May 19, 2015
With the addition of the adult dental benefit, there seems to be some confusion in the dental community about when a Medicaid patient may be charged out-of-pocket for dental services. Prior to the addition of a comprehensive adult dental benefit, some dentists were collecting out-of-pocket payments from adult Medicaid patients, as nearly all dental benefits were not covered by Medicaid for this patient population. It is important to note that the addition of adult dental benefits in Medicaid changes the permissibility of this practice.
State law prohibits providers, including dentists, from collecting fees from Medicaid patients related to a Medicaid-covered service. This restriction applies regardless of whether the provider is enrolled as a Medicaid provider or not. A provider who collects fees on a covered service from a Medicaid patient must refund all fees collected to the patient, and, if a patient files a complaint, the provider may be subject to fines or penalties for unlawfully collecting these payments.
For services that are not covered by Medicaid, that exceed frequency limitations or that are provided once a patient has exceeded the $1,000 adult benefit cap, a provider may enter into a written agreement with the patient where the patient agrees to pay out-of-pocket for the services. This written agreement must be completed on a Medicaid-approved form (found on page A-10 of the current ORM, or page 72 of the PDF document) and be signed and dated by both the provider and patient in advance of services being provided. Best practice is to submit a claim for the non-covered service and keep the Medicaid denial for payment on file for documentation. Also, while not required, dentists are encouraged to charge a reduced fee or a fee in alignment with the Medicaid fee schedule when possible, for non-covered services provided to Medicaid patients. Providers should be aware that out-of-pocket billing for non-covered services is a situation that primarily applies to the adult dental benefit, as federal requirements mandate that states cover any medically necessary service for children. These federal requirements trump any frequency limitations or exclusions in the child dental benefit, which means there are very few non-covered services for children (some exceptions are cosmetic orthodontics and some third molar extractions). We encourage dentists to exercise extra caution in out-of-pocket billing involving a child with Medicaid coverage, and again to keep a Medicaid denial for payment related to the service provided on file.
In addition to the billing questions above, some Medicaid providers have faced challenges around billing a patient’s primary insurance when the patient has Medicaid as a secondary insurance. Several conflicting sections of state law have caused confusion around whether a copayment or deductible associated with the primary insurance plan can be collected from these patients. The CDA is seeking a legal opinion and input from state attorneys on this issue and will update CDA members as additional information becomes available on the correct protocols to follow in this situation. In the meantime, dental offices can add a form asking all patients whether they have any Medicaid coverage (medical or dental) as part of patient intake records. If the patient has any Medicaid coverage, dental benefits can be verified through DentaQuest or the state’s Medicaid Management Information System. If the patient has Medicaid dental coverage, even if they present a private plan as primary coverage, it is wise to exercise caution in collecting any fees from these patients until this issue is clarified.