MEDICAID DENTAL PROGRAMMEDICAID DENTAL PROGRAMPolicy ReviewPolicy Review

What is Medicaid?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).

What is the Affordable Care Act What is the Affordable Care Act (ACA)?(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 “Patient’s Bill of Rights” gives the American people the stability and flexibility they need to make informed choices about their health.

How does the ACA impact How does the ACA impact Wyoming Medicaid?Wyoming Medicaid?

Expands income eligibility for childrenTransitions children from Kid Care CHIP to

MedicaidImplements 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

Medicaid DentalMedicaid Dental

Children’s 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.

State Duties vs. Fiscal Agent State Duties vs. Fiscal Agent DutiesDuties

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.

State Duties vs. Fiscal Agent State Duties vs. Fiscal Agent DutiesDuties

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.

Who reviews dental policies?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.

What does the DAG do?What does the DAG do?

When would the DAG review a policy?1. New ADA codes2. Provider requested fee increase3. Data shows outliers in billed charges4. Clinical appeals from providers

The DAG members also provide professional advice and expertise on current acceptable dental practices.

Who are the current DAG Who are the current DAG members?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.

What is Public Health Dental?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.

Who is in charge of Public Oral Who is in charge of Public Oral Health?Health?

Public Oral Health has a manager, Cassandra Walkama RDH, MPH and a dentist, Dr. Edward Lawler.

These programs were previously administered by Trish O’Grady and Peggy Baluska.

Public Oral Health also employees 4 Community Oral Health Coordinators (public health hygienists).

How many dentists participate How many dentists participate with WY Medicaid?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%)

How many Medicaid clients are How many Medicaid clients are there?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

What are my requirements as a What are my requirements as a provider?provider?

Bill claims timely, within 12 months to avoid timely filing denials

Retain adequate recordsInform 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 servicesReview and understand all policies contained in

the provider manual

What is Program Integrity?What is Program Integrity?

Medicaid Program Integrity Unit is in place to do the following:

1.Review of claims submitted for payment2.Review of dental records related to covered

services3.On-site review of dental records and client

interviews4.Case management oversight5.Recovery of overpayments or payments

made in error based on policies

What is expected from Program What is expected from Program Integrity?Integrity?

Each employee in the provider office are informed of Medicaid rules and policies

Records are kept accurately on each clientAccess to client records as requestedAccess to financial records of

reimbursement from MedicaidOffice policies are enforced the same for

all types of patients EX. Medicaid, Cash pay, Traditional insurance

What is required in the records?What is required in the records?

A patient’s 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:

>Tooth Numbers>Surfaces>Quantities>Medications and dosages>Observed conditions & progress at each visit>Total treatment minutes if codes are used that arereimbursed at 15 minute increments

Severe Malocclusion ProgramSevere 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