DEPARTMENT OF HEALTH AND SOCIAL SERVICES

Division of Medicaid and Medical Assistance

Statutory Authority: 31 Delaware Code, §512 (31 Del.C., §512)

ORDER

Early and Periodic Screening, Diagnostic, and Treatment Program

Nature of the Proceedings

Delaware Health and Social Services (žDepartmentÓ) / Division of Medicaid and Medical Assistance (DMMA) initiated proceedings to amend the Title XIX Medicaid State Plan related to the reimbursement methodology for specialized dental services under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program. The Department’s proceedings to amend its regulations were initiated pursuant to 29 Delaware Code Section 10114 and its authority as prescribed by 31 Delaware Code Section 512.

The Department published its notice of proposed regulation changes pursuant to 29 Delaware Code Section 10115 in the April 2006 Delaware Register of Regulations, requiring written materials and suggestions from the public concerning the proposed regulations to be produced by April 30, 2006 at which time the Department would receive information, factual evidence and public comment to the said proposed changes to the regulations.

Summary of Proposed Amendment

Statutory Authority

∑ 42 CFR §441 Subpart B, Early and Periodic Screening, Diagnostic, and Treatment Services (EPSDT) of Individuals Under Age 21

∑ Social Security Act 1905(r), Early and Periodic Screening, Diagnostic, and Treatment Services

Amending the Following State Plan Page

Attachment 4.19-B, Page 19

Background

The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) service is Medicaid's comprehensive and preventive child health program for individuals under the age of 21. EPSDT was defined by law as part of the Omnibus Budget Reconciliation Act of 1989 (OBRA 89) legislation and includes periodic screening, vision, dental, and hearing services. In addition, section 1905(r)(5) of the Social Security Act (the Act) requires that any medically necessary health care service listed at section 1905(a) of the Act be provided to an EPSDT recipient even if the service is not available under the State's Medicaid plan to the rest of the Medicaid population.

Summary of Proposed Amendment

To facilitate access to EPSDT dental services for Medicaid recipients and to facilitate provider participation in the program, DMMA proposes changes to its reimbursement methodology.

Traditionally, the Department of Public Health (DPH) reimbursed orthodontists for orthodontic care provided to Medicaid children under age 21. This state plan amendment (SPA) will enable the DMMA to assume that responsibility.

Currently, specialized dental services are reimbursed a percentage of charges for routine dental services. DMMA proposes to reimburse a fee-for-service under Medicaid for orthodontic related services.

The proposed amendment to the state plan is subject to approval by the Centers for Medicare and Medicaid Services (CMS).

Summary of Comments Received with Agency Response

The Governor’s Advisory Council for Exceptional Citizens (GACEC) and the State Council for Persons with Disabilities (SCPD) offered the following observations and recommendations summarized below. DMMA has considered each comment and responds as follows:

GACEC

The GACEC endorses the concept of allowing DMMA to process EPSDT dental claims to enhance efficiency; however, the Council would like to make the following comments:

The Council would strongly prefer the adoption of reimbursement approaches, which would provide sufficient incentive for dental providers to participate in the Medicaid program. We would also like to note that Council lacks sufficient information to endorse or disapprove of the change to the fee-based system for most orthodontic services. If more information is available, please let us know.

SCPD

First, it is Council’s understanding that the current arrangement in which the DPH processes EPSDT dental claims is somewhat backlogged. Therefore, the regulations contemplate processing of the claims by DMMA. This appears to be acceptable since DMMA may have a more extensive infrastructure for processing EPSDT claims.

Second, the more difficult issue is the provider reimbursement standard. The significant change is that most orthodontic services will be reimbursed based on a flat rate based on the 75th percentile of orthodontic rates paid by the DPH special dental program. This is ostensibly a favorable rate since the 50th percentile of the DPH would reflect the average DPH reimbursement standard. However, without more data, SCPD cannot determine if providers will generally be paid more under the žpercentage of chargesÓ approach or under the “75th percentile of DPH rates” approach.

In summary, SCPD endorses the concept of allowing DMMA to process EPSDT dental claims to enhance efficiency. In addition, Council strongly recommends adoption of reimbursement approaches, which provide sufficient incentive for dental providers to participate in the Medicaid program. Finally, SCPD lacks sufficient information to endorse or disfavor the change to the fee-based system for most orthodontic services.

Agency Response: We are proud to say that the Delaware Medicaid & Medical Assistance Program has been a leader in adopting innovative reimbursement approaches for the provision of dental care. It is well known nationally that Delaware is the only state, which pays an actual percentage of billed charges for routine dental care – 85%. Delaware’s reimbursement methodology has been touted by CMS and prominent figures such as Dr. Burton L. Edelstein, Professor of Dentistry and Public Health at Columbia University and Founding Director of the Children’s Dental Project, and Dr. James J. Crall, Director of the HRSA/MCH Bureau’s National Oral Health Policy Center and Professor and Chair of Pediatric Dentistry at UCLA. CMS and these dental advocates have noted Delaware’s reimbursement methodology as a model among states. As a result, the DMMA has seen the number of dentists participating in Delaware increase from 1 in 1997 to 140 currently. DMMA can say confidently that Delaware’s reimbursement for dental services under EPSDT is not a barrier to participation.

Although, DMMA is adopting a fee-for-service methodology for orthodontic care, the rates proposed are factored from payment amounts made by the Division of Public Health to their contracted orthodontists. These rates easily meet or exceed those in the commercial sector and DMMA knows that from communication and feedback with the orthodontic community that the proposed rates are sufficient to encourage direct enrollment and participation in the Medicaid Program. DMMA is acutely attuned to the needs of the dental community in Delaware and know, too, that the rates DMMA pay must keep pace with growing treatment costs in order to maintain participation and satisfaction with our program. DMMA does intend to maintain appropriate levels of reimbursement so that Medicaid eligible children with handicapping malocclusions will have the necessary access to be treated comprehensively and timely.

Findings of Fact

The Department finds that the proposed changes as set forth in the April 2006 Register of Regulations should be adopted.

THEREFORE, IT IS ORDERED, that the proposed regulation to amend the Title XIX Medicaid State Plan as it relates to the reimbursement methodology for dental services under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program is adopted and shall be final effective June 10, 2006.

Karryl McManus for

Vincent P. Meconi, Secretary, DHSS, 5/16/06

DMMA FINAL ORDER REGULATION #06-19

REVISIONS:

ATTACHMENT 4.19-B

Page 19

Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services are reimbursed as follows:

1. Screening services - fee-for-service.

2. Treatment services - fee-for-service.

3. Dental Treatment - reimburse a percentage of charges for routine dental services.

4. Specialized Dental Services - reimburse a percentage of charges for routine dental services (a) a percentage of charges for non-orthodontic related services and (b) a flat fee-for-service for orthodontic related services.

(a) Percentage of Charges for non-orthodontic services – The State pays 85% of billed charges for medically necessary non-orthodontic dental care, determined by: 1) the consideration that 65-70% of the usual & customary rate is nationally known to account for the dental provider’s actual costs; and, 2) an allowance of an additional mark-up to permit a reasonable and fair profit and as incentive for providers to participate in the Medicaid Program in order to create adequate access to dental care.

(b) Flat Fee-for-Service for orthodontic services – The State identifies three primary orthodontic-related services that encompass orthodontic reimbursement: 1) Pre-orthodontic treatment visit; 2) Comprehensive orthodontic treatment of the adolescent dentition; and, 3) Periodic orthodontic treatment visit. Rates for each orthodontic service are determined by adopting the 75th percentile of orthodontic rates paid by the Division of Public Health Special Dental Program, which, compare favorably to commercial coverage and encourage provider participation and adequate access to orthodontic care. Care provided outside of these three services will be reimbursed at a percentage of charges. Medicaid reimbursement for these three orthodontic services will be the lower of the submitted charges or the established Medicaid rate.

9 DE Reg. 1976 (06/01/06)(Final)