SDF MEDICAID AND OTHER 3 RD PARTY COVERAGE

  • Slides: 27
Download presentation
SDF: MEDICAID AND OTHER 3 RD PARTY COVERAGE Jeff Kahl – PPA for Colorado

SDF: MEDICAID AND OTHER 3 RD PARTY COVERAGE Jeff Kahl – PPA for Colorado

SDF POLICY/BENEFIT CONSIDERATIONS Considerations and Science – as it applies to benefit design and

SDF POLICY/BENEFIT CONSIDERATIONS Considerations and Science – as it applies to benefit design and policy Scope of Care and Access. Policy and Benefit Process in Colorado

CHALLENGES IN BENEFIT DESIGN Relative newness means that there isn’t a lot of research

CHALLENGES IN BENEFIT DESIGN Relative newness means that there isn’t a lot of research or data. From an evidence based standpoint the research available is low-quality. Multiple popular protocols with some variance.

BENEFITS OF SDF Cost of managing severe early childhood caries is disproportionately high. Dental

BENEFITS OF SDF Cost of managing severe early childhood caries is disproportionately high. Dental surgery rates are much higher in less affluent populations (25. 7 vs 6. 9 per 1000) Decrease need for treatment under sedation or general anesthesia. Decrease need for more costly restorative procedures.

BENEFITS OF SDF Adult Populations Many of the same treatment challenges/benefits exist especially for

BENEFITS OF SDF Adult Populations Many of the same treatment challenges/benefits exist especially for patients with special needs and patients in long term care facilities.

OTHER CONSIDERATIONS How many patients will utilize the benefit? National Untreated Caries Rates in

OTHER CONSIDERATIONS How many patients will utilize the benefit? National Untreated Caries Rates in Children Acceptance around 20%

OTHER CONSIDERATIONS How many teeth are treated at one time? No current data because

OTHER CONSIDERATIONS How many teeth are treated at one time? No current data because of relative newness. Manufacturer recommends no more than 5 teeth. How many teeth need restorative treatment or extraction later? No current data because of newness.

AAPD GUIDELINE AAPD supports the use of 38% SDF as part of a comprehensive

AAPD GUIDELINE AAPD supports the use of 38% SDF as part of a comprehensive caries management program. The recommendation is conditional based on low-quality evidence. Pooled evidence suggests: 68% of lesions would be expected to be arrested 24 months after one to two applications. Reapplication 1 -3 months later may be required to fully arrest lesion. Biannual application higher arrest rates than annual. 50 % of arrested lesions reverted to active lesions at 24 months. Annual reapplication required to maintain arrested lesions.

WHAT IS IDEAL?

WHAT IS IDEAL?

FROM A PRACTICAL STANDPOINT Billed Per tooth. Benefit would allow for. At least 1

FROM A PRACTICAL STANDPOINT Billed Per tooth. Benefit would allow for. At least 1 -2 applications/year Reimbursement? Needs to be reasonable. More applications better.

STATES WITH SDF MEDICAID COVERAGE As of June 2018 – 27 states had some

STATES WITH SDF MEDICAID COVERAGE As of June 2018 – 27 states had some coverage for D 1354

VARIATION IN COVERAGE Only Pediatric Patients Adults and Children Only Children under 5 Limit

VARIATION IN COVERAGE Only Pediatric Patients Adults and Children Only Children under 5 Limit 1 or 2 times per year Cap of 2, 4, or 6 applications

FLORIDA MEDICAID $6. 44 per application/tooth 2 applications per year

FLORIDA MEDICAID $6. 44 per application/tooth 2 applications per year

KENTUCKY MEDICAID $25 per application per quadrant 2 applications per year

KENTUCKY MEDICAID $25 per application per quadrant 2 applications per year

VIRGINIA MEDICAID $32. 28 per application/tooth 2 applications per lifetime 2 nd application no

VIRGINIA MEDICAID $32. 28 per application/tooth 2 applications per lifetime 2 nd application no less than 90 days later. If restorative/endo/ext of treated tooth is done within 180 days. That fee will be reduced by $32. 28.

COMMERCIAL BENEFITS Metlife - $17 1 application per tooth in 60 months Aetna Plus

COMMERCIAL BENEFITS Metlife - $17 1 application per tooth in 60 months Aetna Plus - $80 Posterior permanent teeth only 1 application/quadrant per 36 months. UCCI - $3. 97 1 per tooth every 36 months. Some Deltas - $27 -31 2 applications/year

SCOPE OF CARE/ACCESS TO CARE Goals of your delivery system Not just to reduce

SCOPE OF CARE/ACCESS TO CARE Goals of your delivery system Not just to reduce or prevent disease but to bring children who aren’t otherwise engaged into the dental delivery system. Coordination and communication allows for more appropriate migration of patients across spectrum of the delivery system.

SCOPE OF CARE/ACCESS TO CARE

SCOPE OF CARE/ACCESS TO CARE

SCOPE OF CARE/ACCESS TO CARE How Does SDF fit into the Dental Delivery System?

SCOPE OF CARE/ACCESS TO CARE How Does SDF fit into the Dental Delivery System? School Based Care/VDH Dental Office or Mobile Clinic Sedation, General Anesthesia

HB - 1045 Allows dental hygienists to apply silver diamine fluoride under the direct

HB - 1045 Allows dental hygienists to apply silver diamine fluoride under the direct or indirect supervision of a dentist Hold a license in good standing Completes a course on the use and limitations of SDF Is covered by professional liability insurance Has a collaborative agreement with a dentist that describes the SDF protocols, any restrictions or limitations, and follow-up referral mechanisms.

HOW DID THIS GET DONE IN COLORADO? Patience Unified stakeholder group Good relationship with

HOW DID THIS GET DONE IN COLORADO? Patience Unified stakeholder group Good relationship with department of healthcare policy and finance. Pre-session work to educate legislators and bill sponsors. The Dental Board?

COLORADO MEDICAID BENEFIT Live on Oct 1 st 2 applications per tooth per year

COLORADO MEDICAID BENEFIT Live on Oct 1 st 2 applications per tooth per year Up to 4 applications per lifetime of tooth. Reimbursement - $15 -27

OTHER INSURANCE The contract for the CHP Dental benefit is in RFP we are

OTHER INSURANCE The contract for the CHP Dental benefit is in RFP we are hoping to address D 1354 coverage in that process. Delta PPO in Colorado provides some coverage. We’re working on expanding that to other plans offered here.

QUESTIONS?

QUESTIONS?

MEDICAID By Allen Jiles History of Medicaid MedicaidMEDICAID By Allen Jiles History of Medicaid Medicaid
Potentially eligible Medicaid population without Medicaid coverage AuthorsPotentially eligible Medicaid population without Medicaid coverage Authors
Anthem Medicaid KY Medicaid Coverage Area The KentuckyAnthem Medicaid KY Medicaid Coverage Area The Kentucky
Medicaid Coverage for Methadone In Illinois AATOD MedicaidMedicaid Coverage for Methadone In Illinois AATOD Medicaid
Data Coverage and Code Coverage Data Coverage DataData Coverage and Code Coverage Data Coverage Data
WhiteBox Testing Statement coverage Branch coverage Path coverageWhiteBox Testing Statement coverage Branch coverage Path coverage
Party Organization and Functions Party Organization Party MembershipsParty Organization and Functions Party Organization Party Memberships
Charter Party Voyage Charter Party Time Charter PartyCharter Party Voyage Charter Party Time Charter Party
Charter Party Voyage Charter Party Time Charter PartyCharter Party Voyage Charter Party Time Charter Party
birthday party new years party New Years Partybirthday party new years party New Years Party
Party Polarization A deeper Exploration Party Systems PartyParty Polarization A deeper Exploration Party Systems Party
Brainstorm Birthday Party Welcome Party Housewarming party GardenBrainstorm Birthday Party Welcome Party Housewarming party Garden
PARTY SYSTEMS Dominant Party single party MultiParty CorporatistPARTY SYSTEMS Dominant Party single party MultiParty Corporatist
Medicaid Managed Care and Health Insurance Exchanges MedicaidMedicaid Managed Care and Health Insurance Exchanges Medicaid
Wyoming Medicaid Provider Information and Resources Wyoming MedicaidWyoming Medicaid Provider Information and Resources Wyoming Medicaid
MEDICAID ELIGIBILTY Trusts Promissory Notes and LLCs MEDICAIDMEDICAID ELIGIBILTY Trusts Promissory Notes and LLCs MEDICAID
Medicaid Waivers Understanding and Acting on Medicaid PolicyMedicaid Waivers Understanding and Acting on Medicaid Policy
Putting Reform into Medicaid and Medicaid into ReformPutting Reform into Medicaid and Medicaid into Reform
Medicare and Medicaid provide health coverage for threeMedicare and Medicaid provide health coverage for three
Medicaid Oral Health Coverage for Older Adults andMedicaid Oral Health Coverage for Older Adults and
Michigan Families Medicaid Project REDESIGNING STATE MEDICAID POLICYMichigan Families Medicaid Project REDESIGNING STATE MEDICAID POLICY
Washington Medicaid HCA Tribal Affairs Office HCA MedicaidWashington Medicaid HCA Tribal Affairs Office HCA Medicaid
UPDATE Medicaid Expansion Implementation of HB 2572 MedicaidUPDATE Medicaid Expansion Implementation of HB 2572 Medicaid
MEDICAID MEDICARE THIRDPARTY BILLER COMPLIANCE TRAINING MEDICAID MEDICAREMEDICAID MEDICARE THIRDPARTY BILLER COMPLIANCE TRAINING MEDICAID MEDICARE