Medicaid Information Series: Part 2

Understanding what benefits are available to MO HealthNet participants.

by Amanda Fahrendorf 

Now that you are enrolled as a Dental Medicaid provider (or are in the enrollment process), it’s time to understand what benefits are available to MO HealthNet participants. MO HealthNet benefits can differ based on how an individual qualifies for services. The good news is that most participants eligible for MO HealthNet qualify for dental benefits.

Each person who is determined eligible for MO HealthNet is assigned a Medical Eligibility (ME) code. ME codes drive most MO HealthNet benefits. The Provider Resource Guide provides definitions for each ME code.

How do I know what ME Code a participant has? ME codes can be found when checking a participant’s eligibility. Providers can check eligibility on eMOMED or via the interactive voice response (IVR) system by calling 573-751-2896.

How do I know who qualifies for dental benefits? MO HealthNet offers a Comprehensive Dental Benefit and a Limited Adult Dental Benefit. The Dental Benefit Table breaks down which coverage an individual is eligible for based on their assigned ME code.

COMPREHENSIVE DENTAL

Children under 21, persons under a category of assistance for pregnant women, the blind, and participants residing in a nursing facility are eligible for the Comprehensive Dental Benefit. Section 19 of the Dental Provider Manual provides a detailed list of covered Current Dental Terminology (CDT) codes for this group along with age limitations and other requirements.

Examples of covered benefits: clinical oral exams, tests and laboratory examinations, preventative/dental prophylaxis, fluoride treatments, space management therapy, restorative, endodontics, periodontics, prosthodontics, dentures, maxillofacial prosthetics and many more.

LIMITED ADULT DENTAL

Participants over 21 who are not under a category of assistance for pregnant women, the blind, or participants residing in a nursing facility are eligible for the Limited Adult Dental Benefit. (Excluding family planning ME 80 and 89.) Section 13.1 of the Dental Provider Manual provides a comprehensive list of all covered CDT codes for those who are eligible for the Limited Adult Dental Benefit.

Examples of covered benefits: limited oral evaluations, x-rays, extractions, restorative, periodontal scaling and root planing, additional services considered for underlying health conditions or trauma, as well as many more.

MANAGED CARE VS FEE-FOR-SERVICE

What is Managed Care and Fee-For-Service and why is it important to know the difference? Providers often hear the terms “Managed Care” and “Fee-For-Service” when working with MO HealthNet.

Managed Care: In 2017 children, pregnant women, newborns, and families were transitioned to our three Managed Care plans: UnitedHealthcare, Home State Health and Healthy Blue. The managed care plans are responsible for administering benefits and coverage on behalf of MO HealthNet to these populations.

Fee-For-Service (FFS): The aged, blind, disabled, and women with breast or cervical cancer remain in FFS. This means providers will work with MO HealthNet directly when providing services to these individuals.

It’s important to know the difference between Managed Care and FFS MO HealthNet when discussing benefits. I previously outlined how to know who qualifies for the Comprehensive benefit vs the Limited Adult Dental benefit. The information provided in sections 13 and 19 of the Dental Provider Manual serves as a foundation for what benefits are provided through FFS and the Managed Care plans. Participants who are enrolled in Managed Care may have additional benefits. The Managed Care plans will have their own policies and processes they use to provide services. These processes can differ from the MO HealthNet Fee-For-Service program. Providers should refer to each Managed Care plan’s resources for additional information and contact information follows.

UnitedHealthcare
Provider contract, credentialing and enrollment processes are initiated online at uhcprovider.com. For real-time person-to-person assistance call 800-822-5353. There also is a general mailbox for dental provider credentialing for the central region: ce_packetrequest@uhc.com.

HealthyBlue-DentaQuest
dentaquest.com/provider-enrollment
Member 888-696-9533
Provider 844-234-9832
provider.healthybluemo.com

Home State/Envolve
providerrelations@envolvehealth.com
PR 855-735-4395
Enrollment contact information: envolvedental.com/providers/join-our-network.html

How can I find out if a participant is enrolled in Managed Care? Providers can see if a participant is in a Managed Care plan when checking a participant’s eligibility. Providers can check eligibility on eMOMED or via the interactive voice response (IVR) system by calling 573-751-2896.

Why are some services not covered by MO HealthNet? The Limited Adult Dental Benefit was approved in 2016, which allows participants who are over 21, not blind, pregnant or residing in a nursing home to access dental benefits. Many health care professionals were involved in deciding what services should be included while considering the constraints of the budget. For example, some providers feel that D0120 is an essential service, but it is not part of the Limited Adult Dental Benefit at this time.

Can I provide a non-covered service to a participant? Yes. Providers can provide noncovered services, however; they can’t bill MO HealthNet. Billing for non-covered services may result in an overpayment, which is considered improper billing. For example, many providers feel providing Silver diamine fluoride SDF (D1354) is a best practice to help slow decay for patients, regardless of age. But MO HealthNet covers this service only for participants ages 1-5. 

Can I bill a participant for a non-covered service? Yes. Providers may bill a MO HealthNet participant for a non-covered service only if the participant signed a written statement, prior to receiving the service, indicating their understanding that MO HealthNet does not cover the service and that the participant accepts financial responsibility for the service. The statement must include the date of service, the service for which the participant has accepted financial responsibility, the participant’s signature and the date signed. This should be maintained by the provider in the patient record. MO HealthNet has a resource for this, Participant Liability (Balance Billing) Hot Tip.

MO HealthNet provides a wealth of training and resources to educate providers about
what services are covered. Providers are encouraged to visit the MO HealthNet Education and Training page to enroll in trainings and access resources. 

MO HealthNet is collaborating with the MDA, the Missouri Coalition of Oral Health
and the Department of Health and Senior Services to increase access to care for all MO
HealthNet participants—through increased provide enrollment. This collaboration will allow us to streamline our processes as well as provide resources and training to help providers be successful while they serve Missouri’s most vulnerable citizens.

Amanda Fahrendorf works in the MO HealthNet Education and Training Unit. Contact her at 573-751-0352 or amanda.fahrendorf@dss.mo.gov

This article originally appeared in the Focus MDA magazine. Click here to view.

21828841570