CMS oral Health Initiative an opportunity for Dental Hygienists April 23 rd 2015 Nancy Gurzick, RDH, BSDH, MA Course objectives Part I Federal and State Oral Health Programs Understanding Medicaid/Federal and State Dental Programs Knowledge of EPSDT guidelines Understanding Public Health Programs Describe Collaboration and Accomplishments of Michigan Oral Health Coalition Part II CMS Oral Health Initiative What is the CMS Oral Health Initiative? How does it impact our programs? How does it affect RDHs? Part III What is new and how does it affect the Future for RDHs? State Oral Health Action Plan (SOHAP) Oral Health Workgroup Goals Altarum Project PA 161: Public Dental Prevention Program PART I Medicaid is a Federal Program operated by the Center for Medicare/Medicaid Services (CMS) Enacted in 1965 through amendments to the Social Security Act, (Title XIX). Medicaid is a health and long-term care coverage program that is jointly financed by states and the federal government. Each state establishes and administers its own Medicaid program and determines the type, amount, duration, and scope of services covered within broad federal guidelines. http://www.medicaid.gov/federal-policy-guidance/federal-policy-guidance.html Dental Services Title XIX allows states to receive matching Federal Funds for providing certain mandatory and optional services to most categorically needy populations. Dental care is considered an Optional service for adults. It is the individual state s decision on whether to include adult dental benefits. Dental care is mandated for children under EPSDT. States set individual eligibility criteria within federal minimum standards. Managed Care Managed Care Organizations (MCOs) companies agree to provide most Medicaid benefits to people in exchange for a monthly payment from the state. Limited benefit plans only provide one or two Medicaid benefits (like mental health or dental services).
The Children s Health Insurance Program (CHIP) was created in 1997 through an amendment to the Social Security Act to provide health care coverage to low-income children not already eligible for Medicaid. MIChild is a managed health care program using State funds, as well as CHIP funds authorized under Title XIX of the Federal Social Security Act, to furnish health care coverage to a targeted population. For individuals under age 19 who are not eligible for Medicaid Family income is above 150% and at or below 200% of the federal poverty level Do not have comprehensive health care coverage. MIChild benefits are modeled after the State Employee dental benefits package. States have the option to charge premiums and to establish out of pocket spending (cost sharing) requirements for Medicaid enrollees. EPSDT Covered services EPSDT covers a range of dental and oral health services for children (at a minimum, relief of pain and infections, restoration of teeth, maintenance of dental health, and medically necessary orthodontic services) Section 1905(r) (3) of the Social Security Act Periodicity schedule States are required to establish a periodicity schedule for regular preventive dental visits for children. CMS State Medicaid Manual 5140 (A) Dental visits EPSDT requires that children receive dental visits. Dental visits must be performed by a dentist, or other licensed dental professional working under the supervision of a dentist according to the provisions of state scope of practice laws, and can occur in settings other than a dentist s office, such as a clinic or a school. Guidelines established by American Academy of Pediatric Dentistry (AAPD) First dental visit within 6 months of the eruption of the first tooth, or no later than 12 months of age. PACE program of All Inclusive Care for the Elderly (PACE) The Program of All-Inclusive Care for the Elderly (PACE) is a capitated benefit authorized by the Balanced Budget Act of 1997 (BBA) that features a comprehensive service delivery system and integrated Medicare and Medicaid financing for frail, elderly individuals that meet Long Term Care (LTC) level of care criteria. For most PACE participants (enrollees), the comprehensive service package permits them to continue living at home while receiving services rather than being institutionalized. Participants must meet the following criteria: State Oral Health Programs CDC support provides additional opportunities to educate residents about the importance of oral health and effective preventive measures, to identify communities with the greatest unmet dental needs, and to develop state plans to improve oral health and address disparities. State Oral Health Plan 10 goals identified Maintain a statewide Oral Health Surveillance System Implement Emotional Behavior Disability (EBD) preventive practices Increase knowledge of relationship between oral health and systemic health
Provide info about comprehensive and culturally sensitive education resources Develop strategies to increase access and establish dental homes Support a public & private system of care to ensure access Increase access to OH services in underserved populations Increase access for persons with special needs Increase access for the elderly Develop and sustain the necessary infrastructure to implement the State Oral Health Plan Michigan Oral Health Coalition Mission is to improve oral health in Michigan by focusing on prevention, health promotion, oral health data, access and the link between oral health and overall health. Established 6 policy priorities in 2013 Complete the statewide expansion of Healthy Kids Dental Increase payments on preventive oral health care services, especially for high-risk populations Advocate for a mandated oral health screening prior to school entry Investigate the expansion of the oral health workforce Increase general fund appropriations for the Oral Health Program Support and advocate for community water fluoridation PART II NEW PROGRAMS AND WORKING TOGETHER! CMS Oral Health Initiative State Oral Health Action Plan (SOHAP) Healthy Kids Dental Expansion Oral Health Workgroup Managed Care Federal State Statutory and regulatory requirements Determine who is eligible Matching funds (50% - 100%) Determine scope of optional services Data collection and quality measures Determine delivery system / contracting Technical assistance to states Overall administration / claims payment Oversight Set payment rates CHIP Program Medicaid & Children s Oral Health CMS Oral Health Initiative Goals Goal #1 Increase by 10 percentage points the proportion of Medicaid and CHIP children ages 1 to 20 (enrolled for at least 90 days) who receive a preventive dental service. Baseline year is FFY 2011. National baseline is 42%. Progress in FFY 2013. National rate is 44%. Goal year is FFY 2015. National goal is 52%. Every state has its own baseline and goal. Michigan s baseline is 36% and goal is 46%. Goal #2 Increase by 10 percentage points the proportion of Medicaid and CHIP children ages 6 to 9 (enrolled for at least 90 days) who receive a sealant on a permanent molar tooth.
Michigan by the Numbers Beneficiaries 1.03M children enrolled in Michigan Medicaid (2012) 70,604 children enrolled in MIChild Healthy Kids Dental 80 of 83 counties 565,000 children (55% of all Michigan child Medicaid enrollees) Fee for Service Dental 3 of 83 counties 460,000 children (45% of all Michigan child Medicaid enrollees) CMS Oral Health Resources CMCS July 2014 Informational Bulletin: Update on CMS Oral Health Initiative and Other Oral Health Related Items: http://www.medicaid.gov/federal-policy-guidance/downloads/cib-07-10-2014.pdf CMCS April 2013 Informational Bulletin: CMS Oral Health Initiative and Other Related Items http://www.medicaid.gov/federal-policy-guidance/downloads/cib-04-18-13.pdf Dental page on Medicaid.gov: http://www.medicaid.gov/medicaid-chip-program-information/by-topics/benefits/dental-care.html CMS 416 data, by year and by state http://www.medicaid.gov/medicaid-chip-program-information/by-topics/benefits/early-and-p eriodic-screening-diagnostic-and-treatment.html CMS OHI baselines, goals and progress, by state http://www.medicaid.gov/medicaid-chip-program-information/by-topics/benefits/downloads/ OHIBaselineGoals.pdf Dental Excerpt from the 2013 Secretary s Report on Quality of Care for Children in Medicaid and CHIP http://www.medicaid.gov/medicaid-chip-program-information/by-topics/benefits/downloads/sec retarys-report-dental-excerpt.pdf Keep Kids Smiling: Promoting Oral Health through the Medicaid benefit for Children and Adolescents http://www.medicaid.gov/medicaid-chip-program-information/by-topics/benefits/downloads/ Keep-Kids-Smiling.pdf Medicaid and CHIP State Agency Dental Contacts http://www.medicaid.gov/medicaid-chip-program-information/by-topics/benefits/downloads/sta te-medicaid-and-dental-contacts.pdf Improving Oral Health Care Delivery in Medicaid and CHIP: A Toolkit for States http://www.medicaid.gov/medicaid-chip-program-information/by-topics/benefits/downloads/ Oral-Health-Quality-Improvement-Toolkit-for-States.pdf CMS Oral Health Strategy Work with states to develop State Oral Health Action Plans (SOHAP) Provide technical assistance to states & facilitate peer-to-peer learning
Michigan s Approach to Meeting the SOHAP Goals: Provide outreach through schools and include dental assessment as part of requirements for kindergarten entry. Hygienists working in alternative settings to provide services. Research and outreach efforts to target children not utilizing HKD benefits. Expand the Healthy Kids Dental Program statewide. Oral Health Learning Collaborative Governor proposal to expand HKD to 3 remaining counties (Kent, Oakland and Wayne) starting with ages 0-8 Expansion of Public Act-161 Oral Health Prevention Program to include additional places of service. PA 100 of 2014-Mobile Dentistry Bill, Effective date: April of 2015, will allow monitoring and oversight for mobile providers which will promote coverage in underserved areas and require documented follow-up referral. Technical Assistance from CMS An increase in collaborative efforts between Delta Dental and MDCH to promote the Healthy Kids Dental program Increasing cultural competency with our statewide expansion. PART III Opportunities for Dental Hygienists New CDT Procedure Codes CDT 0190 screening of a patient A screening, including state or federally mandated screenings, to determine an individual s need to be seen by a dentist for diagnosis. CDT 0191 assessment of a patient A limited clinical inspection that is performed to identify possible signs of oral or systemic disease, malformation, or injury, and the potential need for referral for diagnosis and treatment. CDT 0601 caries risk assessment low risk CDT 0602 caries risk assessment moderate risk CDT 0603 caries risk assessment high risk RENDERING Any licensed or certified dental professional may render billable and reimbursable services to a Medicaid enrollee as long as the services provided are within her scope of practice. BILLING A state must include in its Medicaid State Plan a list of all the types of dental providers allowed to bill for Medicaid services, e.g., dentist, dental hygienist, dental therapist. If a provider type will render but not bill, there is no need to list the type on the Medicaid State Plan. What does this mean for the Michigan RDH? January 2013 Michigan added the two new codes: D0190 and D0191 PA-161 programs allow RDHs to provide services without direct supervision in Michigan
Oral Assessment (D0191) codes can be billed to Medicaid under the dental hygienists NPI. Screening codes (D0190) can be billed by Medical Providers performing oral health screenings. What is the National Provider Identifier (NPI)? The NPI is a unique identifier for each health care provider to use for electronic transactions, including claim submissions. NPI Numbers NPI numbers are 10-digit numbers assigned by the federal government through the National Plan and Provider Enumeration System (NPPES) that are unique to each covered health care provider and health care organization. NPI's are permanent and do not expire or change if you move. National Plan and Provider Enumeration System (NPPES) https://nppes.cms.hhs.gov Enrolling as a Medicaid Provider http://www.michigan.gov/mdch/0,1607,7-132-2945_42542_42543_42546-104293--,00.html RDH s Role in the CMS Strategic Goals STRATEGY #1 Improve State Medicaid Program Performance through Policy Change. Aligning the dental periodicity schedule to clinical recommendations Use dental delivery system contracts to improve dental program performance Reimburse medical providers for preventive oral health services. Incentivize dental providers through new payment models. Address Form CMS-416 & core measure data collection challenges. RDH Role: Reimbursement for D0191, fluoride varnish, sealants STRATEGY #2 Maximize Provider Participation Reduce Administrative Burden Help dentists feel more comfortable treating young children RDH Role: Take an active role in educating and training dental/medical professionals on oral care of young children. Maximize the capacity of the dental workforce RDH Role: Reduced supervision/expanding scope of practice STRATEGY #3 directly educate children and families Provide outreach and education to parents and children on the importance of preventive care. RDHs Role: to provide educational programs in multicultural settings (e.g. OB and Pediatric offices, WIC Centers, school settings) address the role that families and children play in maintaining good oral health.
STRATEGY #4 Partner with State s Oral Health Stakeholders State Oral Health Plan State Oral Health Coalitions Association of State and Territorial Dental Directors (ASTDD) Medicaid-CHIP State Dental Association (MSDA) Title V agencies (maternal and Child Health Program) Working collaboratively with all of the above stake holders to meet the goals of Michigan s Oral Health Action Plan! RDH Role: We are the prevention specialists! Healthy Kids Dental Reimbursement MDCH pays a capitation rate (PMPM) to Delta Dental Delta Dental will reimburse providers based on the provider s charges or the Delta Dental PPO fee schedule, whichever is lower. Providers must accept the Delta Dental Reimbursement as payment in full Beneficiaries do not pay co-pay and there is no limit for medically necessary dental services. The Affordable Care Act of 2010 This creates a new national Medicaid minimum eligibility level that covers most Americans with household income up to 133 percent of the federal poverty level. This new eligibility requirement was effective January 1, 2014. 133 % of Federal Poverty level for: Individual: $15,521 Family of Four: $31,720 Healthy Michigan Plan Launched April 1 st 2014! The Healthy Michigan Plan covers the federal healthcare law essential health benefits, as well as other services and benefits (dental) EXPAND THE DENTAL WORKFORCE The ACA provides an opportunity to expand the dental workforce through the use of alternative practice and Mid-level providers, such as dental therapists and dental hygienists, can be trained and licensed to perform preventive care and other routine restorative procedures. This workforce expansion can help to reduce dental provider shortages and expand access for low-income populations, especially those in rural areas. Health Care Innovation Award (HCIA) Overview The CMS Center for Medicare & Medicaid Innovation supports the development and testing of innovative health care payment and service delivery models. Our Project: Michigan Caries Prevention Program (MCPP) Project Funding: $9.4M over three years Award released September 1, 2014 Altarum is a nonprofit organization with more than 70 years of experience researching, developing, and implementing solutions that serve the public good.. Michigan Caries Prevention Program: THE NEED Childhood dental disease is relatively inexpensive to prevent, yet dental decay is the most prevalent chronic condition among children in the United States and the most common unmet health care need of poor children across the country. There is profound disparity in the impacts of childhood dental disease.
Michigan Caries Prevention Program: THE CHALLENGES Dental capacity issues In many communities there are not enough dentists willing to see pediatric Medicaid patients.* Pediatric practice barriers Resistance common to oral health assessment and preventative treatment. Interest groups likely have differing perspectives on what our project should be doing. Provider incentives potentially misaligned to optimal practice. In-place technology and information flows do not yet adequately support data-driven decisions and most efficient practice. Michigan Caries Prevention Program: THE GOALS Build the information architecture necessary to: Better understand the problem and its determinants. Support the flow of information between medical and dental providers. Enable statewide quality monitoring. Promote medical & dental care integration: Raise awareness and provide the medical community the tools necessary to support better care. Demonstrate the utility of risk stratification in the delivery of preventative care. Advance appropriate care practices in both the medical and dental provider community statewide. Improve the flow of patients between medical and dental providers. Monitor the efficacy of the intervention statewide: Monitor its impact on health, healthcare, dental utilization, preventable utilization and cost trends. PARTNERS: Delta Dental of Michigan Support communication with dental providers. Support data acquisition and analysis of utilization trends, referral management, and monitoring of project impact. Support the creation of a statewide quality monitoring program. University of Michigan School of Dentistry Develop or select oral health risk screening tools Support development of training materials targeting medical community Assist in developing outreach materials for patients, families, and providers Oversee pilot implementation at Mott Children s Health Center in Flint Support program monitoring and evaluation Provide subject matter expertise for development of a statewide quality monitoring program Michigan Department of Community Health Establish connections between project team and public health professionals delivering screenings in non-traditional settings Support education and outreach to Medicaid families Assist with exploring and planning potential changes to state systems or data flows in support of advancing children s oral health Support pursuit of data to inform decisions and monitor project impact Collaborative Opportunities Altarum supports the MOHC as a Diamond level member
The statewide children s oral health initiative provides a wide reach for engaging new dental professionals and children s oral health advocates to participate with MOHC Support integration and care coordination of Michigan s children s oral health system statewide Align with ongoing efforts Additional efforts for non-hkd counties Develop strategies for rural areas Michigan Caries Prevention Program: Contacts Team Email: MI.OralHealth@Altarum.org Mobile Dentistry & PA161: Dental Public Prevention Program REQUIREMENTS: Public or nonprofit entity, or a school or nursing home, that administers a program of dental care to a dentally underserved population. Employ or contract with at least 1 dentist and 1 dental hygienist. PA-161 of 2005: A dental hygienist may perform dental hygiene services under the supervision of a dentist as part of a program for dentally underserved populations in this state conducted by a local, state, or federal grantee health agency for patients who are not assigned by a dentist Grantees are approved for a 2-year period Programs receive approval, not individual hygienists Original intention was related to public health agencies and their program MDCH Oral Health Workgroup Goals of the Workgroup Identify the care delivery, policy, financing and community factors that impact the delivery of oral health care services in Michigan, with special attention to the needs of at risk populations Identify best practices and emerging strategies being employed in Michigan and in other states to enhance access to oral health care Identify and prioritize recommendations that support a patient-centered, integrated, evidence-based, and data-driven oral healthcare system. Top Ten Action Steps 1) Expand Healthy Kids Dental to Kent, Oakland and Wayne Counties in Fiscal Year 2016. 2) Appoint an MDCH Oral Health Advisory Committee to oversee the implementation of activities recommended by the Oral Health Work Group. 3) Add questions regarding oral health status and/or dental services utilization to the standard Health Risk Assessment for Healthy Michigan Plan enrollees. 4) Modify Medicaid policy to ensure that all adults enrolled in Medicaid Health Plans have the same dental benefit administration as those enrolled in the Healthy Michigan Plan. 5) Add preventive dental visit to list of healthy behaviors that qualify for cost-sharing reduction under the Healthy Michigan Plan. 6) Incorporate pediatric quality measures for dental care and oral health prevention into the Healthy Kid Dental and the Medicaid Health Plan contracts. 7) Require screening programs (e.g., mobile dentistry, PA 161 sites) to submit data on numbers screened and referred, source of referral, and the number receiving follow-up dental care. 8) Implement payment reform modification for dental services under Medicaid. 9) Create and disseminate materials to educate Medicaid beneficiaries about their dental benefits and the process for finding a dental provider. 10) Evaluate different strategies to activate Medicaid beneficiaries to seek preventive dental care.