FAQs; D-DNP Dental Coverage

Dental Benefits Implementation Questions

  • FAQs also available in Portable Document Format (PDF)

      • April 2024

      When does this mandate go into effect?

      This requirement begins January 1st, 2025, and was included in the 2024 State Medicaid Agency Contract for the 2025 bid filing period. It will also be included in the 2025 State Medicaid Agency Contract which plans will sign and submit to CMS in June 2024.

      Are plans required to cover the entire Dental Medicaid Benefit?

      Yes, plans must cover the entire Dental Medicaid Benefit using their Medicare rebate dollars.

      What if a plan's Medicare rebate is not enough to cover the entire Medicaid Dental Benefit?

      DOH has analyzed New York D-SNP plans' Medicare rebates and is confident that the rebate amounts more than cover the cost of the Medicaid Dental Benefit.

      If a plan believes their rebate is not enough to cover the entire Dental Benefit in future years, the plan should contact DOH using the duals mailbox: dualintegration@health.ny.gov

      Does the requirement include the recent Medicaid settlement (settled on May 1, 2023)?

      Yes. DOH has included the increases in covering the Medicaid Benefit in the analysis and plans must cover the entire Medicaid Dental Benefit which beginning January 2024, includes expanded coverage.

      How will DOH monitor implementation?

      As part of the annual requirements outlined in the SMAC, plans submit their signed SMAC along with their bids to CMS for the upcoming year. DOH will review these documents to ensure that plans are covering the entire Medicaid Dental Benefit as a Medicare supplemental benefit.

      Are there new network requirements as part of this requirement?

      Per the SMAC, D-SNPs must already have an appropriate network of providers and specialists available, to assist its members by identifying participating Medicaid providers in the D-SNP's provider network, and as of 2024 have a network congruency between its Medicare and Medicaid participating providers of 80%. Plans must have an acceptable network congruency of 85% beginning January 2025.

      The 2024 SMAC establishes that the plan shall demonstrate network congruency in a format and timeframe to be determined by the Department. DOH reserves the right to require D-SNPs provide Dental network congruency information to ensure member access to care.

      Where can I find more information about the Medicaid Dental Benefit?

      The Department of Health maintains a Section of the eMedNY website for the Dental benefit: Provider Manuals - Dental (emedny.org) and here: Information for Medicaid Members (ny.gov)

      What should I do if I have other questions after reviewing the policy and more details links?

      You may reach out to the Dual Integration BML at: dualintegration@health.ny.gov

      Can you define what non-capped benefit means in relation to the Medicaid plan offering?

      As stated on slide #2 of the February 28, 2024, DOH dental benefit presentation, the benefit design may not offer a capped allowance. This means that the dental services covered under the Medicare supplemental benefit cannot be offered as a limited allowance amount (ie. "this plan provides coverage up to $1,000 for dental services").

      DOH stated that it is not differentiating between DSNP beneficiary categories, i.e. Full Dual vs. Qualified Medicare Beneficiary (QMB). However, if a plan offers a QMB-only plan where dental is not currently provided to partial dual eligibles, can DOH confirm whether the Medicare supplemental dental benefit required per the SMAC includes this QMB (ie. partial dual eligibles) category?

      All DSNPs, whether they serve full or partial dual eligibles, operating in New York will be required to cover the Medicaid Dental benefit as a Medicare Advantage supplemental benefit.

      Can you please confirm if you expect changes to the 2025 dental package (i.e. adding or removing any of the benefits) or should we consider the 2024 package the guide for 2025.

      We do not expect changes to the 2025 dental package. For CY 2025, D-SNPs must cover the Medicaid dental benefits defined in the 2024 package as of April 1, 2024. In the event of benefit modifications after April 1, Health Plan's D-SNP shall cover any newly added Medicaid dental services under the Medicare supplemental benefit beginning on January 1st of the following year.

      What are DOH's congruency expectations where the health plan has both a Medicare and a Medicaid product offering and the service areas overlap but are not identical?

      DOH would expect provider network congruency in the overlapping counties.

      We enroll partial duals who are not eligible for full Medicaid benefits such as dental, please confirm what is the expectation to provide the Medicaid covered dental to these members that are not currently eligible for the Medicaid dental package.

      Please refer to Question #10 above.

      Would a Medicaid Advantage Plus (MAP) still be required to contract for dental services in 2025 if these benefits are no longer covered by Medicaid but will now be required to be offered as a Medicare supplemental benefit?

      Yes, however, the D-SNP for MAP will be required to cover the Dental Medicaid benefit as a Medicare supplemental benefit.

      Will an updated MAP member handbook be provided without the dental benefits for 2025?

      DOH will provide updated language for the MAP member handbook regarding D- SNP coverage responsibility for dental care services.

      1. Regarding an 85% overlap with the provider network for Medicare and Medicaid, can you clarify which descriptor is accurate:
        1. Does the state require 85% of the actual Medicaid providers to be included in the MA network OR
        2. Does the state require 85% of the actual network to be Medicaid providers.

      The State is requiring plans to have 85% of their Medicaid providers to be included in the Medicare network.

      Certain D-SNPs may want to still include supplemental dental benefits above and beyond the Medicaid dental benefit (i.e., covering services that are not covered by Medicaid). Though Medicaid dental benefits cannot be limited, our understanding is that D-SNPs could set a maximum amount on whatever benefits offered above and beyond the Medicaid benefit. Could you please confirm that's correct?

      DOH agrees that any additional benefits offered beyond the Medicaid required services would not be impacted by this provision.

      Could you please share the reporting requirements that D-SNPs will need to provide for the dental supplemental benefit? Will D-SNPs report all dental encounters to Medicare under the new SMAC because they are paid for via MA supplemental benefit dollars? Or will there be a requirement to report on services by program (for example, reporting to the state on services covered because they are part of the Medicaid dental benefit and reporting services that are above and beyond the Medicaid benefit to Medicare)?

      NYS does not require Medicaid encounter reporting from D-SNPs for Medicare services at this time.