what's inside - New York State Dental Association

New York State Medicaid Program to Undergo ChangeAnticipated changes will affect covered patients and dentists.Judith L. Shub, Ph.D.As New York State struggles to meet itsever-increasing Medicaid costs, Gov.Andrew Cuomo and the Departmentof Health (DOH) are looking to managedcare organizations (MCOs) tohelp reduce and control these costs. The good news is thatthe governor and the Medicaid Redesign Team have notcalled for a reduction in dental services in the coming year.However, several planned changes will affect many coveredpatients and dentists who participate in the Medicaidprogram. Specifically, DOH plans to implement twosignificant changes to the Medicaid dental program.The first of these changes occurs on July 1, whenDOH will require all managed care plans to offerdental coverage (except orthodontia) to their Medicaidenrollees. This will be followed on Oct. 1, whenDOH will end the carve-out of orthodontic servicesby requiring patients enrolled in MCOs to obtaintheir orthodontic care through their MCOs.Patients who are not enrolled in an MCO willcontinue to receive their dental benefit through thecurrent “fee-for-service” Medicaid program.State governments across the nation are turning tomanaged care to control the ever-increasing financialliability associated with public healthcare programs.Unlike Medicaid, neither the Child Health Plus(SCHIP) nor the Family Health Plus programs providesfunding (benefits) for actual healthcare. Instead,the state purchases benefits in total or in part for eligibleprogram recipients from third party payers. Thebenefit plans purchased in these programs are managedcare plans.In 1996, New York received a waiver from the federalgovernment allowing it to enrollMedicaid recipients in managed care plans.Since then, DOH has entered into contractswith a number of managed care companies/organizations and endeavored to enrollMedicaid recipients in these health plans fortheir medical and dental care. Up until now,these MCOs were not required to offer dentaltreatment to Medicaid recipients. Forthose that did, orthodontic treatment wascarved out of the required treatment offerings.It is these two policies that are scheduledto change in the months ahead.DOH’s current policy continues tocall for the transfer of all Medicaid recipientsinto managed care. And DOH willrequire that all MCOs with which it contractsprovide both medical and dentaltreatment services, including orthodonticservices, to its Medicaid enrollees. Thiswill have two immediate effects. First, itwill require MCOs to create or expandtheir panels of participating dentists. As aresult, MCOs will be competing toincrease their panels by contracting withmore dentists. This should improve theability of dentists to achieve more favorableterms when negotiating managedcare contracts. Second, it will broaden thepresence of MCOs in the benefit marketplace.Both of these factors underscore theimportance of dentists understandingmanaged care before entering into legalcontracts with managed care companies.While DOH has set dates for transitioningpatients into managed care plansfor their dental treatment, it has notexplained how these transitions will occur.For example, DOH has not announcedwhether the current protocols for eligibilityscreening for orthodontic patients in NewYork City will be discontinued or whatarrangements will be made for orthodonticpatients who are currently in treatment.Regardless, the change underscoresthe need to verify the eligibility and paymentsource for every Medicaid patientat every appointment. Dentists who donot have participation agreements with apatient’s managed care plan will not beeligible to receive Medicaid reimbursementfor that patient’s treatment. zDr. Shub is NYSDA Assistant Executive Directorfor Health Affairs. She can be reached by callingthe NYSDA office, 1 (800) 255-2100, or writingto jshub@nysdental.org.NYSDA NEWS / May 20124