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  • Introduce myself, DHHS, MaineCare Services, Director, Division of Health Care Mgt where pharmacy program resides. Pharmacy unit has staff which includes mgr, Bruce McClenahan, 4 professional staff and help desk staff.
  • These data are from surveys conducted by the ME CDC and represent statewide data, not only MaineCare members. Maine data indicates that the need among Maine children is comparable to national estimates – about 20% of children have about 80% of the total decay and the need for care.
  • Data is from the Pregnancy Risk Assessment Monitoring System, a national survey system coordinated by the federal CDC, that is conducted in Maine by the Office of Data, Research and Vital Statistics in the Maine CDC.
  • This data is from the Behavioral Risk Factor Surveillance System. BRFSS is the world’s largest, on-going telephone health survey system, tracking health conditions and risk behaviors throughout the United States and its territories. 
  • Initial contract amounts in this program are based on estimated patient volume and prior year experience; additional amounts are encumbered proportionately after six months of data is available, based on actual program utilization.

DHHS Presentation Transcript

  • 1. MaineCare Dental Benefit Overview for Joint Standing Committee on Health and Human Services
  • 2. Oral Health in Maine: Some Snapshots
    • Children’s Oral Health Status
    • Maine State Smile Survey, 1999:
    • 20% of kids, grades K & 3, needed treatment (untreated decay)
    • 31% of grade K and 45% of 3 rd graders had a history of tooth decay
    • 47% of 3 rd graders had at least one sealant, and 57% needed at least one more
    • Maine Child Health Survey, 2003-04*
    • 15% of kindergarteners and 17% of 3 rd graders needed treatment
    • 11% of kindergarteners had never seen a dentist
    • 27% of grade K and 41% of 3 rd graders had a history of tooth decay
    • 57% of 3 rd graders had at least one sealant, and about 50% needed at least one more
    * Due to a low response rate, the 2004 survey was not representative of all children – just those who were screened.
  • 3. Oral Health in Maine: Some Snapshots
    • Pregnant Women and Oral Health
    • In 2004, nearly half (46%) of Maine women who had a baby had a dental visit during their pregnancy.
    • More likely to have a dental visit: women 35 years old or older
    • Least likely to have a dental visit: women younger than 25
    • Of those who had a dental visit, fewer were likely to be enrolled in the WIC Program or to be MaineCare members
    • About 25% of new mothers said they needed to see a dentist for a dental problem during their pregnancies. They were more likely to be 20-24 years old, enrolled in WIC, be MaineCare members, and have annual incomes less than $16,000.
    • 60% of the women who were not MaineCare members saw a dental provider during pregnancy compared to only 28% of MaineCare members
    • 40% of all women, but only 26% of MaineCare members, said a health care worker talked with them during their pregnancy about how to care for their teeth and gums.
    Data is from the Pregnancy Risk Assessment Monitoring System
  • 4. Oral Health in Maine: Some Snapshots
    • Adults and Oral Health Status
    • Data for 1995-97 indicated that for people age 65 and over, Maine was the 5 th most edentulous (toothless) state in the country
    • In 2002, the percentage of adults aged 65 and older who reported loss of all their natural teeth was 30.4%, and 43.8% reported retention of “most” of their natural teeth
    • In 2006, 3.8% of adults aged 25-34 and 7.6% of those aged 35-44 reported they had lost six or more teeth
    • In 2006, having lost all teeth was reported by 4.3% of people 45-54, by 11.5% who were 55-64, and by 26.2 4% of those 65 and older. For this last age group, Maine was ranked in the middle third of all states.
    • 70% of Maine adults (age 18+) reported a dental visit within the past year (with a dentist or to a dental clinic)
    Data is from the Behavioral Risk Factor Surveillance System
  • 5. Oral Health in Maine: Some Snapshots Community Water Fluoridation
    • About 75% of Maine people with public water supplies have fluoridated water
    • Because 50-55% of Mainers get their water from private wells, only about 38-40% of the total state population has access to this public health benefit
  • 6. DHHS Dental Coverage
    • DHHS provides access to dental prevention, diagnostic, and treatment/restorative services to all MaineCare children and primarily emergency services to adults as specified in Maine Law
  • 7. Members Served
    • In SFY 07 DHHS provided reimbursement for dental services provided to:
      • 60,992 children
      • 22,333 adults
      • Payments totaled:
      • $27,561,736.56
      • (All totals include dental services provided in FQHCs)
  • 8. Service Providers
    • Providers who provided the majority of dental services to MaineCare members included:
      • 201 private practice dentists served 33,449 MaineCare members
      • 11 Dental hygienists served 7,141 members
      • 9 Dental clinics served 19,480 members
      • (Not including FQHCs)
  • 9. Service Providers
      • 9 Federally Qualified Health Centers (FQHCs) served 11,987 members
      • 14 Orthodontists served 828 members
      • 17 Oral Surgeons served 9,870 members (does not include oral surgeons who bill as physicians)
      • As well as services provided by other specialists of dental care
  • 10. Payment
    • Payment for dental services is based on a fee for service for each procedure provided
    • Appendix A indicates the top 10 procedures MaineCare pays and how our rates compare to commercial carriers
  • 11. Access Strategies
    • Many groups have spent a considerable amount of time trying to resolve the issue of dental access including but not limited to: DHHS staff, the MaineCare Dental Advisory Committee, the Maine Dental Access Coalition, the Maine Dental Association, and many others, joined recently by the Governor’s Oral Health Task Force
  • 12. Access Strategies
    • Some of the activities undertaken include:
      • Streamlined prior authorization (PA) by eliminating several PA requirements on dental services and developing criteria forms to make it easier to submit for PA on those that still require PA
  • 13. Access Strategies
    • Implemented a new billing system for orthodontists mirroring the billing procedures used by commercial insurers
    • Implemented a supplemental payment for the first exam when dental providers agree to provide a dental home. (This strategy is now being reconsidered by the Dental Advisory Committee and the dental clinics and will require rule changes as it has not yielded the desired results and does not benefit all types of dental providers)
  • 14. Access Strategies
      • Working with individual dentists, MaineCare customer service staff provides personal assistance:
        • to troubleshoot and resolve claims payment issues,
        • to provide policy clarification so that dentists understand the services covered by MaineCare, and;
        • to provide claims research for providers so that interim payments are not collected until the dentist’s cash flow has resumed.
  • 15. Access Strategies
    • Provide education to families on the importance of dental care at regular intervals, proper nutrition for healthy teeth, keeping appointments, and assistance with scheduling transportation
    • Provide dentists with a postage paid postcard to let us know when outreach to families is needed for assistance with keeping appointments, education about treatment plans, and other types of assistance as the provider deems necessary
  • 16. Access Strategies
    • DHHS Efforts in the Maine CDC:
    • Provide grants for building dental infrastructure and providing community education
    • Provide adult coverage using the Funds for Healthy Maine to provide services to the uninsured and payment for services provided to adults that are not covered by MaineCare
  • 17. Dental Subsidy Program Funded by FHM (administered by the MCDC) Intent: to assist qualified community programs to maintain fee structures that help to keep their services financially accessible to patients without any coverage or who pay on a sliding fee scale. Agencies are paid a subsidy based on the difference between what patients pay on their sliding fee scale and a benchmark based on the MaineCare rate.
  • 18. Dental Subsidy Program
    • In FY 2007, the Subsidy Program partially reimbursed 13 participating agencies for an estimated 27,972 visits by 15,986 patients, who received nearly 28,000 dental services.
    • Of these patient visits, about 6,398 (23%) were for MaineCare members who received dental services not covered by MaineCare.
    • In FY 2007, these agencies received a total of $685,000.
  • 19. Dental Services Development Program
    • Grants for building dental infrastructure and community oral health education & case management (funded by FHM & administered by the MCDC):
    • “ for the start-up or expansion of public or nonprofit oral health care programs and to provide oral health case management and community oral health education designed to encourage good oral hygiene and to prevent oral diseases and tooth decay.”
    • Since 2001, 29 grants have supported local agencies in every county, some for multiple years.
  • 20. Dental Advisory Committee
    • Maurice Belden, DMD
    • Geoffrey Wagner, DDS
    • Jeffrey Dow, DMD
    • Debbie Keefer, RDH
    • Robert Berube, DMD
    • Lisa Kavanaugh, FACHE
    • John Bastey, Director
    • Governmental Affairs
    • Orthodontist
    • Private dental practice
    • Private dental practice
    • Dental hygienist
    • Oral surgeon
    • Director, Community Dental Clinics
    • Maine Dental Association
  • 21. Challenges
    • The supply of dentists in Maine is inadequate to meet demand
    • Inadequate reimbursement rates
    • MaineCare participation rate by general private practice dentists is about 30% (based on SFY07 claims data)
    • Prevention rates have risen to 41% but treatment/restorative services remain low at just under 14%. (One dentist reports that 60%-80% of his new MaineCare members require follow up services)
    • Anecdotal reports indicate a perception that MaineCare members miss appointments more frequently than other insurers or private pay (MaineCare members cannot be billed for no shows)
  • 22. Moving Forward
    • Moving Forward with any future financial investments:
      • Continue to work with the dental advisory committee and the dental clinics to redistribute the $300,000 (State) currently being used for the supplemental payment
  • 23. Moving Forward
    • With any future financial investments:
      • Allow dental clinics (not including FQHCs) to bill differently so that reimbursement can reflect the treatment of a higher MaineCare member population
      • Provide funding to:
          • Allow reimbursement for physicians to apply fluoride varnish
          • Allow dental benefits for pregnant women over 21