Welcome and Introductions

Linda Ferraro, RDH, BS Director, Office of Oral Health, Connecticut Department of Public Health Chair, ASTDD Healthy Aging Committee

General Reminders

• Please mute your phone by pressing *6 or your “Mute” button;

• Webinar will be recorded and archived on the ASTDD website;

• Questions may be entered into the chat box and will be addressed after the speakers are done;

• Please respond to the 3 polling questions at the conclusion of the webinar.

Purpose of the Webinar• Nursing facility residents enrolled in Medicaid

can pay for non-covered dental services. This webinar will provide information about how this can work using the Incurred Medical Expense (IME) regulations.

• You may find How-to Guides at: http://www.ada.org/6097.aspx?currentTab=2

Today’s Topics

• What is IME and how does it work?• IME in practice – case examples• Who needs to be at the table?• Audience questions and comments

Three Related Webinars:

• September 2012 – ADA webinar for dentists

• Today’s webinar – State Dental Directors and State Medicaid Directors

• Spring 2013 – American Health Care Assoc. webinar for long-term care administrators and staff

IME Collaboration

• Mary E. Foley, MPH Executive Director Medicaid-CHIP State Dental Assoc.

• Contact your state Medicaid Dental Program Director/Manager;

• Identify the IME Program lead;• Explore current program guidelines;• Identify any policies specific to dental care;• Collaborate with both the Medicaid dental

and IME programs in establishing next steps and opportunities for promotion.

Medicaid & State Oral Health ProgramsIncurred Medical Expense

Mary FoleyMSDA

Importance of Dentistry in Long-term Care

• Sandra Fitzler, RN Senior Director of Clinical Service American Health Care Association

Why is dental care needed in nursing facilities?

1. Residents in nursing homes need care- Long-term care facilities are aware of this- They are actually required to provide that care- Dental services can be considered an “incurred

medical expense” under federal regulations

2. Dentists want to provide residents with care3. However, limited finances are a significant

barrier to care.

Federal Regulations related to IME

Go to:•http://edocket.access.gpo.gov/cfr_2004/octqtr/pdf/42cfr435.725.pdf

There are financial solutions!

• Incurred Medical Expense (IME) is a reimbursement mechanism that can be used for dental services.

• Most nursing facility residents who are enrolled in Medicaid can pay for dental care using their Social Security or other retirement income.

• This mechanism has been in use in many states for more than a decade.

What is “IME” and

how does it work?

• Michael Helgeson, DDS Chief Executive Officer Apple Tree Dental

What is the definition of “IME?”

• Incurred Medical Expenses• IME include medically necessary health

services that are NOT covered by Medicaid, such as glasses, hearing aides and dental care.

• Laws governing IME permit Medicaid recipients to use their Social Security income to pay for Incurred Medical Expenses through an approval process involving county case workers.

How does this payment process work?

• Residents’ Social Security and other retirement income arrives monthly even when they are enrolled in Medicaid.

• This income is generally used to pay the nursing facility’s bill each month, with Medicaid paying any remaining balance.

• Under federal laws, this monthly income can be used to pay for medically necessary health care, including dental care.

How-to guide for Incurred Medical Expense

• ADA’s How-to Guide:

• http://www.ada.org/6097.aspx?currentTab=2

The How-to Guides target three audiences

Dental professionals Nursing facility

residents and their representatives

State and county Medicaid caseworkers

How does IME work for dental professionals?

IME provides a way for dental professionals to be paid for dental services NOT covered by their state’s adult dental Medicaid program.

How does IME work for county case workers?

•IME approval processes are usually in place, but may not be routinely used for dental services in some states or counties. Education and/or training may be needed.

IME: Two Sample Cases

Gregory Folse, DDS President Outreach Dentistry

Case #1: Miss Sylvia Simple• For her income and insurance

– She receives $1,200 per month from Social Security and has no other retirement income.

– She is on Medicaid, but in her state Medicaid doesn’t cover adult dental benefits.

– This makes all medically necessary dental benefits eligible to be paid using IME

• Her dental needs are simple…– She needs only an exam and preventive care.– Her total dental bill is $200.

Case #1: Miss Sylvia Simple• The Dentist:

– Performs the services;– Creates a dental bill for the balance of $200

and provides it to Miss Simple’s financial overseer; (Miss Simple, her responsible party, or the nursing facility.)

– Forwards the dental bill to her Medicaid case worker.

Case #1: Miss Sylvia Simple • The Case Worker:

– Instructs Miss Simple’s financial overseer (Miss Simple, her responsible party, or the nursing facility) to pay $200 to the dentist and $1,000 to the nursing facility from the next $1,200 Social Security check;

– Authorizes Medicaid to pay the facility $200 more, so the nursing facility bill is paid in full.

Case #2: Miss Cathy Complex

• For Her Income and Insurance:– She receives $1,000 per month from Social

Security and other retirement income;– She is on Medicaid, and her state has

LIMITED adult dental Medicaid benefits (extractions only);

– The services not covered by Medicaid can be billed using the IME mechanism;

– The services covered by Medicaid must be billed to Medicaid.

Case #2: Miss Cathy Complex

• Her dental need are more complex:– She needs diagnostic, preventive, restorative,

surgical and denture services;– Her total dental bill is $3,000

• $2,500 are IME eligible• $500 are Medicaid eligible services

Case #2: Miss Cathy Complex• To Bill

– Requires the dentist to use two different billing methods:

• Non-covered services through IME• Covered services through Medicaid

– IME eligible fees totaling $2,500 are greater than one month of her retirement income ($1,000 per month) so these fees will be paid over time.

Case #2: Miss Cathy Complex• To Bill

– For Medicaid services the dentist:• Must be enrolled as a Medicaid provider or,• May provide those covered services pro-bono.

– Medicaid eligible fees are billed directly to Dental Medicaid.

Case #2: Miss Cathy Complex• The Dentist:

– Performs the services;– For IME services, creates a dental bill for

$2,500 and provides it to Cathy’s financial overseer (Cathy, her responsible party, or the nursing facility);

– Forwards the IME eligible dental bill to her Medicaid case worker;

– Bills $500 directly to Medicaid for Medicaid eligible services.

Case #2: Miss Cathy Complex

• The Case Worker:– Instructs Cathy’s financial overseer to pay

$1,000 for 2 months and $500 for one month to the dentist in order to pay the entire $2,500 IME bill;

– Authorizes Medicaid to pay the facility $1,000 more for 2 months and $500 more for one month so the nursing facility bill is paid in full.

Who Needs to be Engaged in the IME Process?

• Sarah J. Dirks, DDS President

Geriatric Dental Group of South Texas, PA

Who Can Assist You With IME Adjustments?

• Dentists Currently Using IME To Fund Dental Service

• Nursing Facility Staff • Nursing Facility Medicaid Case Workers• State IME Procedural Contacts• State Dental Director• State Medicaid Dental Director

What Nursing Facility (NF) Staff Need To Know To Support Oral Health Services Through IME

Adjustments (IME A’s) NF administrators, social workers and

business managers should understand:

• IME A’s can provide critical oral health services to their residents.

• IME A’s are critical to Regulatory Compliance and Survey Success.

Specifically:NF Administrators:

• Should realize IME A’s improve both the oral health of their residents and the regulatory compliance of their facility.

• The business manager and social worker will need time to work on the IME A’s.

NF Social Workers:• Should be able to communicate the IME

process to residents and their families.

NF Business Managers:• Will need to provide income information

to dentists prior to treatment. • Will need to assist dentists, patients, and

families with processing IME A’s.

Specifically:

Considerations in Moving Forward:

• The IME process is Federal Law and likely being used for other medical expenses such as glasses, wheelchairs, hearing aids, etc.

• Your state may be using Federal IME policy or may have it’s own protocols.

To Identify Current IME State Protocols:

• Nursing facility business managers and state Medicaid case workers are the best people to answer existing protocol questions such as:– What is our state’s specific

procedures/policies to utilize the IME process for other medically necessary expenses such as glasses and hearing aids?

– Has our state utilized the IME process for medically necessary dental expenses?

Questions to Ask the Nursing Facility Business Manager to

Start Care for a Patient:• Does Ms. Jones have income available for

IME A’s?

• Who is Ms. Jones’ Medicaid Case Worker?

Questions to Ask the Medicaid Case Worker to Start Care for a

Patient:• What specific paperwork is needed in

order to process a resident’s IME A for their needed medically necessary dental services?

• How does our state notify the LTC facility and dentist that the IME adjustments have been made?

Practical Issues:• High turnover of NF staff can complicate

the continuity of the IME process. • Payment of dental bill is not “guaranteed.”

– NF residents must be “current” with their monthly payments to nursing facility.

– If NF residents leave the NF or expire before IME A is processed and paid; no payments will be received as no income is available to pay for the care provided.

Final Thoughts:• The determination of the medical

necessity of dental care is best done by a dentist.

• All medically appropriate dental services for NF residents are medically necessary.

• If problems arise with the IME process a meeting of all IME stakeholders in a given state may be advised.

Frequently Asked Questions• Is this IME billing process a “burden” or an

“opportunity” for dentists and facilities?• How long does it typically take for the

dentist to receive payment?• How can the billing workflow be optimized

for the nursing facility and dental staff alike?

Thank You!

• Our speakers will now respond to questions submitted via the chat box.

• Please remember to respond to the 3 survey questions at the conclusion of the session so that we may better serve you.