Transition of Dental and Orthodontia

Coverage from Fee for Service to Medicaid Managed Care

June 12, 2012

Goal

To make the transition as transparent and seamless as possible for both the provider and patient.

  • Provide information on transition timelines
  • Explain procedures for existing and new cases
  • Describe steps providers need to take

Discussion Topics

  • Overview of
    • Medicaid Managed Care (MMC)
    • Dental Coverage Transition from Fee for Service (FFS) to Medicaid Managed Care (MMC)
  • Academic Dental Centers (ADC) Services
    • Process of Approval of Orthodontia Services
  • Timeline
  • Prior Approval Requests and Claims (FFS only)
  • Next Steps and Follow Up
  • Questions and Contact Information

Medicaid Managed Care Overview

Streamline and expand enrollment in MMC

Include several previously exempt and excluded populations

  • Homeless Population
  • End Stage Renal Disease Population
  • Low Birth Weight Infants
  • Others

Integrate Several Benefits

  • Personal Care Services as of 8/1/11
  • Pharmacy as of 10/1/11
  • Dental (other than orthodontia) mandatory as of 7/2/12
  • Orthodontia mandatory as of 10/1/12
  • Others

Plan Enrollment and Dental Coverage Status in NYS

Region Total Enrolled Percent of Enrolled
with Dental Coverage
New York City 2,109,869 82%
Upstate 1,052,596 49%
Statewide 3,162,465 71%

*Enrollment numbers are based on May 2012 data

Dental Coverage by Plan

Plans Covering Dental Plans Not Covering Dental
  • Affinity Health Plan, Inc.
  • Health Insurance Plan of Greater New York
  • HealthFirst PHSP, Inc.
  • Hudson Health Plan, Inc.
  • Neighborhood Health Providers Inc.
  • Capital District Physicians´ Health Plan, Inc.
  • Excellus Health Plan, Inc.
  • HealthNow New York, Inc.
  • Independent Health Association, Inc.
  • SCHC Total Care, Inc.
  • Univera Community Health, Inc.
  • MetroPlus Health Plan, Inc.
  • Amida Care
  • VNS Choice (formerly Select Health)
  • Metroplus Health Plan SNP

Dental Coverage by Plan Continued

Mixed Coverage by County

  • Health Plus, and Amerigroup Company
    • Yes- Bronx, Kings, New York, Queens, Nassau, Richmond
    • No- Putnam
  • MVP Health Plan, Inc.
    • Yes- Dutchess, Ulster
    • No- Genesee, Livingston, Monroe, Ontario
  • New York State Catholic Health Plan, Inc.
    • Yes- Bronx, Broome, Cayuga, Chenango, Clinton, Columbia, Cortland, Dutchess, Essex, Franklin, Fulton, Greene, Hamilton, Kings, Livingston, Madison, Monroe, Montgomery, Nassau, New York, Niagara, Orange, Oswego, Putnam, Queens, Richmond, Rockland, Schoharie, St. Lawrence, Steuben, Suffolk, Sullivan, Tioga, Ulster, Warren, Wayne, Westchester
    • No- Albany, Allegany, Cattaraugus, Chautauqua, Chemung, Delaware, Erie, Genesee, Herkimer, Lewis, Oneida, Onondaga, Ontario, Orleans, Otsego, Rensselaer, Saratoga, Schenectady, Schuyler, Tompkins, Washington, Wyoming
  • United Healthcare of New York, Inc.
    • Yes- Bronx, Kings, New York, Queens, Nassau, Richmond, Suffolk
    • No- Broome, Cayuga, Chenango, Clinton, Herkimer, Jefferson, Madison, Oneida, Onondaga, Oswego, Rockland, Tioga, Warren, Westchester
  • WellCare of New York, Inc.
    • Yes- Bronx, Kings, New York, Queens
    • No- Albany, Dutchess, Orange, Rensselaer, Rockland, Ulster

Dental Vendors and Plan Contracts

  • DBPScion
    • UnitedHealthcare of New York, Inc.
  • Dentaquest
    • Empire Health Choice HMO, Inc.
    • Fidelis Care New York
    • Healthfirst PHSP, Inc.
    • Neighborhood Health Providers, LLC
  • Healthplex
    • Affinity Health Plan, Inc.
    • Amidacare
    • CDPHP*
    • Excellus Health Plan, Inc.
    • Health Insurance Plan of GNY
    • Health Plus, and Amerigroup Company
    • Hudson Health Plan, Inc.
    • Independent Health Association, Inc.
    • MetroPlus*
    • MVP Health Plan, Inc.
    • Total Care*
    • Univera Community Health, Inc.
    • VNS Select Health
    • WellCare of New York, Inc.
*Pending Approval

Transitional Care - Dental

  • Interrupted Treatment Rules Apply
    • eMedNY Dental Policy and Procedure Manual pp. 22 - 24
    • If "Decisive Appointment" prior to enrollment, insurer on date of decisive appointment pays for entire procedure
    • Applies to new members enrolling from FFS or another Plan
  • Service Continuation
    • Plans must allow new member to continue treatment with non-participating provider for up to 60 days or until the current treatment plan is complete, whichever is sooner, when:
      • A treatment plan is in progress but has not been completed as of date of enrollment;
      • The provider agrees to accept Plan reimbursement as payment in full, adhere to Plan´s quality assurance and encounter data submission requirements and otherwise adhere to Plan´s policies and procedures.
    • Plan may require prior authorization for services not included in the treatment plan as of the effective date of enrollment

Timeline for Transition - Dental Services for Beneficiaries Enrolled in a Managed Care Plan

Beginning Now

Providers should:

  • Identify those MMC Plan(s) that provide, or will provide, coverage for your patients
  • Contact those Plans that you wish to participate with and enroll as a provider
  • Determine what forms, diagnostics, means of submission, etc. will be required by the Plans
  • Prepare to submit prior approval requests to the Plans on and after 7/2/2012
  • Requests for emergency or urgent care can be submitted to FFS

July 2, 2012

  • Providers must begin submitting claims and prior approval requests to the beneficiary´s plan
  • All FFS prior approval requests for beneficiaries enrolled in a MMC Plan will be automatically rejected after 7/1/2012 regardless of when the request was submitted or received by FFS (eMedNY)
  • Any prior approval that has been issued through FFS is NULL and VOID unless the "decisive appointment" for the approved procedure is reached prior to 7/2/2012. If the decisive appointment for the approved procedure has been met prior to 7/2/2012, payment will be made FFS by following the instructions for "Interrupted Treatment" in the "Dental Policy and Procedure Manual".

Academic Dental Centers (ADCs)

ADCs will continue to be "free access" providers.

  • Services to managed care enrollees
    • Dental care and "exam and evaluation for orthodontic treatment" without Plan approval.
    • Provision of orthodontic treatment will require Plan approval.
    • Services provided absent a negotiated rate with a managed care plan will be reimbursed by the plan at the FFS Medicaid rate.*
  • Services to fee-for-service patients
    • Orthodontic exams and evaluation without SDOH approval.
    • Orthodontic treatment will require SDOH approval.
    • Orthodontic exam and evaluation and treatment will be billed using the dental fee schedule.*
*The fee schedule amount for "orthodontic exam and evaluation" codes D8660, D0340,D0330, D0210, D0470, and D0350 and the APG rate for all other services. All D8XXX es for orthodontic treatment codes.

School Based Health Centers

  • School Based Health Center dental services will continue to be carved out of Managed Care and will remain billable Fee-for- Service.
  • SBHC services are identified by the following FFS rate codes:
    • Free-standing APG billers - 1447, 1453
    • Hospital APG billers - 1444, 1450
    • Free-standing FQHCs (not in APGs) - 1627, 1628
    • Hospital FQHCs (not in APGs) - 2888, 2889
    • Any service billed under these rate codes is carved out of Managed Care.
  • The SBHC dental rate codes should only be used by approved providers at appropriate sites of care.

Orthodontia Implementation 10/1/12

MCO Responsibility FFS Responsibility
  • Prior authorize treatment on or after October 1, 2012
  • Contract with a sufficient array of providers
  • Conduct quality of care reviews at least annually
  • Reimburse providers for services
  • Assist patients in identifying orthodontists participating in their Managed Care Plan.
  • Cases Currently in Care
  • Cases prior approved under MA FFS, including NYCORP
  • FFS responsible for duration of treatment/retention
  • Limited extended coverage for patients enrolled in either FFS or MMC if eligibility is lost

Transitional Care - Orthodontia

  • Care Continuation Scenarios
    • Member loses Medicaid eligibility
      • If patient is in FFS (i.e., not enrolled in managed care), if appliances are placed and active treatment begun, member receives a maximum of six months of treatment paid for via FFS
      • For Medicaid managed care enrollees, this process will also be handled FFS
    • Plan Member changes plan or newly eligible
      • Transitional care rules apply and member will transition to participating provider after 60 days or after treatment is complete, whichever comes first.
    • Plan Member changes provider
      • Provider must be participating and agree to provide services

Process for Approval of Orthodontia Services

Current: Outside of New York City

"Examination and Evaluation" performed by ANY orthodontist or clinic participating in Medicaid FFS for both FFS and MMC enrollees. Reimbursed for procedures performed, typically: Examination and diagnostic workup (D8660), Cephalometric X- ray & Tracing (D0340), FMX (D0330 or D0210), Diagnostic Casts (D0470), and, Photographs (D0350)

⇓

"Evaluation and diagnostic materials submitted by provider for review and determination to FFS Dental Bureau in Albany

⇓

"Submitting provider notified of determination
  • approval to begin treatment, or
  • provider and client notified of denial and rights to appeal.
  • Treatment occurs where the examination and evaluation was done (submitting provider)                      

Current: New York City

"Screening" done at Screening and Review      
Institutions (SRI´s):
  • Columbia,
  • NYU
  • Montefiore
Reimbursed for Rate Code 3141

⇓

Submits recommendation to NYCORP (DOHMH)

⇓

NYCORP issues Medicaid authorization and      
assigns treatment to a "panel" provider.

Process for Approval of Orthodontia Services

Entire State After 10/1/2012

"Examination and Evaluation" performed by ANY orthodontist or clinic participating
in the MMC Plan or in Medicaid FFS based on client´s eligibility. Reimbursed for
procedures performed, typically:
Examination and diagnostic workup (D8660), Cephalometric X-ray & Tracing (D0340),    
FMX (D0330 or D0210), Diagnostic Casts (D0470), and, Photographs (D0350)

⇓

Evaluation and diagnostic materials submitted by provider for review and determination.
  • MMC enrollee: sent to health plan
  • FFS Medicaid client: sent to Albany

⇓

Submitting provider notified of determination
  • approval to begin treatment, or
  • provider and client notified of denial and rights to appeal.
  • Treatment occurs where the examination and evaluation was done (submitting provider)  

Timeline for Orthodontia Transition

Beginning Now

  • Providers continue to perform exam and evaluations for both FFS and MMC patients and submit prior approval requests for review and determination by FFS Dental Bureau
  • Providers should:
    • Identify those MMC Plan(s) that provide, or will provide, coverage for your patients
    • Contact those Plans that you wish to participate with and enroll as a provider
    • Determine what forms, diagnostics, means of submission, etc. will be required by the Plans

September 4, 2012

  • Last day for providers to submit prior approval requests for MMC patients to FFS for review and determination
  • Providers should:
    • Continue to submit requests for clients that are FFS (not enrolled in a MMC plan) to SDOH for review and determination
    • Submit emergency/urgent cases (MMC enrolled) to SDOH for review and determination
    • Submit any new cases where the client is enrolled in a MMC Plan directly to the Plan for review after 10/1

October 1, 2012

  • All NEW cases will be authorized by the MMC Plan or FFS. A Medicaid FFS or MMC network provider or clinic can perform and submit the examination and evaluation to OHIP Dental Bureau for FFS or to the MMC Plan for MMC enrollees.
  • All EXISTING cases that have begun treatment or have been reviewed and approved for treatment prior to 10/1/2012 through FFS and issued an eMedNY prior approval number* will continue being paid FFS until the completion of the approved course of treatment.
* A "prior approval number" is also issued for FFS denials and other determinations. Check the roster for the actual determination.

Existing Orthodontia Cases - Key Points

  • To be paid for initial placement (D8070, D8080 or D8090) through FFS the provider will need an eMedNY PA
  • To be paid for ongoing orthodontic treatment FFS (quarterly payments(D8670), retention (D8680 etc.), there will have to be a claims history for initial placement

Prior Approval (PA) Request Procedures

  • MMC:
    • Prior Approval Request for MMC enrollees will be subject to Plan procedures - future discussion
  • FFS ONLY:
    • Electronic Submission
      • Advantages of electronic submission
        • Free HIPAA compliant software available through CSC (ePACES)
        • Speed and efficiency- immediate feed back if an error is made
        • No paper forms to obtain, fill out and store
        • Photographs and x-rays can be submitted electronically with the request*
        • Cost savings in printing, staff time, postage, etc.
      • Payments can also be sent electronically via "Electronic Funds Transfer (EFT)". Paper checks and rosters are being phased out and EFT will become mandatory Paper Submission
      • Prior Approval Request Form eMedNY361401 and Claim Form ´A´ are obtained through CSC at: (800) 343-9000

Sample eMedNY Forms (FFS ONLY)

Sample eMedNY Forms (PDF, 468KB)

Medicaid Eligibility Changes - Orthodontia

  • The decisive appointment for active orthodontic treatment is the time at which the total appliance(s) is/are completely placed and activated. The placement of the component parts (e.g. brackets, bands) does not constitute complete appliance insertion or active treatment.
  • When Medicaid eligibility is lost after active orthodontic treatment has been initiated, the FFS or MMC patient may choose to continue treatment as private pay or through commercial insurance, or access Medicaid FFS for limited extended coverage.
    • As clinically indicated, FFS Medicaid provides for limited extended coverage for:
      • Two (2) quarterly payments;
      • One (1) quarterly payment and retention;
      • Retention alone; or
      • Removal of appliances

The limited extended coverage is provided through FFS for up to a six-month period following loss of Medicaid eligibility.

When billing for limited extended coverage, submit a paper claim at the end of the period to FFS using procedure code D8999:

  • Listing all covered procedures being claimed
  • Original authorization from the Plan
  • Plan denial (EOB)
  • Stage of treatment when eligibility was lost
  • Use the last date of eligibility for the date of service

Limited extended coverage for lost eligibility is only payable one (1) time during the course of orthodontic treatment.

Next Steps & Follow Up

  • Schedule meeting with Providers and Plans
    • Contracts
    • Enrollment/Credentialing Process
    • Networks
    • Prior Approval Process
  • Notify providers in advance of revisions to orthodontic guidelines and coverage criteria

Questions & Contact Information