Medicaid and CHIP Promising Practices

Name of Practice: Delaware Medicaid Dental Program (DE0701)

Category: Access (Dental)

Abstract

In 1997, only one private dentist in the State of Delaware participated in the Medicaid program. The State sought to improve the access of Medicaid-eligible children to quality dental care by increasing reimbursement to 85 percent of each dentist's submitted charges, developing new provider enrollment forms, simplifying prior authorization and eligibility verification, and conducting outreach. The program has significantly increased both the number of participating practitioners and the number of children treated in private dental offices.

The Problem

Private dentists did not participate in the State Medicaid program before 1997. Prior to 1998, dental services were available almost exclusively through State-operated, school-linked public health clinics. Over time, the number of dentists working at these clinics declined and it became more difficult to obtain appointments. The State Legislature became interested in the lack of access to care and, ultimately, the State hired a consultant to examine the availability of dental care for children in Delaware. In 1997, the Dental Health Administrative and Consulting Service issued a report, commissioned by the State's Department of Health and Social Services, which addressed access to dental care through Medicaid and other State programs. The report's recommendations contributed to the subsequent appointment of a State dental director, passage of a statewide mandatory fluoridation law, and implementation of a major change in how the Medicaid dental program operates.

The State of Delaware also became aware of the need to educate children and their families about the benefits of regular dental care and to reduce the number of missed patient appointments.

Discussion of Approach

Pursuant to the recommendations of the consultant's report released in 1997, the Delaware Medicaid program made a series of changes in 1998 to enhance access to dental care. Effective January 1, 1998, Medicaid began reimbursing dentists on a fee-for-service basis at 85 percent of each dentist's submitted charges. For example, a dentist charging $100 for a dental exam would be reimbursed $85 by Medicaid. This reimbursement methodology is similar to the "reasonable and customary" approach used in commercial dental insurance and is clearly competitive in the dental marketplace. No other State Medicaid programs are known to be using this payment mechanism.

The State has also implemented a number of Medicaid administrative changes aimed at enhancing participation of private dentists, primarily through reducing the provider's administrative burden. The State has developed new provider enrollment forms capable of linking with all clearinghouses and billing vendors, encouraged electronic claims processing, streamlined prior authorization requirements and procedures, and offered various methods for verifying patient eligibility for Medicaid services.

Outreach efforts have increased, as well. State fiscal agent staff visit dental offices to assist dentists in enrolling as Medicaid providers and in resolving billing and eligibility verification problems. A dental provider manual is now available on the Internet. The Medicaid program has also worked with the Delaware State Dental Society to recruit dentists at Dental Society conferences, presentations at monthly society meetings, and meetings with the society's Executive Committee. The Dental Society president holds meetings in each county to urge enrollment, and an annual letter is mailed to all dentists, describing progress made in enrolling Medicaid dentists.

Results

In Delaware, an increase in reimbursement rates has dramatically expanded access to dental care. Since the program changes were implemented in January 1998, the number of dentists participating in Medicaid has increased initially from 1 to 177. As of March 2007, nearly 60 percent of dentists licensed in the State participate in the Medicaid program. The number of children treated in private dental offices increased nearly 500 percent between 1998 and State fiscal year 2003.

Future Plans

The State has requested approval to add dental benefits to its CHIP plan. The State will need to recruit more dentists to serve the additional 5,000 children who will qualify for dental services through CHIP. The addition of dental benefits to CHIP has received strong support from the dental community, in contrast to its early reluctance to become involved with Medicaid. While reimbursement no longer seems to be a barrier to provider participation, some dentists remain concerned about patients missing appointments and participating in a government program generally.

The Division of Social Services is also working with the public health component of DHSS to pilot a case management program that would identify children without dental coverage, refer them to participating dentists, and try to educate them and their parents about the importance of oral health care and the need to keep appointments.

Further Information

Contact:

David Michalik
Senior Administrator, Delaware Department of Health and Social Services
Division of Social Services
P.O. Box 906
New Castle, DE 19720
Tel: (302) 255-9577
Fax: (302) 255-4455
E-mail: dave.michalik@state.de.us

This Profile has been posted to the CMS Medicaid/CHIP Quality website for informational purposes only and does not convey CMS endorsement of the practice itself. The descriptive information supplied and the results reported in this Profile have been supplied by sources familiar with the practice but have not been independently validated by CMS.

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