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Understanding Available Benefits MEDICAID


by AMANDA FAHRENDORF


ow 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 par- ticipants eligible for MO HealthNet qualify for dental benefits.


Each person who is determined eligible for MO HealthNet is assigned a Medical Eligibil- ity (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 ben- efits? 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, re- storative, endodontics, periodontics, prosth- odontics, dentures, maxillofacial prosthetics and many more.


Information Series LIMITED ADULT DENTAL


Participants over 21 who are not under a cat- egory of assistance for pregnant women, the blind, or participants residing in a nursing fa- cility 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, ad- ditional 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 dif- ference? 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 tran- sitioned 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, dis- abled, 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.


HealthBlue-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: envolve- dental.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.


CONTINUED NEXT PAGE


It’s important to know the difference be- tween 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 addi- tional 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-Ser- vice 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: 800-822-5353. There also is a general mailbox for dental provider credentialing for the central region: ce_packetrequest@uhc.com.


ISSUE 6 | NOV/DEC 2022 | focus 21


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