NOTE: DentaQuest had contacted us and the fees used for comparison initially were their commercial fees, not the Medicaid fee schedule available to providers and not publicly available online.
We did not receive the correct fees from DentaQuest. However, we obtained them from a provider. The DMO fee schedule for the codes shown is the same as the TMHP fee schedule.
The American Dental Association’s Health Policy Institute has updated its report on state Medicaid reimbursement rates as a percentage of dentists’ original fees for select procedures. We’ve used this to extrapolate some further data.
Updated report more accurate
As was previously reported, there were errors in the 2020 version which made it inaccurate and state agencies such as in Texas HHS may have been using as a tool in determining if a fee schedule increase was warranted.
It should be noted that fee-for-service rates are used for this comparison not DMO fee schedules. The report states (from “Data Sources and Methods” tab in the spreadsheet):
“Many state Medicaid programs contract with managed care organizations to administer their dental benefit and, therefore, may not reimburse dental care providers according to the publicly available FFS schedules we captured. The lack of transparent, publicly available data on reimbursement rates within managed care programs presented a significant limitation to our analysis, as we are not able to include such data. While Medicaid FFS reimbursement rates are intended to be a benchmark or guide for managed care organizations, it is unclear whether this truly happens in practice. We focused solely on Medicaid FFS reimbursement rates in our analysis, understanding that in many states, these rates may not be representative since reimbursement rates paid by managed care entities may differ from the FFS rate. Further, after scanning the literature and reaching out to several experts, we concluded that there is no reliable, up-to-date data source categorizing state Medicaid programs according to their dental benefit administrative arrangement (e.g., managed care, FFS, managed care with carve-out). Thus, we are not able to list the states where this particular data shortcoming is relevant. Readers must judge this themselves and interpret our data accordingly.
“Many state Medicaid programs contract with managed care organizations to administer their dental benefit and, therefore, may not reimburse dental care providers according to the publicly available FFS schedules we captured. The lack of transparent, publicly available data on reimbursement rates within managed care programs presented a significant limitation to our analysis, as we are not able to include such data. While Medicaid FFS reimbursement rates are intended to be a benchmark or guide for managed care organizations, it is unclear whether this truly happens in practice. We focused solely on Medicaid FFS reimbursement rates in our analysis, understanding that in many states, these rates may not be representative since reimbursement rates paid by managed care entities may differ from the FFS rate. Further, after scanning the literature and reaching out to several experts, we concluded that there is no reliable, up-to-date data source categorizing state Medicaid programs according to their dental benefit administrative arrangement (e.g., managed care, FFS, managed care with carve-out). Thus, we are not able to list the states where this particular data shortcoming is relevant. Readers must judge this themselves and interpret our data accordingly.
“The analysis for child dental care services is based on: D0120, D0150, D0210, D0220, D0230, D0272, D1120, D1206, D1351, D2391, D2392, D2393, D7210, D7240.”
The comparison also includes Medicaid adult dental care services as well as for children. Texas does not provide adult services.
Using report to calculate actual dollar amount for DSO comparison
According to the new report, Texas pays 46.3% of what private dental insurance would pay for child services. It isn’t the lowest but it certainly isn’t the highest.
Applying a little research and mathematical skill, we found that:
| TMHP/DMO | ||
| D0120 | $ 28.85 | |
| D0150 | $ 35.32 | |
| D0210 | $ 70.64 | |
| D0220 | $ 12.56 | |
| D0230 | $ 11.51 | |
| D0272 | $ 23.38 | |
| D1120 | $ 36.75 | |
| D1206 | $ 14.70 | |
| D1351 | $ 28.24 | |
| D2391 | $ 80.34 | |
| D2392 | $ 105.30 | |
| D2393 | $ 117.98 | |
| D7210 | $ 98.23 | |
| D7240 | $ 286.65 | |
| Total | $ 950.45 |
** https://public.tmhp.com/FeeSchedules/StaticFeeSchedule/FeeSchedules.aspx
So if the TMHP/DMO fees total $950.45 for the services used for comparison in the report and if this represents 46.3% of private insurance fees, private insurance would pay $2,052.81 for the same services. The dollar value represents a difference of $1,102.36 for the same services.
Texas DMOs pay the same as the TMHP fee after getting the rates from a Medicaid dental provider.
For a dental provider to take $950.45 instead of $2,052.81 for their vital healthcare service is remarkable.
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