It is finally here, not with a bang but with a sigh. It's been out over a week and not a whisper about it until today despite the fantastic anticipation by dental Medicaid providers over the last number of months, if not years. But with the recent foofaraw and resignations over HHS contracts again, maybe that is wise.
But, last week Monday, HHS quietly released their long-awaited Request for Proposals for dental management organizations (DMO) to manage dental services for Texas Children’s Medicaid and the Children’s Health Insurance Program.
The RFP is some 132 pages long so you'll have to excuse us if we haven't fully digested it yet. But it is below if you would like to download it and analyze it yourself along with the list of approved dental services (Exhibit D). They also released the contract (Exhibit A) which you can download too.
As we do more analysis, we'll tell you more.
NOTE: All documents relating to the RFP can be downloaded here.
Some points gleaned from the RFP
However here are some salient points that leaped out at us.
- Deadline for proposals is September 7.
- HHSC intends to award contracts to at least two Dental Contractors.
- HHSC makes no guarantee of volume, usage, or total compensation to be paid to any Respondent under any Contract awarded as a result of this RFP.
- Dental Contractor will begin serving Dental Members on the Operational Start Date, which HHSC anticipates will be January 1, 2020.
- HHSC anticipates that the Initial Contract Period will begin on the Contract’s Effective Date and will continue through December 31, 2022, (the “Term”). HHSC may, at its option, extend any awarded Contract for an additional period or periods, not to exceed a total of eight operational years.
- 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.
- The Dental Contractor may propose additional services for coverage which are Value-added Services (VAS). VAS may be actual dental services, benefits, or positive incentives that HHSC determines will promote oral health, healthy lifestyles, health literacy, service access, and improved oral health outcomes among Dental Members. If approved by HHSC, VAS may also include transportation. A VAS must not be Medicaid or CHIP benefits covered under the Contract. Best practice approaches to delivering Medically Necessary Covered Dental Services are not considered VAS.
What are Medically Necessary Covered Dental Services?
The Dental Contractor is responsible for authorizing, arranging, coordinating, and providing Medically Necessary Covered Dental Services in accordance with the requirements of this RFP. 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.
The Dental Contractor must not practice discriminatory selection, or encourage segregation among the total group of eligible Dental Members by excluding, seeking to exclude, or otherwise discriminating against any group or class of individuals.
Dental Contractor is responsible for providing all Medically Necessary Covered Dental Services available to clients of the Fee-for-Service (FFS) program to the Dental Contractor’s eligible Medicaid members, in no less than the amount, duration, and scope as is available through FFS, as reflected in the state plan under Title XIX of the Social Security Act Medical Assistance Program and detailed in the Texas Medicaid Provider Procedures Manual (TMPPM) as Exhibit “F,” and as required by 42 C.F.R. subpart B of Part 441 for Members under the age of 21, and in accordance with 42 C.F.R. § 438.210, with the exception of Non-capitated Services explained in Section 18.104.22.168. Dental Contractor must provide the services described in the most recent TMPPM and any updates thereto. The Dental Contractor is responsible for educating Dental members about the availability of Non-capitated Services, and referring Dental members to and helping coordinate care for Non-capitated Services.
Exhibit “D” [SEE PDF BELOW] includes a comprehensive list of Medically Necessary Covered Dental Services for CHIP members, including preventive, diagnostic, restorative, endodontic, periodontal, prosthodontic, and oral and maxillofacial surgery.
The Dental Contractor is responsible for paying for or reimbursing for all Medically Necessary Covered Dental Services provided to CHIP members, up to maximum benefit amounts.
Dental Members who receive Medically Necessary Covered Dental Services are not responsible for paying the costs of such services, other than any authorized cost-sharing under CHIP, unless the Dental Member has exhausted his or her applicable maximum benefit limits.
Certain dental services are benefits of CHIP, but are excluded from the Covered Dental Services provided by the Dental Contractor. The Dental Contractor is not responsible for coverage of or payment for these “Non-capitated Services,” which are described more fully in Section 22.214.171.124. The Dental Contractor is responsible for educating CHIP Dental members about the availability of these Non-capitated Services, and referring CHIP Dental members to and helping coordinate care for these Non-capitated Services.
Medically Necessary Covered Dental Services for Medicaid and CHIP Dental Members are subject to change due to changes in federal and state law; changes in the Medicaid or CHIP state plan; changes in Medicaid or CHIP policy; and changes in dental practice, protocols, or technology.
In the development of medical necessity determinations, the Dental Contractor must adopt practice guidelines that:
- Are based on valid and reliable clinical evidence or a consensus of oral health care professionals in the particular field;
- Consider the needs of the Dental Contractor’s Members;
- Do not conflict in part or in whole with state or federal policy;
- Are adopted in consultation with contracting oral health care professionals;
- Are reviewed and updated periodically as appropriate or as requested by HHSC; and
- Are shared with Providers in the Dental Contractor Network as a means of transparency.
Exhibit D – CHIP Medically Necessary Covered Dental Services
Exhibit A – Dental Contract Terms and Conditions