Module 5: Operating Effective Programs
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Please Note: This curriculum was developed prior to the COVID-19 pandemic and may not reflect current guidance for materials, procedures, and infection control.

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5.4 Use of Public Funding

Medicaid and the Children’s Health Insurance Program

Given FRPM eligibility requirements of ODH-funded dental sealant programs, a large proportion of children at schools with sealant programs are expected to be Medicaid beneficiaries.

ODH uses federal Maternal and Child Health (MCH) Block Grant funds to fund sealant program grants to local agencies, most of which are local health departments. To ensure that as many children at higher risk for dental caries as possible receive sealants, ODH relies on the programs it funds to engage in good-faith efforts to use their grant funds primarily for children who do not have a third-party source of payment.

Medicaid is the most common third-party payer for oral health care for children, particularly those at schools with large proportions of children at higher risk. Per federal law, programs that receive MCH Block Grant funds can be reimbursed for Medicaid-covered services rendered to Medicaid beneficiaries, even if those services are provided free of charge to the general public.8

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Therefore, ODH-funded dental sealant programs must identify the children they serve who are Medicaid beneficiaries and must collect the reimbursement due to the program. In addition, programs should provide parents of children potentially eligible for Medicaid with enrollment information. Given that sealant programs may be unlikely to have direct contact with parents, this may amount to sending home written materials.

Parents can receive application assistance, answers to general questions, and referral to their local county office or a health professional through the Ohio Medicaid Consumer Hotline at (800) 324-8680 or (800) 292-3572 (TTY). To enroll in the plan of their choice, beneficiaries can contact the Ohio Department of Job and Family Services’ (ODJFS’) Medicaid Managed Care Enrollment Center at (800) 605-3040 or (800) 292-3572 (TTY) or via its website. ODJFS in each county determines individuals’ eligibility for Medicaid. Applications can be found at county offices or from its website.

ODH considers projected Medicaid income in determining the grant funding awarded to the school-based dental sealant programs it funds. Therefore, the ODH grant plus third-party reimbursement should cover the costs of program operations.

Medicaid services in Ohio are delivered primarily through managed care plans (MCPs). Learn more about Ohio Medicaid in this series from the Health Policy Institute of Ohio. 9

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Most Ohio Medicaid MCPs contract with a third-party administrator (TPA) for the administration of oral health services. The remaining MCPs administer oral health care directly. Therefore, sealant programs are likely to be involved in billing multiple sources for Medicaid reimbursement (i.e., a TPA, ODJFS, MCPs that administer their own oral health programs).

Details about the respective payers for dental services provided to Medicaid beneficiaries (i.e., ODJFS, TPAs, MCPs that administer their own oral health programs) can be found in the School-Based Dental Sealant Program Manual. Information on the reimbursement process, provider credentialing, and other key topics is included.


Reimbursement

ODH-funded school-based dental sealant programs may submit claims for Medicaid beneficiaries for sealants, using diagnostic and preventive code D1351 (sealant). ODH does not approve ODH-funded programs routine billing for examinations, X-rays, or topical fluoride applications for Medicaid beneficiaries. ODH believes that examinations and X-rays should be conducted by dentists who provide all needed care. If programs were reimbursed for those services, dental offices (where children enrolled in Medicaid eventually receive care) would not be reimbursed.


Health Professional Enrollment

Dentists participating in sealant programs must be credentialed by Ohio Medicaid and each of the Medicaid MCPs or the TPA serving their region. Health professional enrollment information for Ohio Medicaid is available from Ohio Department of Medicaid. Health professionals may also call the provider enrollment unit at (800) 686-1516. Information about the credentialing process for MCPs that administer oral health programs or TPAs must be obtained directly from the appropriate company by phone or via the National Plan and Provider Enumeration System website.


Filing Claims

All health professionals must obtain a National Provider Identifier (NPI) for filing and processing of claims. NPI applications are available from the National Plan and Provider Enumeration System at (800) 465-3203 or (800) 692-2326 (TTY) or via its website.

School-based dental sealant programs may submit claim forms electronically or via paper. Electronic submission results in faster claims processing, reduced administrative costs, reduced probability of errors, faster feedback on claims status, and minimal staff training or cost. The School-Based Dental Sealant Program Manual has information about available options for claim submissions to the respective MCPs that administer oral health programs or TPAs, but local sealant programs may wish to check with those payers directly.

Ohio Medicaid and each Medicaid MCP or TPA that administers claims has systems to provide health professionals with information that they need.