July 3, 2023
Administrator Chiquita Brooks-LaSure
Centers for Medicare and Medicaid Services
Department of Health and Human Services
7500 Security Boulevard
Baltimore, MD 21244-1850

Re: CMS–2439–P, Medicaid Program; Medicaid and Children's Health Insurance Program(CHIP) Managed Care Access, Finance, and Quality
Dear Administrator Brooks-LaSure:On behalf of the members of the undersigned dental organizations, we are writing in responseto the proposed rule, CMS–2439–P, “Medicaid Program; Medicaid and Children's Health
Insurance Program (CHIP) Managed Care Access, Finance, and Quality.”
We are dedicated to assisting dentists in advancing the oral health of the public and believe that
Medicaid plays an essential role in our nation’s oral health safety net. Additionally, oral health isan essential part of overall health, especially for Medicaid beneficiaries, many of whom aredisabled and face other serious health conditions. We appreciate the Centers for Medicare andMedicaid Services’ (CMS) efforts to improve access to care, quality, and health outcomes, aswell as better address health equity issues for Medicaid and Children's Health Insurance
Program (CHIP) managed care enrollees and offer the following comments on how this canbest be achieved in dentistry.
Rate Transparency Requirements
The rule proposes that for Medicaid managed care plans, payment rates would not be sharedpublicly each year, but plans would provide the state with comparisons of their total Medicaid
and CHIP payments for these service categories against what Medicare Fee-For-Service (FFS)
would have paid. Both the FFS and Managed care analyses would be public and account for
rate variations based on provider type, geographical location, site of service, or age of thebeneficiary (i.e., adults vs. children). We support transparency requirements for managed
care rates but urge CMS to improve transparency further by also requiring more granular
data within the dental category, such as utilization numbers, median fees, and service
frequency. The tendency towards categorizing dental as a whole, without greater
breakdowns in data, does not meet the transparency standards CMS seeks to implement
more broadly. Further comparisons to Medicare FFS would be inapplicable for dental
services. We urge use of commercial data such as federal or state employee dental plan
payment rates or FAIR Health data as benchmarks for such comparisons.

Provider Payment
Acknowledging the role of provider payment in promoting access and not having national data
regarding Medicaid provider rates, the rule requires states to undertake rate analysis for
OB/GYN, primary care, and mental health services. However, the proposal excludes publiccomparative rate analysis, such as for federally qualified health center (FQHC) and rural healthclinic (RHC) rates, stating that federal rate-setting standards apply to these providers. We
would like to see evidence that a wide rate variation does not exist before precluding thesecenters from a comparative rate analysis. Further, for dental services we are unaware of federal
rate setting standards.
The proposed rule would use Medicare rates as the benchmark while acknowledging that aMedicare comparison does not work for all services, such as dental and especially for pediatricservices. We wish to emphasize that comparisons to Medicare FFS are not applicable fordental services. Instead, Medicaid rates should be compared to commercial market rates
or FAIR Health data in each geographic area.
Although the rule requires publication of rates, it does not require states to take corrective
action in the case of very low rates especially when they impact network sufficiency and qualityof care. Corrective actions should be initiated in payments to maintain network adequacy
and at a minimum, incentives should be offered. We support Medicaid programs
establishing policies that incentivize any dentist willing to provide a dental home for children
from birth to age 5 and providing opportunities for early-career dentists to engage with state
Medicaid programs through loan repayment programs for dentists who are willing to treat adisproportionate number of Medicaid beneficiaries. We also support additional funding such asenhanced reimbursement to dental schools that treat Medicaid beneficiaries.
In addition to the policies put forth by CMS above, we are also supportive of allowing dentists toclaim a tax credit for the first $10,000 of services (based on the most recent Code on Dental
Procedures and Nomenclature (CDT) codes) and credited at a rate consistent with the dentists’full fees for that region or state.
We applaud CMS for noting “that provider payment rates in managed care are inextricably
linked with provider network sufficiency and capacity” as there is a strong correlation between
beneficiary access to dental services and payment rates. Establishing an adequate dental
provider network and setting a minimum payment level are both elements that ultimatelytranslate into timely access for enrollees and dentist participation.
There are sound, reasonable principles related to payment that can be tailored to meet thespecific needs of states while being uniformly required by all. Two of these concepts are:regular assessments of fees; and establishing parity in payments across eligibility groups.
Fee Assessment

Many states have not revisited their Medicaid dental payment rates for years. (This is important
not only in traditional FFS programs, but also in the state-provided fee guidance that is provided
to managed care contractors.) When rates do not adjust for the price of inflation or the CPI year
over year, this can eventually become prohibitory to participation, as the provision of carebecomes costlier than the associated reimbursement received for delivering the care.
We believe that a CMS requirement for states to conduct regular assessment of fee policies isprudent. The requirement could be to review on, for example, a tri-annual basis so as not tobecome too burdensome on the state agencies. The states should be required to make publicly
available the results of these fee assessments.
CMS could support states by providing information crucial to their assessment, such as rates ofinflation and dental CPI. When data is available, state agencies could compare Medicaid
payment rates to private insurance rates.
Payment ParityIn states that administer Medicaid programs separately from CHIP programs, it is notuncommon for the provider payment rates to be substantially higher for services rendered tochildren covered by CHIP compared to those in the Medicaid program. This is discriminatory
and perpetuates oral health disparities, as it disproportionately affects lower income families.
Establishing payment parity between Medicaid and CHIP and regardless of age promotes
health equity, as it reduces the likelihood of one underserved population accessing care at theexpense of another. Payment rates for all CMS programs should be on par with other CMS
programs, and states should benchmark these rates to private insurance rates using state-level
FAIR Health data.
Similarly, reimbursement rates for child dental services are typically higher than for the same
service delivered for the adult population in Medicaid. In a recent analysis, the American Dental
Association’s Health Policy Institute found that 2020 Medicaid reimbursement rates were 61.4%
of private insurance reimbursement rates for child dental services on average in the U.S., ascompared to 53.3% of private reimbursement rates for adult dental services. 1 The authors of
this analysis note that “the data were collected from Medicaid fee-for-service (FFS)
reimbursement rate data from state Medicaid program web pages in December 2020. Manystate Medicaid programs contract with managed care organizations to administer dental
services and therefore do not pay dental care providers via the publicly available FFS schedule.
The lack of transparent, publicly available data on reimbursement rates within managed careprograms presented a significant limitation to our analysis, as we were not able to include suchdata in our analysis. While Medicaid FFS reimbursement rates are intended to be a benchmark
or guide for managed care organizations, it is unclear whether this happens in practice.” Thus,

1

American Dental Association. Reimbursement rates for child and adult dental services in Medicaid bystate. Health Policy Institute Infographic. October 2021. Available from: https://www.ada.org//media/project/ada-organization/ada/ada-org/files/resources/research/hpi/hpigraphic_1021_1.pdf.
Accessed March 31, 2022.

rate transparency within managed care is critical to even begin to understand issues aroundaccess.
State Directed Payments (SDP)
While CMS seeks to overhaul SDPs by reigning in increasingly large, unjustified payments, wenote that currently the number of dental providers receiving payments through SDPs is arelatively low. 2 We are supportive of efforts to increase accountability for dollars directed
through SDPs. However, we also strongly support the original intent of creating
exceptions for circumstances in which a state may make specified payments to healthcare providers such as funding to ensure certain minimum payments are made to safety
net providers (like FQHCs and dental schools, which provide care to a disproportionately
high amount of Medicaid beneficiaries) to ensure access to care or funding for quality
payments to ensure providers are appropriately rewarded for meeting certain program
goals. The ability for states to influence managed care plans through SDPs when done
correctly and justifiably is overall beneficial to states and their beneficiaries by allowing for thesepayments to providers as no less than the FFS rate approved in the Medicaid state plan or to
pay a uniform dollar/percentage increase in payment above negotiated base payment rates.
Federal Standards for Measuring Access
CMS proposes a new national standard to promote access in managed care which would set
maximum wait times for getting routine appointments for primary care, obstetrics/gynecology,
and outpatient behavioral health services and at least one additional service selected by thestate. States could also adopt standards for nonroutine visits, allow exceptions to the wait -time
requirements, and/or apply more stringent standards than those proposed. We believe in theimportance of ensuring that dental plans offered within Medicaid managed care plans include
an adequate provider network that meets beneficiary needs. This network must include
pediatric dentists, other specialty dental providers, and general dentists. Should a statechoose to select dental as an additional service, we are supportive of using appointment
wait times in addition to time and distance standards as a way to measure access.
Access Monitoring
Oversight of access to care is important and the proposed rule would require ongoing
monitoring. This monitoring could include “secret shopper” surveys through which states could
assess appointment wait times for managed care enrollees and verify information in provider
directories. If plans fail to perform, states would be required to devise “remedy plans.”
To further the engagement of enrollees and stakeholders and advance equity goals, theproposed regulations would bolster opportunities for public input at the state level. Annual
2

MACPAC Issue Brief. Directed Payments in Medicaid Managed Care. June 2022. Available fromhttps://www.macpac.gov/wp-content/uploads/2022/06/June-2022-Directed-Payments-Issue-BriefFINAL.pdf. Accessed July 3, 2023.

“satisfaction” surveys of managed care enrollees would be required, and we support thisrequirement.
CMS notes it proposes approaches that states could consider addressing the access issue,
such as “increasing payment rates to providers, improving outreach and problem resolution toproviders, reducing barriers to provider credentialing and contracting, providing for improved orexpanded use of telehealth, and improving the timeliness and accuracy of processes such asclaim payment and prior authorization.” We fully support these approaches to improveaccess. Additionally, we believe that an important part of ensuring access for patients is
reducing administrative burdens, especially audits, for dentists so that they enroll andstay in Medicaid. Any necessary audits should be conducted by a dentist who has asimilar educational background and credential as the dentist being audited, as well as alicense in the state in which the audit is being conducted. We also support efforts toensure that each managed care entity establishes a designated Provider Advocate
position to conduct educational sessions for participating providers and provide
ongoing technical and navigational support. As CMS seeks to mandate every stateestablish a uniform credentialing and recredentialing policy that requires each plan tofollow those policies, we strongly urge inclusion of dental providers within these policy
updates, wherein processes and timelines should be benchmarked against private
carriers. All MCO’s and PAHP’s within a state should share a single system for provider
data collection and ensure that re-credentialing cycles are aligned to reduce
administrative burden.
We also support CMS in requiring states to have a remedy plan within 12 months if
issues are identified, and further by requiring that steps be taken by states to address
issues for another 12 months by requiring revisions to the remedy plan if warranted. We
agree with CMS that this proposal would improve access and is critical to ensuring that thestate's and managed care plans' efforts are effective at addressing the identified access issue.
Medical Loss Ratio
While there is no federal requirement pertaining to Medicaid plans as there is for insurers andemployer plans under the Affordable Care Act, states have discretion to require remittances
under Medicaid plans. We note that President Biden’s FY 2024 Budget proposed requiring
Medicaid managed care plans meet an 85% minimum MLR and would require the states
to collect remittances if plans fail to meet the minimum MLR, efforts we support.
In this rule, CMS assumes that states will determine their actuarial rates consistent with an 85%
MLR. To stop plans and states from raising their MLRs and distributing additional funds tocertain network providers unrelated to care or quality improvement, CMS proposes to stop
inclusion of any payments not tied to permissible MLR activities and instead creates new,detailed, compliance procedures for showing MLR integrity. We support efforts seeking
further transparency in these payments.

Separately, as we have previously noted, in January 2022, the Medicaid and CHIP Paymentand Access Commission (MACPAC) published an issue brief, Medical Loss Ratios in Medicaid
Managed Care, in which they detail the implementation of MLR requirements within Medicaid
managed care organizations (MCOs) and state that “MLR requirements went into effect in
2019, and data on plan and state experience with them is expected to be available in 2022.” In
September 2022, the Health and Human Services’ Office of Inspector General (OIG) issued areport reviewing 495 annual MLR reports that it obtained from states for completeness, to see ifthese reports contained the seven required data elements: claims costs; non-claims costs;
quality-improvement expenses; premium revenue; taxes and fees; calculated MLR; andmember months. Close to half (49%) of the MLR reports submitted by MCOs in 28 states wereincomplete and missing at least 1 of the 7 required data elements, thus allowing the reporting
requirement to become optional.
The OIG report made a number of recommendations that the we agree with, however, it did not
identify the MCOs or PAHPs that submitted the incomplete MLR reports or the states that didnot address the reporting gaps. We encourage CMS to publish this information, which
could further encourage the MCOs and PAHPs along with states to meet therequirements. Furthermore, we encourage CMS to publish in a timely manner a state-bystate assessment of MCOs and PAHPs with the percentage of allocated Medicaid fundingthat is being spent on dental services and asks that CMS require each state Medicaid
agency to monitor the specific dental loss ratio among their contractors. Because
Medicaid is a critical access point for dental care to millions of enrollees, tracking thecorrect data is important to ensuring Medicaid enrollees are getting the dental care theyneed going forward. In summary while all dental PAHP’s should report their MLR, any
MCO that includes dental services should report the dental component of their MLR
separate from the medical services especially in cases where the provision of dental
services is subcontracted by the MCO.
Website Improvements
The proposed rule would require states to update their websites to simplify navigation andensure the availability of certain types of information such as provider directories, formularies,enrollee handbooks, and information about payment rates and payment evaluation reports.
Improvements would be required as quickly as two years from the date of finalization. We agreewith requiring states to have a more simplified, single website with links to specificprogram and health plan information, explanations of the availability of assistance, andsecret shopper survey results to assist enrollees.
Mandatory Medicaid and CHIP Core Set Reporting
CMS is seeking to establish intent with this proposed rule to align with the stratification factors
required for Core Set measure reporting, believing that it would minimize state and health planburdens to report stratified measures. To further reduce burdens on states, CMS would permit
states to report the same measurement and stratification methodologies and classifications as
those proposed in the Mandatory Medicaid and CHIP Core Set Reporting proposed rule and theEnsuring Access to Medicaid Services proposed rule. We fully support aligning thestratification factors for Core Set Reporting along with enrollees having greater access tomore detailed quality measures. We also would support dentists having access to thosequality measures.
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Thank you again for your commitment to Medicaid and for the opportunity to comment on thisimportant rule. We would welcome the opportunity to meet with you to discuss how we canassist CMS in meeting the challenges outlined here on Medicaid and dentistry. If you have any
questions, please contact Mr. David Linn at 202-789-5170 or linnd@ada.org.
Sincerely,
American Dental Association
Academy of General Dentistry
American Academy of Oral & Maxillofacial Pathology
American Academy of Oral & Maxillofacial Radiology
American Academy of Pediatric Dentistry
American Academy of Periodontology
American Association of Oral and Maxillofacial Surgeons
American Society of Dentist Anesthesiologists
American Student Dental Association
Association of Dental Support Organizations