Coverage & Financing

 

 

 

Is dental coverage and financing different from other healthcare coverage and financing in Florida? 

Yes, as nationwide, most health care provided in Florida is covered by public or private insurance. This is not true of dental care in Florida (or the nation). For example, Florida ranks near last among states in the proportion of children reported to have a dental visit paid by Medicaid.

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How does the publicly financed component of dental insurance work in Florida? 

Florida’s currently publicly funded health insurance program for children is a complex mix of programs for which eligibility varies by child age and family income (see “For Parents” section). Medicaid dental care for children is required by federal law and offers comprehensive coverage (involving Early and Periodic Screening, Diagnosis and Treatment and known as “EPSDT”). A state is responsible for treating a patient if screening identifies a problem (even if the service is not in the state’s Medicaid plan). Medicaid costs are shared between federal and state governments (two states also share costs with local governments).

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How does passage of health reform and other federal legislation affect coverage for children? 

The combination of new laws in 2009 (the Children’s Health Insurance Program Reauthorization Act (CHIPRA)) and in 2010 the Patient Protection and Affordable Care Act ((“ACA”) or “Health Reform”) have the potential to bring oral health coverage to nearly all children in all states. Florida, like other states, is required (based on CHIP reauthorization legislation) to provide dental coverage that “is necessary to prevent disease and promote oral health, restore oral structure to health and function and treat emergency conditions.” In addition, state officials were notified by the federal Center for Medicaid and State Operations (CMS) that states are required to provide the federal legislation’s full dental benefit to a child, even if the cost to the states exceeds $1,000 in a year, with limited cost sharing by the parent.

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What is the extent of Florida’s Medicaid budget for dental services, Medicaid participation, and reimbursement? 

Less than 1% of Florida’s Medicaid budget is spent on dental services and fewer than 1% of practicing dentists are active Medicaid providers. Current Medicaid reimbursement to dentists does not reflect market levels.

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Does public financing of provider services differ if a patient goes to a community health center, school-based health center, hospital or other treatment center?  

In Florida, County Health Departments (CHDs) and Federally Qualified Health Centers (FQHCs) are reimbursed through encounter rates, based on cost reports, with the CHD and FQHC submitting claims for reimbursement. Additional federal funding streams help to sustain safety net providers.

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What about dental Medicaid managed care vendors? 

States cannot contract away their legal responsibility to follow federal Medicaid regulations, but can contract with MCO’s while remaining liable. States are permitted experiment with Medicaid reforms and have undertaken demonstration projects that draw on the experience of MCO’s in increasing utilization, for example. Florida has experimented, for example, by shifting financial risk from MCO vendors to dentists (“capitation”).

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What federal programs support coverage and financing that relate to oral health?  

As noted, under Medicaid, CHIPRA and ACA, all US children and adolescents under the age of 21 who now lack dental insurance will have access to dental coverage as part of the law’s essential benefits program (e.g., insurance plans through state Exchanges must include oral care for kids and may not charge “out-of-pocket” for preventive services). The ACA (Health Reform) law also addresses coverage and financing as follows:

  • Creates a option for purchasers to buy pediatric dental coverage directly from stand-alone dental plans or through medical plans
  • Requires Medicare Advantage to use rebates to pay for dental coverage
  • Puts payments to dental professionals under review by the Medicaid and CHIP Payment and Access Commission (MACPAC)
  • Establishes grants for school-based health centers that include oral health services
  • Establishes standards for accessibility of medical and dental diagnostic equipment for persons with disabilities

     

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How can Florida optimize federal CHIPRA funds?  

In a nutshell: CHIPRA has the potential to improve access to dental care in addition to expanding efforts to prevent dental disease, improve quality of care, and increase accountability through the following provisions. See CDHP Issue Brief. New Allotment formulas are designed to deliver federal CHIP funding to states that use it, so efforts by Florida to expand eligibility and outreach while simplifying administration will gain more federal funding.

 

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