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Medicaid CHIP State Dental Association Who We Are Directors, managers and staff of state Medicaidand Children’s Health Insurance Program (CHIP)Oral Health ProgramsMedicaid-CHIP State Dental AssociationSilver TsunamiMARY E. FOLEY, MPHExecutive DirectorMedicaid-CHIP State Dental Association Individuals and groups who collaborate or have aninterest in Medicaid and CHIP Oral HealthPrograms and their beneficiaries2013 National Oral Health ConferenceApril 2013Medicaid-CHIP State Dental AssociationObjectives To increase knowledge and understanding ofMedicaid To share information about Medicaid as it presentlyrelates to older adults To raise awareness of public payment programs forolder adultsVision: All Medicaid and Children’s Health InsuranceProgram beneficiaries receive quality oral health care services.Mission: To develop and promote evidence-basedMedicaid/Children’s Health Insurance Program (CHIP) oralhealth best practices and policies through innovativecollaboration with a broad spectrum of stakeholders.Oral Health for Seniors - A Health Systems ApproachU.S. Department ofHealth and Human ServicesCMS: MedicareHealthcare Delivery for Seniors 65 , Disabled and ESRDStatutory Dental Exclusion Section 1862 (a)(12) of the Social Security Act states, "wheresuch expenses are for services in connection with the care,treatment, filling, removal, or replacement of teeth or structuresdirectly supporting teeth, except that payment may be madeunder part A in the case of inpatient hospital services inconnection with the provision of such dental services if theindividual, because of his underlying medical condition andclinical status or because of the severity of the dental procedure,requires hospitalization in connection with the provision of suchservices."Stronger linkages and interconnectivity needed.5It’s time to reopen the conversation and expand oralhealthcare to Medicare beneficiaries.

MedicaidMedicaid“Entitlement Program”Federal and State Responsibility Enacted in 1965 under Title XIX of Social Security Act Jointly administered by federal and stategovernments Pays for “medically necessary” healthcare servicesdefined in statute– EPSDT for children– Minimum income and eligibility criteria set by federal government– States may expand eligibility criteria State variability– Eligibility– Benefits– Payment Provide appropriate access to careMaintain coverage of individuals and benefitsEnsure adequate provider participationCoordinate care with Medicare (dual eligibles)Contain costsMaintain program integrityMaintain fiscal accountabilityDental Coverage in MedicaidChildren Comprehensive for under EPSDT 2014 -Estimated 5.3 M additional children Limitations under CHIPAdults Optional coverage for states Not included as part of “essential benefitspackage” offered in state ExchangesMedicaid Eligibility Varies by state Statute creates the mandate Federal government– Establishes minimum criteria - (FPL) State government– Upholds federal mandate– May opt to expand eligibility (i.e. Increase to 200% FPL) U.S. Citizenship, nationals or qualified aliensCovered Services Federal Role: Establish the Law– EPSDT for children defined under statute- mandatorybenefits State Role: define services and benefits based onamount, duration and scope– “Essential Benefits” are not defined under Medicaid– Highly variable among states– States may expand services (optional)Basic Eligibility Requirement Financial– Income and resources Non-financial criteria– State residence– Citizen or qualified alien– Social Security Number– Assignment of rights to medical support andpayment– Special populations

Medicaid ProgramState Level FinancingMedicaid Eligibility Criteria Target populations Low-income Disabled Aged Blind Pregnant women Children Single parents Varies by stateFormulas- Federal and StateEconomic environmentState budgetsMedicaid spending is the largest or secondlargest item in virtually every State budget States have discretion and control over their programsMedicaid EligibilityFederal Mandates2010 Low-income children andtheir parents Pregnant women Individuals with disabilities Individuals ages 65 and over Income levels:– Children age 6 133% of FPL– Children age 6 andolder 100% FPL– FPL 18,310 for family of 3– Differs for other categories2014 – PPACA* Low-income children andtheir parents– Raises eligibility for childrenages 6-9 in 20 states Pregnant womenIndividuals with disabilitiesIndividuals ages 65 and overLow-income adults who donot fall into one of thesecategories (by 2014 or earlierat state option)**Patient Protection and Affordable Care Act14Medicaid Enrollment20102014 and PPACA 68 Million Beneficiaries 33 Million Children 11 Million Low-income withdisabilities 6 Million Low-incomeseniors/long-term care Additional 32 Million Maintenance of Effort (MOE)– State eligibility policies mustremain in place until 2014 oruntil state Exchanges are fullyoperational-for adults– For children –until 2019 New formula for eligibility*Originally in American Recovery andReinvestment Act (ARRA)H.R 3590– “modified adjusted grossincome– IT systems modificationsState Medicaid SpendingNew Administrative Models Historically fee-for-service and “in-house”administration Changing to HMOs, MCOs, TPAs, Hybrid Increased complexity in state programs– Contracting with 1 or more MCOs– Dental carve outs– Subcontracting for administration of dental– Increase in use of risk-based models

Medicaid Spending Driven by– Enrollment growth– Inflation– Policy changes During economic downturn– Eligibles increase– Shortfalls in state budgets emergeMedicaid and CHIP CostsLevers that Affect Spending and Costs EligibilityBenefitsCost-sharingProvider paymentsCMS: MedicaidEnrollment and Spending Overarching costs include– Provider payments– Managed care plans– Administrative tasks Disproportionate share– Individuals age 65 and older and seniors with disabilitymake up 1/3 total eligible 2/3 total costs Major drivers:– Medical practice patterns– New, high cost technologiesAnnual Medicaid Costs byAge and Disability Medicaid and CHIP Costs15% Total U.S. Healthcare Spending (FY2010)Non-disabled child @ 2900*Non-Disabled adult @ 4100*Person with disability @ 16,600*Person aged 65 or older 15,700 AFTERMedicare (Primary payer for hospital,physician and other acute services)76 Million Beneficiaries * 68 Million Medicaid * 8 Million CHIP

Medicaid Payer ModelsMedicaid Spending Traditionally fee-for-service Changing more to Health Maintenance Organizations(HMO)and Managed Care Plans (MCO) Increase in use of risk-based models States contracting with 1 or more managed careorganizations– AZ- 12 managed care contracts (2011)– Dental carve outs– HMOs Subcontracting with dental organizationsState Program Administration is Variable Fee for Service Managed Care Hybrid Models Cost-based Reimbursement FQHC Encounter Rates Title V Agencies26Cost SharingCoverage Cost sharing: [Co-payments] Maximum allowable charge Exclusions from cost sharing– Children under age 18– Pregnant women– Institutionalized individuals– Emergency services– Family planning services No provider may deny services due to inability topay Mandatory Early Periodic Screening Diagnosis and TreatmentProgram [EPSDT] Optional Adult Dental27Snapshot of State Medicaid Programs Do states cover dental services for seniors(adults)? Yes- Some do. If so, do states have a managed carearrangement? Yes- Some do28

States with Medicaid Dental Benefits for AdultsAlaskaDCHawaiiStates with Medicaid Adult Dental Benefits byMCO StatusAlaskaState Medicaid Adult BenefitsBenefitsCovered ServicesQPlease indicate which services are covered by your state Medicaid program for: children, adults, and special adult groups.Does your State Collect Data on dental screening? If yes, how is it coded?ServicesD0150- Comprehensive ExamD0120- Periodic Oral EvaluationDCD0140- Limited Oral Evaluation, Problem FocusedD0145- Oral Exam- Child under 3D1110- Adult ProphylaxisD1120- Child ProphylaxisD1203- Fluoride TreatmentD1206- Fluoride VarnishD1351- Dental SealantD2330-2394- Composite RestorationsD2140-2161- Amalgam RestorationsD7110-7250- ExtractionsMCOHawaiiD2930-2954- CrownsD3220-3999- Endodontic TreatmentAdult MCOD4910- Periodontal MaintenanceD9920- Behavi or sRegion Region Region Region Region Region Region Region Region 633311110000000011000Selected dental services covered under state Medicaid programThis information is associated with question number 17 of the 2012 MSDA Profile.State Medicaid ProgramsNational Summary of Adult Dental BenefitsState Medicaid Programs with Managed CareAdult Dental BenefitsBenefitsStateCovered ServicesQPlease indicate which services are covered by your state Medicaid program for: children, adults, and special adult groups.Does your State Collect Data on dental screening? If yes, how is it coded?ServicesD0150- Comprehensive ExamD0120- Periodic Oral EvaluationD0140- Limited Oral Evaluation, Problem FocusedD0145- Oral Exam- Child under 3D1110- Adult ProphylaxisD1120- Child ProphylaxisD1203- Fluoride TreatmentD1206- Fluoride VarnishD1351- Dental SealantD2330-2394- Composite RestorationsD2140-2161- Amalgam RestorationsD7110-7250- ExtractionsD2930-2954- CrownsD3220-3999- Endodontic TreatmentD4910- Periodontal MaintenanceD9920- Behavior 7Selected dental services covered under state Medicaid programThis information is associated with question number 17 of the 2012 MSDA Profile.AlaskaArkansasColoradoConnecticutDistrict s Name/sFFSFFSFFSFFS/ASO- Hewlett Packard (FA)/ BeneCare- Chartered Health PlanMCO - UnitedHealthCare- HSCSNFFSFFSFFSFFS- WellCare of Kentucky- Coventry Health CareMCO- Kentucky Spirit- Passport Health PlanFFSFFSFFSFFSMCO - Delta Dental of MIAdult BenefitsAdditional Benefits forPregnant 32221

State Medicaid Programs with Managed CareAdult Dental BenefitsState Medicaid Programs with Managed CareAdult Dental piMCOMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevadaNew HampshireMCOFFSFFSFFSFFSFFSFFSNew JerseyMCOContractor/s Name/sAdult BenefitsAdditional Benefits forPregnant AdultsLLNN- Delta Dental of MI- UnitedHealthCare- Magnolia- DentaQuest- AmeriGroup- UnitedHealthCare CommunityHealth Plan- Horizon New Jersey Health- Health First- PACEENLCLLLLENNNYNYNCNStateNew MexicoNew YorkOhioOklahomaOregonState Medicaid Programs with Managed CareAdult Dental BenefitsStateModelPennsylvaniaMCORhode IslandSouth FFSWisconsinWest VirginiaWyomingMCOFFSFFSContractor/s Name/s- Vista Health Plan- Gateway Plan Inc.- UnitedHealthCare ofPennsylvania- Health Partners- UPMC for You Inc.- Aetna Better Health Inc.- CoventryCare- Southeast Dental Associates- DentaQuestAdult BenefitsAdditional Benefits forPregnant AdultsLNLLELEENNYYNYLNELNNMCOContractor/s Name/s- Lovelace- Molina- Presbyterian- Blue Salud- UnitedHealthCare- AmerigroupFFSFFSFFSMCO- Advantage Dental- Capital Dental Care- Willamette Dental Group- ODS Community Health Inc.- Care Oregon- Access Dental Plan- Family Dental Care- Managed Dental Care of OregonAdult BenefitsAdditional Benefits forPregnant AdultsLNLLENNYCNOther ProgramsIncurred Medical Expenses The Incurred Medical Expense regulations canhelp most nursing facility residents who areenrolled in Medicaid pay for dental care. Medicaid residents with Social Security or otherretirement income may be able to pay formedically necessary dental care that is notcovered by Medicaid. pdfs/ime documents.pdfPrograms are only as strong as the policies andfinancing mechanisms in place to support them.Public Health Systems function as the Safety-net forDelivery SystemsNeed to be Better Linked and Interconnected withHealthcare DeliveryModel.Health Reform - Opportunity to Rebuild andStrengthen US Health Systems