Medicaid Managed Care
The Social Security Amendments of 1965 created Medicaid, a public program that is designed to provide health coverage for our nation’s most vulnerable individuals and families. The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit includes comprehensive dental services for children under age 21 who are enrolled in Medicaid. The Medicaid program is jointly funded by the federal government and states. The federal government pays states for a specified percentage of program expenditures, called the Federal Medical Assistance Percentage (FMAP).
Traditionally, state Medicaid programs have paid for services rendered by dental practices through fee-for-service arrangements. However, more states are moving to managed care arrangements. Under managed care arrangements, states contract with third-party payers to deliver care through networks and pay dental offices. More than 16 states deliver dental services through managed care plans. The Centers for Medicare & Medicaid Services (CMS) is the federal agency with jurisdiction over the Medicaid program.
States that use the managed care model typically send a request for proposal (RFP) to third-party payers interested in managing the dental benefit. In some instances states may include the dental benefit within the broader medical contract. In such cases, the dental benefit administrator is a subcontractor to the medical managed care company contracted with the state. In other instances, the state may choose to “carve-out” the dental benefit and have a separate contract directly with a dental benefit administrator. Either way, it is important for dentists to meaningfully participate with their state dental association to ensure that the best system is established to support the oral health of Medicaid beneficiaries. The ADA has developed a toolkit to assist state dental associations in working with state Medicaid program administrators to incorporate key elements into state Medicaid managed care RFPs and subsequent contracts. Medicaid Contract Toolkit
Learn more about ADA’s Advocacy on Medicaid; you may also like Tools for Policymakers.
Thinking about Medicaid? The ADA offers a one-credit introductory Medicaid course on Maintaining Your Sanity and Practice Viability as a Medicaid Provider: Embracing Program Integrity.