NMDA Journal Spring 2020

nmdental.org 11 option to participate in the Fee for Service Program or the Managed Care Medicaid Pro- gram. A provider may participate in one pro- gram or both. The providers need to complete a separate credentialing applica- tion for each program. New Mexico Human Service Department (NMHSD) reports that there are 1,073 active dental providers enrolled in Medicaid and of those, an estimated 690 dentists are enrolled in DentaQuest (BCBS and PHP dental ven- dors). Of the 1,073 dental providers enrolled in Medicaid it is not clear if all the providers continue to accept Medicaid or not. HSD reports that for CY 18, 152 dentists had at least one Fee for Service Claim. According to the HSD CMS 416 Annual EPSDT report for FY 17, there were 416,295 children aged 1 to 20 enrolled in Medicaid that were eligible for Early and Periodic Screening Diag- nostic and Treatment Benefit (EPSDT) partici- pation in New Mexico. Of the 416,295, only 230,443 received any dental services; 208,072 received preventive services such as some form of fluoride and 25,708 received a dental sealant on a permanent molar tooth. The report also shows that 229,635 children received dental treatment services, defined as fillings, tooth extractions, and/or other services. Background Some policy changes that impact the work of the Task Force have been implemented or are under consideration by the HSD. For example, effective July 1, 2019 NM Medicaid covers topical fluoride varnish treatments for children aged six months though age 20. The codes may be billed twice per year by either the child’s dentist or primary care provider (PCP). Fluoride Varnish is a highly concentrated form of fluoride which is applied to the tooth's surface by a dentist, dental hygienist or other health care professional, as a type of topical fluoride therapy. It may be applied to the enamel, dentine, or cementum of the tooth and can be used to help prevent decay, re-mineralize the tooth surface, and treat dentine hypersensitivity. In addition, effective July 1, 2019, HSD restored the 2016 2% reduction of dental reimbursement. HSD is also studying the possibility of cover- ing Silver Diamine Fluoride (SDF). SDF is commonly used to arrest tooth decay. SDF is an advanced form of fluoride used to destroy harmful bacteria. The application of SDF will curtail the spread of decay and lessen the need for fillings or extractions. Reimbursement for SDF will be an additional way for providers to reduce the costly treat- ment of tooth decay among children enrolled in Medicaid. Effective October 1, 2019, HSD established a new minimum encounter rate for Federally Qualified Health Centers (FQHC) dental ser- vices of $200 based on the national average cost of a dental encounter as established by the Health Resources and Services Adminis- tration (HRSA) Uniform Data System for 2017. » Reimbursement Issues New Mexico and other states have identified low reimbursement rates as the reason for poor dental provider participation in Medic- aid programs. Analysis An ongoing study conducted by the New Mexico Dental Association (NMDA) found that the number one reason for not being certified as a Medicaid provider is the low reimbursement rates, followed by the diffi- culty with claims being rejected, scope of allowable care, and patient unreliability. An additional increase in the reimbursement rates would increase the number of dental professionals applying to become a certified Medicaid provider, since dental providers would be reimbursed at a rate that would adequately compensate them for the clinical and administrative cost of their services. Such an increase would also encourage existing Medicaid providers to remain in the program and recruit new Medicaid Patients. The NMDA membership also reported that some of their members accept Medicaid patients, some would see Medicaid patients if the enrollment and reimbursement process was improved, and some would not see Med- icaid patients even if the system was improved. The survey also reported that improving 3rd party payer issues is very important to the membership. It should be noted that the survey is a small sample. Other dentists interviewed for this report con- curred with the findings of the NMDA survey. Recommendations • Increase dental reimbursement rates by an additional increase of 3% • Implement a pilot Public Partnership in underserved counties to increase provider participation (like the one provided for Medicaid by Delta Dental of Michigan). The pilot project’s goals are to improve children’s oral health targeting counties in need, based on gaps in services according to data obtained from the CMS 416 report. Review of the CMS 416 report will define the enhanced benefits that may be needed. The project will enlarge the provider network for children enrolled in Medicaid and/or (depending on the pilot counties) increase provider participation in outreach to Medicaid patients, e.g. increasing education to patients regarding their benefits and responsibilities. The project’s performance will be measured using Healthcare Effectiveness Data and Information Set (HEDIS) and other metrics, such as an increase in dental provider participation, and number of annual visits by age. The results will be compared to encounters reported by HSD and Managed Care Organizations (MCOs) in previous years. Should the legislature approve this pilot project, a study will be required to identify the underserved counties and population in need. Delta Dental of New Mexico (DDNM) is requesting funds from the Legislature for this pilot project that would allow specific additional dental benefits and enhance reimbursement to dentists using negotiated rates approximating the average commercial reimbursement rates. This project would operate in addition to the current Medicaid program. • Develop collaborations within counties to educate Medicaid recipients about the importance of oral health. • Demonstrate increased outcomes for established quality improvement metrics. » System Issues The existing system for provider enrollment for Medicaid and Managed Care Organiza- tions certification and reimbursement is com- plicated and burdensome. Analysis Currently, the certification to be a Medicaid dental provider requires a provider to be cer- tified by state Medicaid and the Managed Care Dental Administration (MCO), a dupli- cative process. Dentists do have the option to provide services to members who are fee-for- service, managed care, or both. Recommendations • Update and streamline the provider enrollment, reimbursement, and appeal (for denied claims) processes • HSD implement a single combined application process for certification continues on page 12 