HOW CAN MEDICAID and CHIP PAY PROVIDERS TO USE THE MYSMILEBUDDY PROGRAM?

Of particular interest is having Medicaid pay CHWs functioning as MySmileBuddy Program Coaches. In the 29 states that had already allowed Medicaid payments to CHWs by July 2022, costs of the MySmileBuddy Program can be recouped by billing Medicaid. In states without this allowance, Medicaid authorities can pursues one or more options that may allow CHWs to provide oral health counseling. Of particular interest and potential among Medicaid options to fund CHWs according to the Kaiser Family Foundation are:

State Plan Coverage under the “prevention services benefit” or the “outpatient services benefit;”
Health Home Option for children with chronic health conditions as well as risk for tooth decay;
Managed Care Organization Contracting by contracting their vendor(s) to utilize CHWs or as a “value-added” service; and
Section 1115 Demonstration Waiver authority.

Any entity that provides direct services, including preventive services using the MySmileBuddy Program, to Medicaid and CHIP enrolled beneficiaries can bill their State’s Medicaid authority under several Medicaid policy programs and policies. Because the MySmileBuddy Program has particular value for socially vulnerable children at elevated risk for dental caries, these public insurance programs are ideal Program sponsors. By paying for the Program, they can improve child beneficiaries’ oral health while reducing downstream treatment costs. Unfortunately, most Medicaid and CHIP programs do not reimburse dental providers for oral hygiene instruction or diet counseling despite having treatment codes for these services. But Medicaid and CHIP have many options to do so and the federal Center for Medicaid and CHIP Services (CMCS) has sponsored 4 demonstration programs to test delivery and payment alternatives (Health Care Innovation Awards, State Innovation Models, Innovation Accelerator Program, and CHIPRA Quality Demonstration). CMCS sponsored a study of the MySmileBuddy Program in New York City that validated its effectiveness.

Among Medicaid programs and policies that can be utilized to pay for the MySmileBuddy Program are:

Preventive Services: In 2013, the federal Centers for Medicare and Medicaid Services (CMS, the parent organization of CMCS) published a final rule allowing states expanded authority to pay unlicensed providers (like Community Health Workers) to deliver preventive services when those services are recommended by a licensed provider. This change gives states the ability to broaden the pool of practitioners available to furnish preventive services and increase beneficiary access to preventive services they may not otherwise have been able to receive.

Medicaid Managed Care Rule: CMS’s 2016 rule allows states to use “in-lieu-of” and “value-added service” to improve access, quality and efficiency in Medicaid programs. States committed to adopting the MySmileBuddy Program statewide can seek a State Plan Amendment to authorize CHWs to deliver preventive dental services and then encourage dentists and physicians to refer families to these CHW-delivered preventive services. The State Plan Amendment must detail the preventive services to be provided, description of providers delivering preventive services, a summary of those practitioners’ qualifications (e.g. education, training, experience, credentialing) and the reimbursement methodology to pay them. Approval of the State Plan Amendment allows CHWs to bill Medicaid directly for preventive services.

Payment and incentive options available for state-wide adoption of the MySmileBuddy Program in Medicaid:
1. Fee for Service (FFS): Medicaid/CHIP can pay MySmileBuddy Program coaches directly if authorized to do so under its CMS-approved State Plan.
2. Primary Care Case Management (PCCM): State Medicaid authorities can pay primary care managers (e.g. community-based organizations or healthcare system that employs or contract with CHWs) to coordinate, locate, and monitor health care services that expand beyond what is expected from FFS payment. States can provide incentive payments (e.g. per member per month payments and shared savings arrangements) for providers who demonstrate improved performance on quality and cost measures.
3. Contracting to Managed Care Organizations (MCOs), Dental Management Organizations (DMOs) or Dental Service Organizations (DSOs): States can contract with these organizations to refer beneficiaries to CHWs who provide preventive services. These organizations can hire CHWs directly or subcontract to community-based organizations that employ or contract with CHWs.
4. Incentivizing medical and dental insurers in contracting arrangements: Through contracts, State Medicaid authorities can incentivize their insurance vendors to meet specified performance targets (up to 5% of capitation rates) or could impose “withholds” for specific outcomes (e.g. reduction in numbers of children treated under general anesthesia in the operating room). Such incentive payments by States are eligible for federal matching dollars.
5. Episode and bundled payments: States can work with their vendors to develop a bundled payment for caries prevention whereby a child identified at risk for or experiencing dental caries is enrolled in the bundle and receives a defined set of prevention and management services over a defined period at a set payment rate.
6. Accountable Care Organization (ACO) contracting: To advance outcome-based accountable care, States can work with ACOs to incentivize preventive services by CHWs by holding ACOs accountable for specific outcomes (e.g. reduction in children treated for caries under general anesthesia in the operating room).
7. Health Homes: The Affordable Care Act established the Medicaid Health Home Program for individuals with chronic conditions. States can petition CMS to categorize dental caries as a chronic condition and enroll affected children who have at least one other chronic disease or susceptibility to one other chronic disease in a Health Home. Once designated, states receive a 90% federal match for costs of care for eight calendar quarters.
8. Quality Initiatives: States can incorporate pediatric oral health in their contracts with External Quality Review Organizations (EQROs) and/or establish pediatric oral health Performance Improvement Projects (PIPs).
9. Section 1115 Research and Demonstration Waiver authority: MACPAC (the federal Medicaid and CHIP Payment and Access Commission) describes this authority as combining “extensive waiver authority” with “a broadly defined purpose.” Under this authority, CMS can waive “almost any Medicaid state plan requirement…to the extent necessary to carry out a demonstration or experimental project furthering the goals of the [Medicaid] program. Under this authority, federal matching dollars are available to cover services and populations not included in the State Plan.
10. Hospital outpatient services: According to MACPAC’s brief on outpatient services, ”States have broad flexibility to determine payment policies, including payment amounts, for outpatient services. Outpatient hospital services can include preventive, diagnostic, therapeutic, rehabilitative, or palliative services furnished to Medicaid enrollees in hospital outpatient departments.”

Payment and incentive options available for incremental adoption of the MySmileBuddy Program in Medicaid:
1. In-lieu-of Services: In-lieu-of services are state plan services offered by a different provider or in a different setting than authorized in the approved State Plan as long as those services are detailed in the managed care contract and approved by CMS. For example, a state could implement caries prevention and management services delivered by a CHW if those services are medically appropriate and are a cost-effective alternative to state plan services covered in the Medicaid managed care contract. Although beneficiaries cannot be compelled to use “in-lieu-of” services, with state contract approval a Medicaid vendor (Insurer or MCO) could engage CHWs to deliver preventive services, education, and care management under this allowance.
2. Value-Added Services: A Medicaid vendor (Insurer or MCO) could pay CHWs in specified locals or with particular populations (without meeting the state-wideness rule) to provide preventive services on their own in the expectation of downstream cost savings.