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ADA, AAPD comment on Medicaid, CHIP managed care revisions

January 15, 2019

By Jennifer Garvin

Washington — The ADA and American Academy of Pediatric Dentistry are jointly commenting on proposed revisions to a Centers for Medicare and Medicaid rule on Medicaid and Children's Health Insurance Plan managed care plans.

In formal comments submitted Jan. 11, ADA President Jeffrey M. Cole and AAPD President Joseph B. Castellano praised CMS Administrator Seema Verma for the agency's efforts to find balance "between maintaining critical beneficiary protections and providing states with flexibility in overseeing their managed care programs." The two organizations offered the following suggestions — including adopting minimum rates and expanding network access — on how this can be achieved in dentistry.

Regarding the delivery system and provider payment initiatives, Drs. Cole and Castellano said "there is a strong correlation between beneficiary access to dental services and payment rates."

"ADA and AAPD support states requiring managed care plans to adopt minimum rates to ensure adequate access to providers," they wrote. "States and managed care plans should reach out to dental stakeholders, utilize existing dental fee and claims data, and analyze utilization patterns when developing these rates."

For network adequacy standards, they stressed the "importance of ensuring that dental plans offered within Medicaid managed care plans include an adequate provider network that meets beneficiary needs." This network "must include" pediatric dentists and other specialty dental providers and general dentists and states "should not be given the flexibility to create definitions for specialists and instead should recognize providers certified by the appropriate dental specialty board."

The ADA and AAPD said they are also concerned about the rule's proposal to eliminate the time and distance standards in favor of allowing states to choose from a variety of quantitative standards.

"Rural areas of states can face dental provider shortages that are not found among medical providers," wrote Drs. Cole and Castellano. "We ask CMS to require states to address geographic variations when establishing network adequacy standards," adding that states should be required to have quantitative and nonquantitative standards such as wait time, appointment availability and the ratio of Medicaid patients to non-Medicaid patients.

Both ADA and AAPD said they would be happy to assist CMS and states in defining network adequacy standards for dental services and encouraged CMS to look at the Dental Quality Alliance, a multi-stakeholder coalition established at the request of CMS, and its efforts on developing service utilization measures.

The ADA and AAPD also said they "strongly believe" in the timely and accurate updating of provider directories and said they are concerned about the proposal to allow for quarterly, rather than monthly, updates to paper directories since many low-income Medicaid beneficiaries may not have access to a smartphone. Requiring beneficiaries to call the plan's customer service line or the state to confirm if a provider is still in-network "adds another layer of complexity and burden for these already vulnerable beneficiaries."

The ADA and AAPD "support the proposed requirement that provider directories include the provider's cultural and linguistic competencies," and think this is "critical" in ensuring patients are comfortable selecting a provider.

"This is especially important in Medicaid where patients have low incomes, English may not be their first language and health literacy levels may be low," Drs. Cole and Castellano wrote. "These problems are compounded in the field of dentistry where patients often have a fear of visiting the dentist and need to connect with a provider who can explain dental procedures to them in simple, meaningful terms."

For the Medicaid Managed Care Quality Rating System (QRS), the ADA and AAPD appreciate the 2016 final rule's provision requiring states to operate a Medicaid managed care quality rating system. The two organization urged CMS and states to seek input from the Dental Quality Alliance, which is "well positioned to collaborate, coordinate, and lead efforts on access to care measures." Additionally, the DQA has developed a comprehensive set of measures and obtained their endorsement from the National Quality Forum.

Drs. Cole and Castellano said that ADA and AAPD recognize the challenges in applying quality ratings across different states, and "support the proposed revisions that would balance the goal of facilitating these comparisons of plan performance with the need for state flexibility." Since many states provide the dental benefit through a prepaid ambulatory health plan, they encouraged CMS to assure that states have dental-specific QRS systems that includes a comprehensive measure set to assess oral health rather than a single measure within a broader set.

For the enrollee encounter data, ADA and AAPD agree with CMS that encounter data is critical for properly monitoring and administrating the Medicaid program and supports the agency's proposal to include the allowed amount and paid amount in the data collected in the Transformed Medicaid Statistical Information System.

Finally, regarding the Children's Health Insurance Program, the two organizations said they agreed with CMS' proposal to apply the Medicaid changes described above to CHIP.

"This program provides much needed oral health services to children. Good oral health is an essential part of children's overall health and dental disease is linked to other medical conditions," Drs. Cole and Castellano concluded. "Untreated dental disease can also lead to problems in school and can persist into adulthood, resulting in higher treatment costs and making it harder to find employment. It can also impact military readiness and the deployment of troops. The protections offered to children enrolled in Medicaid managed care should also apply to children enrolled in CHIP."

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