Does the 3-Year Rule Violate State DMO Contract?

TDMR has done a review of the Texas Medicaid dental maintenance organization contract available publicly on the Texas HHS website and found a requirement that all medical necessity determinations be based on "valid and reliable clinical evidence or a consensus of oral health care professionals."

Valid and reliable clinical evidence

This may mean that the 3-year rule adopted by dental maintenance organizations which allows them to refuse to pay member dental practices for replacing a failing or broken restoration/filling in a child that was done at the same office within the last 36 months violates their contract with Texas Medicaid.

Under section 2.3.4 Medical Necessary Covered Dental Services, the contract states:

The Dental Contractor is responsible for authorizing, arranging, coordinating, and providing Medically Necessary Covered Dental Services in accordance with the requirements of this Contract. The Dental Contractor must provide Medically Necessary Covered Dental Services to all Dental Members beginning on the Member's date of enrollment regardless of pre-existing conditions, prior diagnosis, receipt of any prior dental health care services, or for any other reason, subject to the HHSC-prescribed benefit limitations. The Dental Contractor must not impose any pre-existing condition limitations or exclusions or require evidence of insurability to provide coverage to any Dental Member.

...

In the development of medical necessity determinations, the Dental Contractor must adopt practice guidelines that:

1. Are based on valid and reliable clinical evidence or a consensus of oral health care professionals in the particular field;
2. Consider the needs of the Dental Contractor's Members;
3. Do not conflict in part or in whole with state or federal policy;
4. Are adopted in consultation with contracting oral health care professionals;
5. Are reviewed and updated periodically as appropriate or as requested by HHSC; and
6. Are shared with Providers in the Dental Contractor Network as a means of transparency.

12-month rule for CHIP 

The contract itself also contains a schedule of CHIP Medically Necessary Covered Dental Services which includes:

AMALGAM (SILVER FILLINGS) All amalgam fillings are limited to one per tooth per 12 months.
RESIN FILLINGS (WHITE FILLINGS) All resin fillings are limited to one per tooth per 12 months.

Considering the above and that the 3-year rule apparently violates #1, #2 and possibly #3, how could such a rule come into existence?

Approved by HHS

Per the contract, it must have been approved by Texas HHS.

2.3.1 GENERAL SCOPE OF WORK
The Dental Contractor must provide Medically Necessary Covered Dental Services to Dental Members enrolled with the Dental Contractor on or after the Operational Start Date. The Dental Contractor must comply, to the satisfaction of HHSC, with all Contract requirements and all applicable provisions of state and federal laws, rules, regulations, and all state plan or waiver agreements with CMS.

Cost control

Apparently implementing the prior authorizations process for replacement fillings less than three years old is a cost-control measure.

Under 2.3.3 HHSC PERFORMANCE REVIEW AND EVALUATION

...HHSC may monitor the Dental Contractor to confirm the Dental Contractor is using prior authorization and Utilization Review processes that ensure appropriate utilization and prevent overutilization or underutilization of services.

Prior authorizations commonly not approved

However, the common experience with Medicaid dentists, as related to TDMR, regarding prior authorization requests for exemptions from the 3-year rule is that they are not approved. We are told by HHS that the individuals reviewing the prior authorization requests for each DMO are qualified dentists.

The upshot is that the costs of replacing the filling are borne by the dental professional rather than by the DMO. The treatment is medically necessary.

This does not appear to be providing the medically necessary care dictated by the contract.

Why not appeal and complain?

Dental professionals generally find it more troublesome, frustrating and expensive to appeal prior authorization refusals by DMOs and exhaust the DMOs' appeal procedures. They take the easy road out.

Yet, going to the end of the road on an appeal is what HHS expects dental professionals to do before HHS will accept a complaint about a DMO's practices including the 3-year rule. Another barrier here is the daunting prospect that a Medicaid dentist may get excluded from the DMO's network by lodging a complaint with HHS.

HHS doesn't even know the 3-year rule is a problem

So here we have the current situation. From our correspondence with HHS, the agency doesn't even know that providers are upset about the 3-year rule. The lack of provider complaints is one reason. The other is that neither the Texas Dental Association nor the Texas Association of Pediatric Dentistry has made it an issue.

Ouch! How can individual Medicaid dental providers get consideration in a situation like this?

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