skip over navigation

Medicaid Contract Purchasing Specifications

Purchasing Specifications For Medicaid Pediatric Dental And Oral Health Services
March 10, 2000

Table of Contents

§201. Enrollee Access to Dental and Oral Health Care Providers
§202. Enrollment and Disenrollment
§203. Provider Network Requirements
§204. Data and Reporting
§205. Quality Measurement and Improvement
§206. Compliance Measures

Note on symbols that appear alongside sample purchasing specifications: In order to provide additional guidance to Medicaid purchasers, these sample purchasing specifications contain applicable symbols that are designed to identify the basis (or bases) for the sample specification. The meaning of each symbol is as follows:

L: The provision is based in whole or in part on federal Medicaid law, as articulated in the Medicaid statute, a federal regulation, or other written HCFA policy such as an Action Transmittal, State Medicaid Directors Letter, Regional Office Memorandum, or other formal HCFA transmittal. Just because an item is marked "L" does not mean that the service or activity is mandatory either for state agencies or for managed care contractors. Where the legal basis in question identifies a required service or activity, a footnote will so indicate. Law-related provisions that relate to optional services and activities also will be identified in a footnote. "L" is also used to indicate provisions that are based on and may incorporate non-Medicaid laws such as those relating to court-ordered treatment services.

G: The provision is based on whole or in part on formal guidelines issued by, or under the auspices of, a government agency (e.g., Centers for Disease Control and Prevention, 1998, MMWR 1998; 47 (No. RR-1), a professional society, or a formally convened, impartial deliberative body (e.g., the Institute of Medicine).

K: The provision is based in whole or in part on the best judgment and opinions of persons knowledgeable in a particular area of health care practice, health care delivery, or health services organization and management. This symbol is used to signify sample specifications that do not reflect a formal legal policy or that are not part of a formal practice guideline but that are recommended for consideration because they reflect good practice in the opinion of experts.

Part 2. Pediatric Dental And Oral Health Service Delivery And Quality

§201. Enrollee Access to Health Care Providers 29

K,L(a) Time lines for covered services -- Contractor shall provide and arrange for services covered under this agreement in accordance with the following standards:

L (1) Contractor shall ensure immediate access to services for emergency dental and oral conditions or injuries;

(2) Contractor shall ensure access to services for urgent dental and oral conditions or injuries on the basis of the professional judgment of the enrollee's treating dentist, other dental professional, primary care provider or a triage nurse who is trained in dental care and oral health care; and

(3) Contractor shall ensure that visits for non-emergency, non-urgent preventive, treatment and restorative oral and dental health services are scheduled to occur within [drafter insert the average waiting period for such visits for enrollees in private-sector managed care organizations doing business in Contractor's service area] of the date on which an enrollee requests an appointment, provided that the scheduling of visits is consistent with:

(A) the state medical assistance plan schedule for referrals to dentists for periodic dental and oral health assessments, as described at §103(b)(3)

(B) the schedule for application for topical fluoride, as described at §103(b)(5);

(C) the schedule for applicant of dental sealants, as described at §103(b)(6); and

(D) the schedule for dental prophylactic services, as described at §103(b)(7).

K (b) Geographic access - Contractor shall ensure that travel time for dental and oral services is no greater than [drafter insert number of minutes or miles] from an enrollee's residence using commonly available public travel arrangements and [drafter insert number of minutes or miles] in the case of those portions of the Contractor's service area designated as rural by a state health agency.

§202. Enrollment and Disenrollment

K (a) Enrollment of individuals receiving dental or oral health services at the time of enrollment - Except as provided in subsection (b), in the case of an individual receiving dental or oral health services at the time of enrollment, Contractor shall provide coverage for items and services in the enrollee's pre-enrollment plan of care until the enrollee has been evaluated by a provider within Contractor's network and a decision regarding continuation or modification of such a plan of care has been made and implemented.

K (b) Payment arrangements for individuals receiving dental or oral health services at the time of enrollment - In the case of an individual described in subsection (a) for whom a specified course of orthodontic or prosthodontic treatment was paid in full before the individual's enrollment with Contractor, Contractor shall arrange for the treatment to be completed by:

(1) the previous provider who was paid for the enrollee's treatment; or

(2) Contractor, provided that Contractor is able to enter into an agreement under which the previous provider agrees to pay Contractor on a pro rata basis to complete the treatment.

K (c) Disenrollment of individuals receiving dental or oral health services at time of disenrollment - In the case of an individual who is receiving dental or oral health treatment or restorative services at the time of disenrollment, Contractor shall: shall:

(1) continue such services until completed or through the last day of the period for which a premium was paid for the enrollee, whichever occurs first, except that in the case of orthodontic or prosthodontic treatment for which the Contractor has been paid in full before the disenrollment, Contractor shall complete the treatment in accordance with enrollee's treatment plan; and

(2) provide, at the written request of the former enrollee, for the transfer of all dental and medical records30 related to such services to the former enrollee's successor medical and dental providers at no cost to the recipients.31

§203. Provider Network Requirements

K (a) Network requirements - Contractor's network shall include the following classes of providers in numbers that are sufficient to enable Contractor to furnish services described in this agreement in accordance with the timeline, geographic and other standards described in §201 of this agreement:

(1) dentists, dental hygienists, nurses who are trained in dental care and oral health care and experienced in performing triage for such care; pediatric dentists; orthodontists; periodontists; endodontists; prosthodontists; oral pathologists; and oral and maxillofacial surgeons.

(2) dentists and other health and dental professionals described in paragraph (1) of this subsection with demonstrated experience in the provision of services to children with acute and chronic medical conditions, including cardiovascular conditions; HIV infection; developmental disability; or cancer; and

(3) medical and dental specialists and subspecialists that furnish multidisciplinary treatment of cranio-facial anomalies.

Contractor may meet the network standards for specialized dental and oral health care professionals described in this subsection by arranging for and covering referrals to specialists and subspecialist providers described in this paragraph who do not participate in the provider's network and reimbursing these providers at Medicaid or other, negotiated rates in accordance with the same coverage and payment timeline principles that apply to providers of services within the Contractor's network.

K (b) Use of publicly-assisted providers -- Contractor shall make a reasonable effort to include in its network publicly assisted providers as defined in §109 that offer dental and oral health programs. Contractor shall pay such providers at negotiated rates in accordance with the same coverage and payment timeline principles that apply to other providers of services within Contractor's network.

K (c) Updating provider network information -- Contractor shall provide to all potential enrollees, to individuals at the time of enrollment, and to any enrollee on request, a list that identifies all providers of dental and oral health services. Such list shall include current provider addresses and telephone numbers and shall be updated no less frequently than [drafter insert frequency of updating]. 32

§204. Data and Reporting

K (a) Integration of dental and oral health information into medical record 33-- Contractor shall ensure that dental and oral health screenings and referrals to dentists which are described in '103(a)(2),(3) are noted by the primary care provider delivering these services in the enrollee's medical record.

K (b) Special rule for certain enrollees -- In the case of an enrollee diagnosed with an illness, disability or condition or receiving a medical treatment(s) that constitutes one or more risk factors for dental or oral disease as defined in §109, Contractor shall ensure that the enrollee's medical treatment plan includes the dental and oral health services recommended by the enrollee's treating dentist.: 34

K (c) Dental and oral health services encounter data: Contractor shall collect encounter data on all dental and oral health services described in Part 1 that utilize universal codes for all dental and oral health services and that at a minimum, identify the enrollee, the date of service, the service provided including the tooth and tooth surface treated, the treating dentist, other dental professional, or primary care provider and, if available, the diagnosis related to the service provided.

§205. Quality Measurement and Improvement

K (a) Practice guidelines - Contractor shall disseminate to all network providers practice guidelines that conform to the clinical guidelines and recommendations incorporated into this agreement and shall regularly update such practice guidelines in accordance with changes in the guidelines and recommendations.

K (b) Quality studies - Contractor shall conduct periodic quality studies of the timeliness and quality of dental and oral health services described in Part 1. Such studies shall at a minimum consider one of the following:

(1) the percentage of all enrollees ages four through twenty-one who are continuously enrolled for a period of at least twelve months (allowing one break in service of up to forty-five days) who had one or more dental visits with a dental provider; 35

(2) the percentages of enrollees from birth through age twenty, stratified by age (<1, 1-2, 3-5, 6-9, 10-14, 15-18, and 19-20 years) who are continuously enrolled for a period of at least twelve months (allowing one break in service of up to forty-five days) who had one or more dental visits with a dental provider;36

(3) the percentages of enrollees from birth through age twenty, stratified by age (<1, 1-2, 3-5, 6-9, 10-14, 15-18, and 19-20 years) who are continuously enrolled for a period of at least twelve months (allowing one break in service of up to forty-five days) who, within the reporting year, received: 37

(A) any dental procedure;

(B) any preventive dental procedure;38 and

(C) any dental treatment other than diagnostic and preventive procedures; and

(4) enrollee experience with pediatric oral and dental health services, as measured with the pediatric oral health survey module of the CAHPS survey instrument prepared by the Agency for Health Care Policy Research (AHCPR). 39, 40

§206. Compliance Measures

K (a) Availability to Purchaser of Certain Documents -- Upon request, Contractor shall make available to Purchaser the most recent version of each of the following documents:

(1) copies of all manuals, memoranda, and other documents that are distributed to participating providers and enrollees that explain coverage requirements for individuals receiving treatment for dental or oral conditions at the time of enrollment and disenrollment;.

(2) a list of all participating providers that furnish dental and oral health services enumerated in Part 1, including the addresses and telephone numbers of such providers and the service capacity of each provider. 41

(3) the list of network providers, with names, locations and telephone numbers, that is furnished to enrollees; and

(4) all practice guidelines and quality study protocols and results.

Endnotes

  1. Commentary: Medicaid purchasers may also wish to consider general service access standards at MEDICAIDSPECS Part 6 and a specialized package of access-related specifications currently under development by CHSRP. Amendments to Medicaid law in the 1997 Balanced Budget Act (BBA) create a general requirement that MCOs serving Medicaid beneficiaries to provide "assurances" of "a sufficient number, mix, and geographic distribution of providers" in the MCOs' service areas. (42 U.S.C. §1396u-2(b)(5)(B)). State Medicaid agencies vary in the geographic access standards for primary care and specialty providers included in Medicaid managed care service agreements; distances for access to providers of dental and oral health services are rarely addressed, however. A thirty-minute or thirty-mile travel time in urban areas is frequently used as a standard, as is 45 minutes or miles in rural areas. Purchasers may wish to review other options at: Rosenbaum, S et al, Negotiating the New Health Care System: A Nationwide Study of Medicaid Managed Care Contracts, Table 3.8. (3rd ed., 1999). For a range of time and geographic standards adopted by state Medicaid managed care programs, see also Dental Care in Medicaid Managed Care: A Report from a 19 State Survey. National Academy for State Health Policy (November, 1998).

  2. Commentary: A Medicaid enrollee's medical and dental records may be maintained by more than one MCO in a state where the Medicaid agency purchases prepaid comprehensive managed medical and health care separately from specialized managed care services for dental and oral health, behavioral health or children with special health care needs. For this reason, Medicaid agencies may wish to include comparable language addressing records transfer in each type of managed care service agreements.

  3. Commentary: Medicaid law does not directly address charges to beneficiaries for transfer of medical records. Arguably, such charges would not be consistent with the generally applicable requirement that covered "care and services" be "provided in a manner consistent with...the best interests of the recipients [beneficiaries]." (42 U.S.C. §1396a(a)(19).

  4. Commentary: For general specifications relating to information for potential and newly-enrolled Medicaid children, purchasers may wish to review MEDICAIDSPECS Part 3, which addresses enrollee information on covered items and services, excluded services that are covered under the state medical assistance plan; information on providers; emergency services; items and services subject to and excluded from prior authorization; cost-sharing and other matters. These specifications are drafted to be consistent with consumer protection requirements of Medicaid managed care provisions of the 1997 Balanced Budget Amendment (Section 1932 of the Social Security Act, 42 U.S.C. §1396u(j)).

  5. Commentary: This specification addresses only medical records of screenings and referrals by a child's primary care provider. It is intended to permit primary care providers' performance of these services to be evaluated. The specification should not be read to require primary care providers' medical records to include the separate records kept by the child's dentist.

  6. Commentary: This provision addresses the specialized dental and oral health needs of enrollees under treatment for HIV infection, cancer and certain other chronic and acute conditions as well as of enrollees with developmental disability, behavioral disorders and other conditions that require specialized interventions. At least one state Medicaid agency (Connecticut) has recognized the specialized needs by providing in its managed care contract for coverage of oral and dental health services in an enrollee's home and for patient "management" in connection with dental services for enrollees with developmental disability. Rosenbaum et al., Negotiating the New Health Care System: A Nationwide Study of Medicaid Managed Care Contracts (2nd ed., 1998). For applicable guidelines, addressing specialized dental and oral health services for children with special health care needs and for hospitalization and use of general anesthesia for pediatric dental services, see §107(k).

  7. Commentary: This performance measure is included in: National Committee for Quality Assurance (NCQA), HEDIS 1999 Technical Specifications, Vol. 2 (Washington, D.C.)

  8. Commentary: This measure is one of several quality measures recommended by an expert advisory panel organized by the National Committee for Quality Assurance (NCQA) under a contract with the Health Care Financing Administration. At the time these sample specifications were drafted, the recommended measures had not been included in the NCQA Technical Specifications; however, anecdotal evidence suggested that certain state Medicaid managed care programs were already collecting data relating to one or more of the measures. Purchasers may wish to review the recommended measures at: NCQA, The Future of Pediatric Oral Health Performance Measurement: Expert Panel Recommendations. Deliverable 203, HCFA, May 19, 1999; see also Crall JJ, Szlyk CI, Schneider DA. Pediatric Oral Health Measurement: Current Capabilities and Future Directions. J Public Health Dent 1999;59(3):136-40.

  9. Commentary: This measure is one of the several recommended quality measures described in the preceding Commentary. This recommended measure incorporates the requirements for state Medicaid agency reporting of EPSDT data relating specifically to dental services for Medicaid-eligible children, under Form HCFA-416 as revised in 1999. The revised HCFA form defines the three categories of services to be reported by service codes as follows: "any dental services...as defined by HCPC codes D0100 - D9999 (ADA codes 00100 - 09999)...preventive dental services as defined by HCPC codes D1000 - D1999 (ADA codes 01 - 01999)...dental treatment services as defined by HCPC codes D2000-D9999 (ADA codes 02000 - 09999)." HCFA State Medicaid Manual, §2700.4.

  10. Commentary: Purchasers may elect to use application of a dental sealant and or application of topical fluoride as the "preventive" service to be measured. Suggested measures for these services are:

    The percentages of enrollees from birth through age twenty, stratified by age (<1, 1-2, 3-5, 6-9, 10-14, 15-18, and 19-20 years) who are continuously enrolled for a period of at least twelve months (allowing one break in service of up to forty-five days) who, within the reporting year, received at least one topical application of fluoride in accordance with §103(b)(5); The percentages of enrollees from birth through age twenty, stratified by age (<1, 1-2, 3-5, 6-9, 10-14, 15-18, and 19-20 years) who are continuously enrolled for a period of at least twelve months (allowing one break in service of up to forty-five days) who, within the reporting year, received at least one dental sealant application on a permanent first and a permanent second molar in §103(b)(6).

  11. Commentary: CAHPS 2.0 - At the time these sample specifications were drafted, the CAHPS survey instrument included questions on whether a child had received dental care in the previous year, the frequency of such care, and the quality of the care (as perceived by the respondent). The expert panel described at Commentary 31 recommended that additional questions be formulated with regard to: (a) access; (b) regular source of care (availability); (c) satisfaction; (d) timeliness; (e) involvement in decision-making; and (f) assessment of unmet needs.

  12. Commentary: The Purchaser may wish to consider other recommended quality measures described at Commentary 31. These include:

    (1) Assessment of Disease Status -- Percentage of all child enrollees who have had their periodontal and caries status assessed within the reporting year;

    (2) New Caries among Caries-active Children -- Percentage of all caries-active child enrollees who receive treatment for caries-related reasons within the reporting year;

    (3) New Caries among Caries-inactive Children -- Percentage of all caries-inactive child enrollees who receive treatment for caries-related reasons within the reporting year.

    (4) Preventive Treatment for Caries-active Children -- Percentage of all caries-active child enrollees who receive a dental sealant or a fluoride treatment within the reporting year.

  13. Commentary: A provider's service capacity would be indicated by whether the provider's practice was open to new Medicaid patients, was limited to a specified number of such patients or was closed to them