RFI # MED-07-019, IME
THIS IS NOT A REQUEST FOR PROPOSAL
NOTICE TO VENDORS
REQUEST FOR INFORMATION
The Department of Human Services,
Iowa Medicaid Enterprise will be receiving responses to a
Request For Information (RFI)
until 4:30 p.m. (Central Time) December 1, 2006 for:
RFI: MED-07-019
Dental Home for Medicaid Eligible Children
Under Twenty-one (21) Years of Age
For additional information contact:
Cathy Coppes, Policy Specialist
Iowa Medicaid Enterprise
100 Army Post Road
Phone: (515)725-1143
e-mail:
Fax: (515)725-1360
Vendors must comply with all affirmative action/equal employment opportunity provisions of State and Federal Laws.
INFORMATION FOR VENDORS
November 1, 2006
Dear Vendor:
The Department of Human Services, Iowa Medicaid Enterprise is seeking information to determine a means by which all children under twenty-one (21) years of age will have a dental home by July 1, 2008. RFI MED 06-025 previously issued by the Department on January 31, 2006 solicited information regarding implementation of the I-Smile Dental Home plan for children twelve (12) years of age and under. This RFI includes expansion of the dental home to all children under twenty-one years of age.
A dental home is that as defined by the American Academy of Pediatric Dentistry in their policy on the dental home, and is inclusive of all aspects of oral health that result from the interaction of the patient, parents, nondental professionals, and dental professionals. Establishment of the dental home is initiated by the identification and interaction of these individuals, resulting in a heightened awareness of all issues impacting the patient’s oral health.
Responses to this Request for Information # MED-07-019 must be received on or before 4:30 PM, Central Standard Time on December 1, 2006.
Responses shall be marked “Confidential” and sent by mail to the following address. Paper responses sent by mail should also include a diskette containing the response.
Cathy Coppes
Iowa Medicaid Enterprise
1305 E. Walnut Street
Des Moines, Iowa 50315
Alternatively, responses may be sent the attention of Cathy Coppes by e-mail at: or by fax to: (515)725-1360
Sincerely,
Eugene I. Gessow
Medicaid DirectorIOWA MEDICAID ENTERPRISE
Section 1.0 DEFINITIONS
AAPD - American Academy of Pediatric Dentistry
Business Day – Monday through Friday, except those days identified by the Contractor or the Department as holidays.
Child and Adolescent Reporting System (CAReS) - A web-based reporting system that allows Title V health agencies to monitor and track all primary and preventive health care services provided to Medicaid EPSDT and Title V enrolled children. These services include health history, physical exams, measurements, nutrition, oral health care, developmental and behavioral assessment, sensor screening, immunizations, anticipatory guidance, and other services.
Centers for Medicare and Medicaid Services (CMS) - The federal agency in
the U.S. Department of Health and Human Services responsible for administration of
the Medicaid (Title XIX) and the State Children’s Health Insurance Program (Title XXI).
Clean Claim – One that is completed in the format specified by the Contractor and capable of being processed without obtaining additional information from the provider of service or from a third party.
Code of Federal Regulations (CFR) – The codification of the general and permanent rules in areas subject to Federal regulation.
Contract Services - Those services that the successful bidder shall be required
to perform pursuant to the contract.
Contractor – The entity under contract with the Department to provide a single source payment system and perform administrative functions of the I-Smile dental home including, but not limited to a financial incentive mechanism for a network of dental and primary health care providers and facilitating linkages with Iowa’s public health system.
Dental Home - The ongoing relationship between the dentist who is the Primary Dental Care Provider and the patient. The dental home includes comprehensive oral health care, beginning no later than age one, pursuant to ADA policy. The dental home is inclusive of all aspects of oral health that result from the interaction of the patient, parents, non-dental professionals and dental professionals.
Department - The Iowa Department of Human Services (DHS).
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) – The comprehensive and preventive Medicaid child health program for individuals under the age of 21 that assures the availability and accessibility of required health care resources and helps Medicaid recipients and their parents or guardians effectively use these resources.
Enrollee – A child 0 through 20 years of age who has been determined by the Department to be eligible for Medicaid benefits.
Hawk-i - Healthy And Well Kids in Iowa, the Iowa program to provide health
care coverage for uninsured children of eligible families, as authorized by Title XXI of
the federal Social Security Act.
Health Plan - A licensed insurer authorized by the Iowa Division of Insurance
to transact the business of health insurance.
Implementation Phase – The six (6)-month period, beginning January 1, 2008
and ending June 30, 2008.
I-Smile – The plan developed by the Department to meet the mandate in House File 841 to provide a dental home for all children through twelve years of age who are eligible for Medicaid.
Iowa Medicaid Enterprise (IME) – The DHS staff and contractors responsible for administration of the Medicaid program.
Medicaid – The program that pays for medical assistance for certain individuals
and families, as authorized by Title XIX of the Social Security Act.
Operations Phase – The three (3)-year base term of the contract, beginning
July 1, 2008 and ending June 30, 2011.
Outcome - The effect of a program or service on clients or customers
RFI - A Request for Information from the Department of Human Services to ascertain the best methods, approaches, solutions, costs, cost analysis and other relevant information related to the provision of services to Iowans.
State Holidays – New Year’s Day, Martin Luther King Day, Memorial Day, Fourth of July, Labor Day, Veteran’s Day, Thanksgiving Day, Day After Thanksgiving, Christmas Day
Title V Child Health Agency – Maternal Child Health and Screening Center agencies established pursuant to Title V of the Social Security Act to improve the health of mothers and children, in particular those with low income or limited access to quality maternal and child health services.
Section 2.0 REQUEST INFORMATION
2.1 Purpose for the RFI
The intended purpose of the RFI is to solicit comment and information from all interested Vendors regarding the proposed I-Smile Dental Home plan. RFI MED 06-025 previously issued by the Department on January 31, 2006 solicited information regarding implementation of the I-Smile Dental Home plan for children twelve (12) years of age and under. This RFI includes expansion of the dental home to all children under twenty-one years of age. Comments and information are being solicited from all interested Vendors about services they currently provide; suggestions for realistic, achievable, measurable performance standards; and identification of potential costs for providing a dental home network for Medicaid enrolled children. The information provided by Vendors will be used by the Department to improve the quality and efficiency of the I-Smile Dental Home services provided to Iowans.
At a later date, the Department expects to publish a Request for Proposals as part of the competitive bid process to secure a Contractor to provide a dental network and administrative services for the I-Smile Dental Home plan. The Department believes that the Contractor may be classified as a Pre-paid In-patient Hospital Plan, subject to all the specifications in 42 Code of Federal Regulations (CFR) 438. The Department additionally anticipates the submission of a 1915b waiver to the Centers for Medicare and Medicaid Services (CMS) for required approval prior to implementation.
Background
On May 12, 2005, Governor Vilsack signed HF841 into law, establishing the IowaCare Act. The bill includes the following language:
DENTAL HOME FOR CHILDREN. By July 1, 2008, every recipient of medical assistance who is a child twelve years of age or younger shall have a designated dental home and shall be provided with the dental screenings and preventive care identified in the oral health standards under the early and periodic screening, diagnostic, and treatment program.
The Iowa Department of Human Services developed the I-Smile Dental Home Proposal to meet the intent of this legislation. This plan was the result of collaborative discussions between representatives of the Iowa Department of Human Services, the Iowa Department of Public Health, the University of Iowa College of Dentistry and Public Policy Center, and other interested parties. The I-Smile Dental Home Plan provides a comprehensive approach to providing a dental home for all children in Medicaid ages 0-12 with the ultimate goal of ensuring that they receive age-appropriate dental care. The strong emphasis on early preventive services is expected to result in a reduced need for costly restorative services over time. In accordance with 42 Code of Federal Regulations (CFR) 440.240 on comparability of services for groups, the Department has expanded coverage under the I-Smile Dental Home Proposal to all children under twenty-one (21) years of age.
Additional detail is included in the I-Smile Dental Home Proposal is located at: http://www.ime.state.ia.us/IowaCare/AdvisoryGroup/ChildrensHealth.html
In State Fiscal Year 2006, there were 170,013 children six months through 12 years of age and 84,309 13 through 20 years of age eligible for Medicaid, a total of 254,322. A total of 84,227 of all these children received a comprehensive or periodic oral examination from a dentist, 58,068 of them were under 13 years of age and 26,159 were 13 through 20 years of age. The total Medicaid expenditures for all dental services that year was $27,324,797 for children through 20 years of age. Of that amount, a total of $1,727,936 was for preventive screenings, fluoride varnish and/or sealants provided through Title V Child Health Agencies and physicians. A total of 1,067 dentists located in Iowa provided dental services to these children. Detailed age specific and county specific details of this information for State Fiscal Year 2006 are located in Attachment 1 to this RFI.
2.2 Expected Outcome
The goal is for all Medicaid eligible children under twenty-one (21) years of age to receive age appropriate dental care by having an established dental home for each child. The dental home should provide each of the components identified in the AAPD Policy Statement on the Dental Home, www.aapd.org/media/Policies_Guidelines/P_DentalHome.pdf.
2.3 Iowa Medicaid Dental Program
Dental services are a mandatory Medicaid benefit for children. Section 1902(a)(43) of the Social Security Act specifically requires that State Medicaid plans provide or arrange for such services. The Iowa State Plan for Medicaid includes provisions for dental benefit coverage for Medicaid children. The Code of Federal Regulations at 42-441.56(c) further stipulates that in addition to any diagnostic and treatment services included in the State Plan, the Medicaid agency must also provide to eligible EPSDT recipients necessary services even if the services are not included in the State Plan.
Iowa Medicaid currently provides dental services on a fee for service basis. Comprehensive services, including orthodontia are covered for children under 21 years of age. Services for adults are covered with some limitations.
The web addresses listed below are links to Iowa Medicaid dental services.
The Medicaid Dental Provider Manual:
http://www.dhs.state.ia.us/policyanalysis/PolicyManualPages/Manual_Documents/Provman/dental.pdf
Title V Child Health Agencies Screening Center Provider Manual:
http://www.dhs.state.ia.us/policyanalysis/PolicyManualPages/Manual_Documents/Provman/scenter.pdf
Title V Maternal Health Agencies:
http://www.dhs.state.ia.us/policyanalysis/PolicyManualPages/Manual_Documents/Provman/maternhc.pdf
The Medicaid dental fee schedule is located at:
http://www.ime.state.ia.us/Reports_Publications/FeeSchedule.html
2.4 Types of Services and Requirements to Consider:
The specific services to be provided and the periodicity for each are those listed in the AAPD Clinical Guideline on Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance and Oral treatment for Children, www.aapd.org/media/Policies_Guidelines/G_Periodicity.pdf.
The primary role of the contractor is to establish a dental provider network to provide access to dental care for all children in Iowa 0 through 20 years of age who are eligible for Medicaid, and to provide administrative oversight for the I-Smile dental home.
In general, the contractor will be responsible for the following:
· Contracting with a network of dentists thereby assuring access for routine preventive and acute dental care for enrolled children
· Member services activities related to dental care
· Provider services activities, including education and training
· Facilitating linkages with Iowa Title V Child Health Agencies and
primary health care providers
· Payment of Medicaid claims to dentists, Title V Child Health
Agencies, hospitals and non-dental providers (physicians)
· Managing the claims/encounter data and providing the
Department with monthly reports about the utilization of dental
services by the enrolled children
· Oral health promotion
· Work with Iowa’s rural health systems to promote new hospital-based
clinic sites
2.5 Scope of Work
2.5.1 Enrollee Services
All Enrollee services must address the need for culturally appropriate interventions. In order to provide necessary dental services, reasonable accommodation must be made for Enrollees with hearing and/or vision impairments and/or other health care needs.
2.5.1.2 Enrollment
The contractor shall automatically enroll all children zero (0) through twenty (20) years of age who are eligible for Medicaid. All eligible children shall continue enrollment throughout their eligibility for Medicaid through the month of their twenty-first (21) birthday.
The contractor shall review on a regular basis the eligibility files provided by the Department and issue a card that must identify the Member, the dental office in which he/she is enrolled, a toll free number for the dental plan, and a coverage code.
2.5.1.3 Termination
Enrollment shall be terminated the first day of the month following the termination of Medicaid eligibility. Enrollment shall also be terminated the first day of the month following the child’s twenty-first (21) birthday. The contractor shall issue adequate and timely written notice of termination. The notice shall include information regarding how to access dental care in the future.
2.5.1.4 Handbook/Provider Directory
The Contractor must provide printed information on accessing services to all Enrollees/Caretakers. When there are program or service site changes, notification must be provided at least ten (10) business days before implementation.