1. Texas Medicaid Dental Services Gary Jessee Deputy Executive Commissioner Medical and Social Services Division Health and Human Services Commission November 7, 2016

2. Overview Texas Medicaid Dental Benefit Dental Benefit Quality Drivers
Managed Care Implementation
Establishment of Dental Home
Measuring Success

3. Texas Medicaid Dental Benefit
Primary and preventative dental services available to most children and young adults age birth through 20
Persons that do not receive services through the Children’s Medicaid managed care dental plans are:
Medicaid recipients who are 21 years of age or older
Recipients who reside in an institution (e.g., nursing homes, state supported living centers, ICF-IID)
Recipients in the STAR Health Program (dental services subcontracted through health plan)

4. Texas Medicaid Dental Benefit
Following medically necessary services included:
Diagnostic and preventive
Therapeutic
Restorative
Endodontic
Periodontal
Prosthodontic (removable and fixed)
Implant and oral and maxillofacial surgery
Orthodontic and adjunctive general

5. Texas Medicaid Dental Benefit
Program Enrollment as of March 2016
Enrolled in Managed Care Dental Plans: 2,931,417
Enrolled in Traditional Medicaid (Fee-for-Service): 214,869
Total Enrolled: 3,146,286
Source: HHSC System Forecasting, October 2016

6. Dental Benefit Quality Drivers

7. Managed Care Implementation
As of March 1, 2012, dental benefits administered under managed care environment by two dental maintenance organizations (DMOs) serving entire state
Members select a dental plan and a main dentist, who serves as the dental home and coordinates care

8. Managed Care Implementation Key Factors
Dental managed care allows a more creative approach to service delivery
Quality initiatives integrated into DMO contracts
DMO contractual requirements regarding network adequacy help ensure a robust network of available dental providers
Medicaid/CHIP Dental Director provides policy guidance and collaborates with stakeholders and agency staff to inform decision-making

9. Dental Home
Based on American Academy of Pediatric Dentistry’s (AAPD) definition:
Supports ongoing relationship with client
Coordinates all aspects of oral health including referrals to specialists
Begins no later than six months of age
Main dental home providers may be:
Pediatric dentists
General dentists
Federally qualified health centers (FQHCs)
Rural Health Clinics (RHCs)

10. Dental Home Dental plans develop networks of dentists and specialists
Members choose a dental plan and dental home upon enrollment
Members can change dental home at any time
Dental plans require dental homes to:
Provide diagnostic and preventive care in accordance with AAPD recommendations
Assess the dental needs of members and provide referrals to specialists as needed

11. Dental Home
Dental home model resembles primary care physician (PCP) model
Encourages delivery of oral health care in a comprehensive, continuously accessible, and family-centered way
Dental home model informed by the success of the First Dental Home initiative
Package of dental services aimed at children ages months
Emphasizes early preventive services and simple, consistent oral health information for parents/caregivers

12. Dental Home
Implementation of dental home required informing members of the importance of remaining with one dentist
Members empowered to participate in care decisions with provider
Initial adjustment for providers
Responsibility to develop dentist/patient relationship
Claims paid only to dental home/main dentist or specialist with main dentist’s referral (unless emergency)
HHSC has worked with stakeholders to receive feedback and ensure dental home model operates as intended

13. Measuring Success

14. Measuring Success Utilization by Service Category
Category of Dental Services
2011 Utilization (Paid FFS Units of Service)
2011 Percent of Total Utilization
2012 DMO Utilization
(Paid Units of Service Reported in DMO Encounters)
2012 Percent of Total Utilization
Utilization Variance
All Other
3,631,029
26%
2,353,350
24%
-35%
Diagnostic
4,351,407
31%
3,655,625
37%
-16%
Orthodontics
1,436,902
10%
401,362 4%
-72%
Preventive
4,783,464
34%
3,570,485
36%
-25%
Total
14,202,802
9,980,822
-30%

15. Measuring Success Fiscal Year
Percentage of Individuals Eligible for EPSDT Receiving Any Dental Services
Percentage of Individuals Eligible for EPSDT Receiving Preventive Dental Services
Texas
U.S.
2012
59.0%
42.7%
46.9%
37.6%
2013
58.1%
43.0%
46.7%
38.3%
2014
56.1%
44.1%
46.3%
39.5%
2015
58.3%
44.8%
56.7%
40.9%

16. Questions