plan contract requires plans to fully enroll/ onboard all providers it chooses to contract with within 60 days– Defined as: Number of days between the day the dental plan receives afull and complete provider enrollment application and the day theprovider appears on the Agency’s Provider Network Verification file.43
Dental Provider Payments The Agency does not establish payment rates for network providers. Payment rates are negotiated through each provider’s contract with thedental plan. Contact dental plans now to begin the contracting process.– http://ahca.myflorida.com/medicaid/statewide mc/pdf/mma/SMMC Provider Plan Contacts2018-08-06.pdf44
Continuity of Care During the Transition Dental providers should not cancel appointments withcurrent patients.–Dental plans must honor any ongoing course of treatment, for at least90 days after the dental program starts in each region if it wasauthorized prior to the recipient’s enrollment into the plan. Active orthodontic services will extend beyond the 90 daycontinuity of care period.– The dental plan must continue the entire course of treatment with therecipient’s current provider.– The dental plan must reimburse the orthodontic provider, regardless ofwhether the provider is in the plan’s network.– This assumes the recipient continues to have Medicaid eligibility.45
Continuity of Care During the Transition Providers will be paid. Providers should continue providingany services that were previously authorized, regardless ofwhether the provider is participating in the plan’s network.Plans must pay for previously authorized services for at least 90days after the Dental program starts in each region.– Plans must pay providers at the rate previously received forup to 30 days.– After 30 days, the plan and provider may negotiate a rate.46
Next Steps47
How Do Recipients Choose a Dental Plan? Recipients may enroll in a plan or change plans: Online at: www.flmedicaidmanagedcare.com By calling toll-free 1-877-711-3662 or 1-866-467-4970(TTY) and speaking with a choice counselor OR using theInteractive Voice Response system Choice Counselors assist recipients in selecting a plan that bestmeets their needs. This assistance will be provided by phone, however recipientswith special needs can request a face-to-face meeting.48
What is the Process for Enrolling in aDental Plan? Recipients are encouraged to work with a Choice Counselor tochoose the dental plan that best meets their needs.Recipients haveabout 45 days tochange their initialplan assignmentbefore their regiongoes live.Recipients have 120days afterenrollment tochange plans.After 120 days,enrollees must stay intheir plan for theremainder of the 12month period beforechanging plans again.*Enrollees can changeproviders within theirplan at any time.*Recipients may change plans again before the remainder of the 12 month period,but only if they meet certain criteria.49
Member Portal Recipients can go to www.flmedicaidmanagedcare.com andclick the login/register button in the top navigation bar50
Member Portal Enrollees can use the member portal for plan enrollment (choosinga dental plan) and disenrollment, monitoring their enrollmentstatus, filing complaints, modifying their profile, and more.51
Member Portal Features52
How to Keep Informed Agency website: http://ahca.myflorida.com/smmc Provider alerts: Sign up online athttp://ahca.myflorida.com/smmc– Under Providers, select “Sign-Up for Program Updates” Webinars Targeted outreach with stakeholders53
www.ahca.myflorida.com/smmc54
Stay loridaTwitter.com/AHCA FLQuestions can be emailed to the SMMC Inbox atflmedicaidmanagedcare@ahca.myflorida.com55
Live Q&A Session We will now address questions. Please type your questions in the “Questions”pane of your webinar control panel.56
–To providers about interacting with the dental plans 3. 4 Evolution of Florida Medicaid Dental Services 2000 2010 2014 Phase 1: Statewide Medicaid Managed Care (SMMC): Fully Integrates Medical Care, Dental, Behavioral and Transportation into . DentaQuest DentaQuest of FloridaFile Size: 2MBPage Count: 56
