Texas Medicaid
Medical and Dental
Information Series
Module 8
Version 1.2 (6/22/2010)
2/22/2013
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Module 8
Medicaid Curriculum Overview
Module 1: General Structure of the Texas Medicaid System
Module 2: Understanding Medicaid Clients and Health Literacy
Module 3: Texas Health Steps
Module 4: Navigating Insurance and Managed Care
Module 5: Interfacing with Medicaid as a Provider
Module 6: Special Medicaid Programs
Specialty Module: Special Medical Issues
Specialty Module: Special Dental Issues
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Special Dental Issues
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Why is dental care important
for Medicaid clients?
More than 51 million school
hours are lost each year to
dental-related illness. Poor
children suffer nearly 12
times more restricted-activity
days than children from
higher-income families.
Poor children suffer twice as
much dental caries as their
more affluent peers, and their
disease is more likely to be
untreated. Children living
below the poverty line have
more severe and untreated
decay.
Highlights of Oral Health Data for
Children from Oral Health in America:
A report of the Surgeon General
Uninsured children are 2.5 times less
likely than insured children to receive
dental care. Children from families
without dental insurance are 3 times
more likely to have dental needs than
children with either public or private
insurance. For each child without
medical insurance, there are at least 2.6
children without dental insurance.
One quarter of poor
children have not seen
a dentist before
entering kindergarten.
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Module 8: Objectives
After completing this module, you should be able to:
Describe the role of Medicaid in providing access to
dental care for children
Identify providers and facilities eligible to provide
Medicaid dental services
List goals of the First Dental Home
Identify advantages of anticipatory guidance
Describe the dental services required for Texas Health
Steps dental check ups
Identify dental services that are eligible for coverage
under Texas Medicaid
Appropriately document Medicaid-eligible services
Describe the components of Oral Evaluation and
Fluoride Varnish in the medical home
List resources available for dental providers
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Module 8
True or False?
Test Your Knowledge about Medicaid and Dental Care
Children whose siblings or caregivers have caries
are at high risk for developing them as well.
Medicaid clients who reside in intermediate care
facilities for persons with mental retardation are not
eligible for covered dental services if they are over
21.
THSteps and children’s dental care is provided
through Medicaid managed care.
The First Dental Home initiative targets children
aged 6 to 35 months.
Prior authorization is required for orthodontia and
cone beam imaging.
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Children at High Risk for Caries
Children with special health care needs
Children from low socioeconomic and ethnocultural groups
Children with suboptimal exposure to topical or systemic fluoride
Children with poor dietary and feeding habits
Children whose caregivers and/or siblings have caries
Children with visible caries, white spots, plaque, or decay
Dental caries are:
• 5 times more common than asthma
• 7 times more common than hay fever
Caries Rate
18% aged 2 to 4 years
52% aged 6 to 8 years
67% aged 12 to 17 years
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Improving Dental Access: The
Role of Medicaid and CHIP
Percent of Low-Income Children with a
Dental Visit in the Past Year, by Dental
Insurance Status, U.S. Data, 2006
40%
43%
34%
Private Dental
Medicaid/CHIP
No Dental Coverage
Low-income children
enrolled in Medicaid or
CHIP fare at least as
well as low-income
children with private
insurance in obtaining
a dental visit.
Compared to
uninsured children,
those with public
insurance are more
likely to have a usual
source of dental care
and to receive
preventive dental care
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Review: Health Implications of
Poverty for Children
Dental Care
Dental Care Among Poor and Nonpoor Children, U.S. Data
50%
45%
43.6%
44.1%
Poor
Nonpoor
40%
35%
30%
25%
18.1%
20%
15%
10.5%
10%
5%
0%
Never Seen a Dentist
1+ Year Since Last Dentist Visit
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Module 8
REVIEW: What is Medicaid?
Medicaid is a federal health care program that is jointly funded by federal
and state money. In 2009 Medicaid funding was:
State of Texas – 30.97%
Federal Government – 69.03% (more favorable in 2009 due to the
American Recovery and Reinvestment Act, ARRA, funding)
In November 2009, about 1 in 8 Texans relied on Medicaid for health
insurance or long-term services (3.2 million of the 24.2 million).
Medicaid was created through Title XIX of the 1965 Social Security Act, and
established in Texas in 1967.
In Texas, Medicaid is administered by the Texas Health and Human
Services Commission (HHSC).
Medicaid is an entitlement program, which means:
The number of eligible people who can enroll cannot be limited.
Any services covered under the program must be paid.
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REVIEW: Medicaid Functions
Department of State
Health Services (DSHS)
Governor
of Texas
Health &
Human
Services
(HHSC)
Executive
Commissioner
Single State
Agency
(HHSC)
Department of Assistive
& Rehabilitative
Services (DARS)
Department of Aging &
Disability Services
(DADS)
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REVIEW: Responsibilities
Medicaid fee-for-service claims administrator
Manages policy development
Collects HMO encounter data
Enrolls providers
Supplies provider relations representatives to enrolled providers
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REVIEW: Texas Medicaid
Texas Medicaid Recipients by Age
2011
Age 21-64
17%
Age 65+
6%
Age 0-5
36%
Age 15-20
11%
Age 6-14
30%
Unduplicated Clients
SFY 2011 = 4,456,077
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Texas Medicaid Spending
by Services Type, State Fiscal Year 2010
PCCM Services
0.2%
Inpatient Hospital
11%
Capitated Care
21.8%
Mental Health Facility
0.3%
Nursing Facility
11.3%
ICF-IID
Other Care
14.4%
4.8%
Physician & Practitioner
5.1%
Personal Support
Services
4.2%
Prescribed Drugs
10.9%
Outpa ent Hospital
1.8%
Lab & X-Ray
3.8%
Home Health Clinic
3.5%
0.7%
Dental
6.2%
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Texas Medicaid Spending
The Major Categories
By Services Type, State Fiscal Year 2011
Clinic &
Hospital
Outpatient
$2.9 billion Hospital Inpatient
$3.5 billion
10%
13%
Physician &
Professional $5.1
billion
18%
Supplemental
Payments
22%
Medicare Parts A, B
& D $1.5B
Disproportionate
Share Hospital
Program $1.6B
Upper Payment Limit
$2.8B
Dental $1.8
billion
5%
Long Term Services
& Supports $6.3
billion
23%
Prescription Drugs
$2.6 billion
9%
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Texas Medicaid Dental Services
At least one preventive dental
services was provided to
1,731,603 children in 2011
Dental
6.2%
Therapeutic dental services
were provided to 1,163,311
Medicaid recipients in 2011
Other
93.8%
Total costs for dental services
rose from $768 million in 2008
to $1,430 million in 2011
Per recipient per month dental
costs rose from $30 in 2007 to
$40 in 2010
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Medicaid Dental
Patients and Providers
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Who is eligible to receive dental
services from Texas Medicaid?
Children age 6 months through
20 from low income working
families
Many families are singleparent, working low-paying jobs
Children in foster care
Social Security Income (SSI)
recipients
Children of parents receiving
SSI benefits
Blind and/or disabled children
Infants of women covered by
Medicaid during their pregnancy
Children must be Medicaid- and
THSteps-eligible at the the time of
the service request and service
delivery. However, Medicaidapproved orthodontic services
already in progress may be
continued even after the patient
turns 21.
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ICF-IID Dental Services
The Intermediate Care Facilities For Persons With Intellectual
Disabilities or Related Conditions (ICF/IID) program provides
residential and habilitation services to people with intellectual and
developmental disabilities or a related condition.
ICF-IID dental services are mandated by Medicaid. Reimbursement
is provided for treatment of dental problems for Medicaid-eligible
residents of ICF-IID facilities who are 21 years of age and older.
Residents of ICF-IID facilities who are 20 years of age and younger
receive services through the regular THSteps Program. Eligibility for
ICF-IID services is determined by DADS.
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Who can be a Medicaid Dental
Provider?
To become a Medicaid provider, a dentist must
Currently be licensed by the Texas State Board of Dental Examiners
(TSBDE) or be licensed in the state where the service was
performed
Practice within the scope of the provider’s professional licensure
Complete the Dental Provider Enrollment Application and return it to
TMHP
All owners of a dental practice must maintain an active license
status with the TSBDE to receive reimbursement from Texas
Medicaid
All dental services must be performed
by the Medicaid-enrolled dental provider
except for permissible work that is
delegated to a licensed dental hygienist,
dental assistant, or dental technician.
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Dental Provider Categories
All dental providers must declare one or
more of the following categories:
General practice
Pediatric dentist
Periodontist
Endodontist
Oral and maxillofacial surgeon
Orthodontist
Other (prosthodontist, public health, others)
Dentists who serve patients using medical
(CPT) procedure codes such as oral and
maxillofacial surgeons, may enroll as a
Doctor of Dentistry Practicing as a Limited
Physician
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Dental Checkup and Treatment
Facilities
All THSteps dental checkup and
treatment policies apply to examinations
and treatment completed in a:
Dentist’s office
Health department
Clinic setting
Mobile/satellite unit
Enrollment of a mobile/satellite unit must
be under a dentist or clinic name. Mobile
units can be a van or any temporary site
away from the primary office and are
considered extensions of that office and
are not separate entities.
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Medicaid Managed Care
Enrollment
Effective March 1, 2012,
children’s Medicaid dental
services are provided
statewide through managed
care for children birth through
20 years of age.
Each member should have a
main dental home provider
who delivers all aspects of oral
health care in a
comprehensive, continuously
accessible, coordinated, and
family-centered way.
Some Medicaid clients
continue to receive dental
services through existing
delivery models and not
through managed care:
Medicaid recipients age 21
and over
Medicaid recipients who
reside in institutions
STAR Health program
recipients (foster children)
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Managed Care Dental Services
Providers must contract and be
credentialed with one of 3 dental
plans to provide dental services.
Current Managed Care
Dental Plans:
Rates are negotiated between the
provider and the dental plan.
Dental plans establish a network to
include general, pediatric, and
specialty care providers.
Dental plans are responsible for
authorizing, arranging,
coordinating, and providing
medically necessary covered
services.
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Dental Managed Care
Main Dentist
Each member will have a dental home – or main
Dentist – who will support ongoing care.
Main dentists include general and pediatric dentists.
Main dentists will assess the dental needs of members and
coordinate members’ care with specialty care providers.
HHSC has delayed the restriction that a Medicaid client must be
served by their main dentist through August 31, 2012. This will give
clients more time to notify their dental plan of their preferred dentist
without any disruption in service.
Dentists should continue to see Medicaid patients they have
scheduled and encourage them to contact their dental plan to
choose their main dentist if they have not already done so.
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Dental Managed Care vs
Fee-For-Service (FFS)
Managed Care
Provider listings
Includes main dentist and
dental specialists
Member handbook
Value-added services
(varies by dental plan)
Fee-For-Service
Client has to locate dental
providers
No member handbook
No value-added services
No mileage requirements
Member chooses main
dentist and can change
through the dental plan
Dental plan must ensure
access to dentists and dental
specialists per contract
requirements
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Member Services &
Coordination of Care
Dental Managed Care
The dental plan must maintain a toll-free hotline to assist
members.
The dental plan hotline must be staffed
from 8am-5pm, CST, with an automated
system available after hours and on
weekends and holidays.
Required member materials include:
•
Member identification (ID) cards
•
Member handbooks
The dental plan is not responsible for emergency dental services
in an inpatient setting. These services will be covered under the
member’s medical plan.
Coordination of care includes protocols for working with Medicaid
medical plans.
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Dental Inquiry Line
The Dental Inquiry Line (1-800-568-2460) is available Monday
through Friday, 7 a.m. to 7 p.m., Central Time, and is the main point
of contact for information regarding dental services and appeals.
Any dental service claim denial may be appealed by telephone if it
was not denied as an incomplete claim and does not require one of
the following items or conditions:
Narratives
Radiographs
Models
Other tangible documentation
Review by the TMHP Dental Director
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Complaints Regarding Dental
Services
Complaints regarding dental services are typically received through the
TMHP Contact Center, although a complaint is accepted from any
source. Examples of complaints:
The provider:
Did not consult with the patient, explain what services were necessary,
or obtain parent or guardian informed consent.
Did not give the child the appropriate local anesthesia or pain
medication.
Did not use sterile procedures; the facility or equipment were not clean.
Or his/her staff were verbally abusive.
Charged a Medicaid client for benefits covered by Medicaid.
The treating provider refused to make the child's record available to the
new provider.
The patient did not receive a service, but the provider submitted a claim
to Texas Medicaid.
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Types of Services
Preventive
Emergency
Treatment
Orthodontic
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Texas Health Steps and
the Dental Home
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Review: Texas Health Steps
Perhaps the best known of Texas
Medicaid programs is THSteps,
which provides medial and dental
preventive care and screening to
eligible children.
THSteps is the name for the
federally-required Early and
Periodic Screening, Diagnosis and
Treatment (EPSDT) services in
Texas.
Module 3 focuses
specifically on
Texas Health
Steps.
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Coloring the Full Picture of
THSteps
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THSteps Dental Checkup
Schedule
Module 8
Birth to 6 months
Emergency dental services
Diagnosis and treatment of
Early Childhood Caries
6 months through 20 years
First dental visit at 6 months of age
Periodic dental checkups every 6 months
thereafter
Children younger than 36 months may be seen
every 3 months due to risk of developing
early childhood caries
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THSteps Dental Checkups
Dental Checkup Components
Prevention &
Maintenance
Treatment for Teeth and
Gums
Emergency Dental
Services
Health-Related
Orthodontic Services
Including examinations, preventive
care and oral education
Such as fillings, extractions and root
canals
Including treatment of injuries and to prevent
loss of teeth
With prior authorization, such as to correct a cleft
palate or treat facial injuries
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Dental Periodicity Schedule
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Exceptions to Periodicity
Additional checkups within a 6-month period
Medically necessary services, based on risk factors and
health needs (includes children birth through 6 months of age).
Required to meet federal or state exam requirements for
Head Start, daycare, foster care, preadoption, or to
provide a checkup prior to the next periodically-due
checkup if the patient will not be available when due.
This includes children whose parents are migrant or
seasonal workers.
Patients’ choice to request a second opinion or change
service providers (not applicable to referrals).
Subsequent therapeutic services necessary to complete
a case for children who are 5 months of age and
younger when initiated as emergency services, for
trauma, or early childhood caries.
Medical checkup prior to a dental procedure requiring
general anesthesia.
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First Dental Home Initiative
The First Dental Home initiative is aimed at improving the oral health
of children 6-35 months of age
Dental managed care plans must provide First Dental Home
Initiative consistent with what is provided in FFS
The goal of the program is to provide simple, consistent messages
about oral health care to parents and caregivers of very young
children
Providers include pediatric and general dentists who are enrolled in
Texas Health Steps and who have completed First Dental Home
training
Upon completion of training, dental providers
are eligible to bill Texas Medicaid for
enhanced reimbursement
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First Dental Home Components
Caries Risk
Assessment
Dental
prophylaxis
Oral hygiene
instructions with
primary caregiver
Establishment of a
recall schedule
Dental
anticipatory
guidance
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First Dental Home: Assessing
Risk and Educating Parents
Why complete a Caries
Risk Assessment
Determine the potential
for the child to develop
severe early childhood
caries (SECC)
Identify the oral health
status of the child and
other family members
Identify potential bacterial
transmission sources
Determine a recall
periodicity schedule
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First Dental Home: Assessing
Risk and Educating Parents
What is
Dental Anticipatory Guidance?
Age appropriate information/
education for parents,
based on:
Questionnaire responses
Parent/caregiver interview
Caries risk assessment
Multi-topic overview of oral
health environmental
influences
Directed at increasing the
parents’ understanding of
good oral health
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THSteps Dental Checkup Materials
Take Time for Teeth
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THSteps Dental Checkup Materials
Your Child’s Teeth Are Important
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THSteps Dental Checkup Materials
Dental Teen Brochure
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Oral Evaluation and Fluoride
Varnish (OEFV) in the Medical Home
The OEFV initiative is aimed at improving the oral health of children
6-35 months of age
The goal of the program is to allow medical and dental providers to
work together to improve the oral health of children
Providers include physicians, physician assistants and advanced
practice nurses who have completed OEFV training
Upon completion of training, dental providers are eligible to provide
intermediate oral evaluation, apply fluoride varnish, and bill Texas
Medicaid for enhanced reimbursement
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OEFV Visit Components
During a THSteps Medical Checkup
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Fluoride Varnish
5% sodium fluoride
Available in 0.25ml or
0.4ml unit doses
Colors: yellow, white,
clear
Package and brush
applicator can be
disposed in garbage can
Application does not
replace the dental home
nor is it equivalent to
comprehensive dental
care
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Oral Health Care:
Recommendations for Physicians
Institute oral health risk assessments into well-child visits
Provide patient education regarding oral health
Provide appropriate prevention interventions (eg, feeding practices,
hygiene)
Document findings and follow-up
Train office staff in oral health assessment
Identify dentists (pediatric/general) in your area who accept new
patients/Medicaid patients
Take a dentist to lunch to establish a referral relationship
Investigate fluoride content in area water supply
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Providing Dental
Services for Medicaid Patients
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Preventive Services
Dental examinations
(initial or periodic)
Preventive
Cleaning (prophylaxis)
Oral health education
Application of topical
fluoride
Application of sealants to
certain teeth
Maintenance of space
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Treatment Services
Restorations (fillings,
crowns)
Treatment
Endodontic treatment
(pulp therapy, root
canals)
Periodontic treatment
(gum disease)
Prosthodontics (full or
partial dentures)
Oral surgery (extractions)
Implant services and
Maxillofacial prosthetics
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Emergency Services
Procedures necessary to
control bleeding, relieve
pain, and eliminate acute
infection
Procedures that are
required to prevent
imminent loss of teeth
Emergency
Treatment of injuries to
the teeth or supporting
structures
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Orthodontic Services
Correction of cleft palate
Crossbite therapy
Treatment for severe,
handicapping
malocclusion
Treatment for facial
accidents involving
severe traumatic
deviation
Prior authorization is
needed
Orthodontic
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Mandatory Prior Authorization
Mandatory prior authorization is required
for the following services:
Orthodontia
Implants
Fixed prosthetic services
Dental general anesthesia
A combination of inlays/onlays or
permanent crowns in excess of four
per client
Procedure codes D4276, D7272 & D7472
Cone beam imaging
Limited dental services for clients who are 21 years of age and older
(not residing in an ICF-IID facility) whose dental diagnosis is
secondary to and causally related to a life-threatening medical
condition
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Prior Authorization for
Orthodontic Services
In fee-for service models, correction of
severe handicapping malocclusion must
be measured on the Handicapping
Labiolingual Deviation (HLD) Index. A
minimum score of 26 points is required
for full banding approval (only permanent
dentition cases are considered).
HLD Index
Level I
Level II
Level III
Level IV
In managed care models, there are
four orthodontic service levels for
severe handicapping malocclusion,
each requiring a different amount of
time for treatment and a different level
of skill and orthodontic procedures.
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Use of General Anesthesia
The dental provider is responsible for
determining whether a patient meets
the minimum criteria of 22 points
necessary for receiving general
anesthesia.
The Criteria for Dental Therapy
Under General Anesthesia form must
be completed as part of the patient’s
chart.
Prior authorization is required for the
use of general anesthesia for patients
who do not meet the 22-point
threshold.
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Filing Dental Claims
TMHP is responsible for reimbursing all THSteps dental services
provided by dentists, including services rendered to STAR and
STAR+PLUS clients
Providers billing for dental services and intermediate care facilities
for persons with mental retardation (ICF-MR) dental services may
bill electronically or use the 2006 ADA claim form.
Electronic billers must submit THSteps dental claims using
TexMedConnect or an approved vendor software that uses the ANSI
ASC X12 837D 4010A format.
Paper billers are required to submit a 2006 ADA Dental claim form
for paper claim submissions to Texas Medicaid
for THSteps dental claims.
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Managed Care Dental Claims
Many managed care claims can be
filed online, and both plans have
online provider manuals
www.dentaquesttexas.com
www.mcnatx.net
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Why Take Medicaid
Patients?
I feel that the children under the
Medicaid program should receive the
best care possible from the best-trained
dentists that Texas can provide. These
children are in their economic situation
by no fault of their own. It is my hope
that these children, treated with dignity
and professionalism from caring dentists
and staffs will develop into adults with
high self-esteem and will too be
productive and caring adults.
Dr. C, Pediatric Dentist
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TMHP Provider Manual
www.tmhp.com
Providers > Reference Manual
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True or False?
Test Your Knowledge about Medicaid and
Dental Care
1. Children whose siblings or caregivers have caries are at
high risk for developing them as well.
TRUE: Low socioeconomic status and poor dietary habits
are linked to high risk of caries, which is likely to apply to the
entire household.
2. Medicaid clients who reside in intermediate care facilities for
persons with mental retardation are not eligible for covered
dental services if they are over 21.
FALSE: Residents of ICF-MR facilities who are over 21 are
eligible for dental services
3. THSteps and children’s dental care is provided through
Medicaid managed care.
TRUE: Effective March 1, 2012, children’s Medicaid dental
services are provided statewide through managed care for
children birth through 20 years of age.
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True or False?
Test Your Knowledge about Medicaid and
Dental Care
4. The First Dental Home initiative targets children aged 6 to 35
months.
TRUE: In part to increase access to early preventive dental
services, THSteps encourages visits for children beginning at
6 months but not beyond the child’s third birthday.
5. Prior authorization is required for orthodontia and cone beam
imaging.
TRUE: Both of these procedures require prior authorization
from the TMHP Dental Director.
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Medicaid Resources
Texas Health & Human Services Commission
www.hhsc.state.tx.us/medicaid
Texas Medicaid & Healthcare Partnership
www.tmhp.com
Texas Health Steps
www.dshs.state.tx.us/thsteps/providers.shtm
www.dshs.state.tx.us/dental/thsteps_dental.shtm
www.dshs.state.tx.us/thsteps/default.shtm
CHIP/ Children’s Medicaid
www.chipmedicaid.org
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This Texas Medicaid curriculum
was prepared by
Betsy Goebel Jones, EdD
Project Director
Tim Hayes, MAM
Project Designer
Module 8
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