We can help by sharing information that highlights the real needs involved in providing oral health care for individuals with special needs. Adequate coverage for necessary accommodations—such as specialized equipment, additional appointment time, and provider training—is essential to ensuring patients receive appropriate care. Increasing awareness of the need for improved reimbursement can encourage more dental professionals to pursue the training required to serve the special needs population.

We can also support efforts to communicate the importance of specialty care and hospital-based services for patients whose needs extend beyond routine treatment. Strengthening understanding of these challenges helps inform policies and partnerships that expand access, improve care availability closer to home, and ensure individuals with special needs receive the comprehensive oral health services they deserve.

Special Needs Reforms:

• The cost of accommodations needs to be covered.

Providing care to patients with special needs often requires specialized equipment and additional time.  These expenses need to be adequately covered.  Some special needs care is a specialty in its own right.  Medicaid needs to recognize and provide incentives to make sure that adequate care is available and provided.  Since there is already a shortage of people providing care there is additional need to encourage more to receive the specialized training needed to treat many patients with special needs.

• Specialty care needs to be covered.

A major issue is the lack of specialty support.  The shortage of specialists participating in Medicaid is a problem for both those with special needs and those without.  The cost of specialty care is higher than primary care and must be reflected in the reimbursement structure.

• Hospital care needs to be available and adequately reimbursed.

Some patients with special needs must be seen in a hospital operating room.  But dental Medicaid pays so poorly that most hospitals do not allow adequate access to dentists needing them.  Dental Medicaid must recognize this need and provide adequate coverage.

Medicaid and Special Needs Dentistry:

Improvements to how Medicaid dental services function would significantly enhance access to care for patients with special needs. Increased participation by dental offices statewide would expand the availability of services and allow patients to receive care closer to home. A more effective system would also improve access to specialty services. Strengthening the functionality of dental Medicaid is an important step toward improving oral health outcomes for the special needs’ population.

• Improve comprehensive care for adults (and children).

Many essential services are simply not covered by Medicaid.  Often these are services that must be done anyway, leaving providers uncompensated.  These deficiencies are short-sighted because they end up costing more when inadequate treatment fails and must be redone.  Or recipients end up in hospital emergency departments where they receive only palliative care.  Failure to treat these conditions properly also ends up costing more in medical treatments for diabetes, heart disease and other chronic conditions.  Even though children are supposed to have all medically necessary care covered, providers often find it difficult to do so under current restrictions.

• Structure Medicaid administration more appropriately.

Medicaid claims processing guidelines are patterned after commercial dental insurance.  These guidelines are based on patients having to pay a portion of their care, but they limit care by discouraging patients from seeking it.  Since there is not a patient “copayment” in Medicaid these rules both discourage dentists from offering care and discourage adult patients from seeking it.

• Improve Reimbursement to sustainable levels.

Current Medicaid reimbursement levels are less than what it costs to provide the service.  Dentists are not paid to provide services and must subsidize the costs of providing them out of pocket.  This makes it nearly impossible for practices which do not receive supplemental government funding from providing care.  Levels must be raised not only to a level of viability, but to a level which will attract new providers, particularly of specialty care.

New Mexico Foundation for Dental Health, Education & Research (dba. NM Dental Association Foundation)

PO Box 16854

Albuquerque, NM  87191

Office: (505) 298-7206

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The NMDAF is the charitable arm of the NMDA