Name of Practice: TennCare Dental Program (TN0701) Category: Dental Abstract: To resolve a class action suit against the State Of Tennessee (John B. v. Menke), which alleged, in part, that Tennessee's statewide managed care program, TennCare, was not providing Medicaid-eligible children with adequate dental services, key stakeholders developed a consensus strategy for improving access to Medicaid dental services. Implementation of this strategy resulted in carving out the dental benefit from Medicaid managed care contracts, appropriation of additional State funds for dental services, the competitive selection of Doral Dental to administer the Medicaid dental benefit, and an increase in fee-for-service reimbursement for participating dentists. Since the initiation of these efforts, the number of dentists participating in Medicaid statewide has increased by 112 percent and the number of eligible children who have received at least one dental service has reached 37.4 percent.
The Problem:
In 1998, a class action suit was brought against the State Of Tennessee (John B. v. Menke), which alleged, in part, that Tennessee's statewide managed care program, TennCare, was not providing Medicaid-eligible children with adequate dental services. Prior to the parties reaching a settlement in Federal Fiscal Year (FY) 2002, only 386 dentists participated in the Medicaid program and 26.1 percent of eligible TennCare children received any dental service. Each TennCare managed care organization (MCO) (or its dental subcontractor) negotiated dental reimbursement rates individually with contracted dentists, who were generally paid about 40 percent of their cost for each dental procedure.
Discussion of Approach
In John B. v. Menke, children and their families alleged that the State's managed care program had not provided children adequate access to a broad range of services through Medicaid's Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. This case was resolved through consent of all parties when the State agreed to implement a plan that would improve outreach and information to beneficiaries, update statewide periodic screening requirements, improve access to needed treatments, and enhance measurement of performance information submitted to the National Committee for Quality Assurance and to the Health Care Financing Administration (now the Centers for Medicare & Medicaid Services) on its EPSDT reporting form. A turning point in resolving this litigation with regard to dental services occurred when key stakeholders, including TennCare, Doral Dental, the Tennessee Dental Association (TDA), and the Tennessee Department of Health (DOH), met in May 2001 to share ideas regarding actions that would improve dental access for children. These discussions resulted in the development of a comprehensive children's oral health strategy that led to removal of the dental benefit from Medicaid managed care contracts, appropriation of additional State funds for dental services, and the competitive selection of Doral Dental to administer the Medicaid dental benefit. Effective October 1, 2002, fee-for-service reimbursement for participating dentists was increased to the lesser of billed charges or the 75th percentile of the fees published in the 1999 American Dental Association (ADA) Survey of Fees for the East South Central Region.
The dental benefits management (DBM) contract requires Doral Dental to maintain and manage an adequate dental provider network, process and make claims payment, manage data, provide beneficiary outreach and education/administrative case management (e.g., hotline and referrals), and achieve certain performance requirements spelled out in the contract, including utilization review, quality improvement, provider network standards, and prompt payment. This arrangement minimizes the administrative burden on participating dentists by requiring them to sign only one provider agreement, undergo a single credentialing process, and use one maximum allowable fee schedule. Doral Dental enhances efficiency by encouraging electronic claims submission, facilitating electronic verification of beneficiary enrollment, and scheduling appointments based on the availability of network dentists.
Doral Dental is also responsible for informing enrollees about the availability of dental services and increasing the number of children enrolled in TennCare who receive dental care. Doral has conducted this outreach through a program in which volunteer dentists participate in community-based events and provide services using mobile dental clinics. The Bureau of TennCare and DOH also conduct outreach activities through a statewide oral disease prevention services initiative, and the TDA has made its members aware of the TennCare dental program changes.as a means of supporting Medicaid efforts to recruit additional dentists. Results:
Since the initiation of these efforts, the number of dentists participating in Medicaid statewide has increased by 112 percent, and the number of participating providers in rural areas has increased by 118 percent. TennCare estimates that the ratio of participating dentists to child enrollees ages 3 through 20 is 694:1. By the end of FY 2005, 37.4 percent of eligible children had received at least one dental service. Further Information: Contact: James Gillcrist
Dental Director
TennCare
310 Great Circle Road
Nashville, Tennessee 37243
(615) 507-6494
e-mail: James.A.Gillcrist@state.tn.us This Profile has been posted to the CMS Medicaid/SCHIP Quality website for informational purposes only and does not convey CMS endorsement of the practice itself. The descriptive information supplied and the results reported in this Profile have been supplied by sources familiar with the practice but have not been independently validated by CMS. | | | Downloads |
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