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Medicaid. Worth Another Look?

Dental Insurance Today — August 2020

Clowns and jokers

It’s not for everybody but it could be worth a look.

This past month, I had the honor to be of service to the membership of the American Dental Association. The webinar recording I did with Mr. Dennis McHugh, ADA Manager of Third Party Payer Advocacy at the Center for Dental Benefits, Coding and Quality, is below.

During the webinar, we shared the mutual pleasure of a no holds barred conversation concerning PPO plan participation and the reality of what the numbers actually represent. If you are of the opinion that you lost $20 when you did a $100 procedure for a contracted maximum allowable charge of $80, then prepare to have your eyes opened to the reality of cost per chair hour.

Get ready for more ways to connect.

We are diligently working in the background over at LIMOLI.com as we make continued enhancements to the Membership Dashboard. We are right now plugging in the 2021 procedure code changes along with educational quick videos to help you more accurately simplify the overall reimbursement process. Take advantage of our special Financial Recovery Pricing on everything from Fee Analysis to Coding and Clinical Documentation as well as face-to-face custom consultation time.

Our next issue of DIT will focus on the misconceptions being spread throughout dentistry concerning when and what to not bill out via the patient’s benefit plan. Too many offices are finding out the hard way that tricking patients into signing a manipulative HIPAA document is no way to legally enhance overall reimbursement.

I never saw that one coming…

If the year 2020 has shown us anything new and noteworthy, it’s probably the redefinition of the old phrase “I never saw that one coming.”

Unprecedented unemployment combined with questionable worldwide economic stability has produced a mostly shallow workforce. Ever-changing job descriptions and work environments all become intertwined in changing everything from commercial real estate, hospitality and interstate travel to name just a few. Complicate this with the new normal of distance learning for children, adults, parents, and executives, and it’s no wonder that the family cat wants everyone to leave them alone.

We have all experienced the ramifications as well as loss of both employees and employers along with their previously protected benefit packages. As a result, many families are being presented with little to no option but to consider Medicaid as well as other government-funded safety nets. Every state in the union is experiencing unprecedented growth in the Medicaid rolls.

Having worked with dental practices in almost all 50 states, I can confidently share with you that there are more than a dozen different ways to successfully, as well as profitably, provide the necessary compassionate services to the Medicaid population. As I shared earlier, “its not for everybody” but realistic, factual and timely, non-political information surely is.

A word from Dr. Sharpe

Now I bring you an article from my friend and fellow consultant, Fred L. Sharpe, DDS, JD.

Dr. Sharpe is a leader in dental benefit programs, both in commercial dental and Medicaid. As dental director and chief dental officer, he has led dental networks in multiple states and worked with state and federal regulatory agencies. His training includes a dental degree and a law degree, which both impact his review of issues in dental benefits. He is currently a consultant for dental insurance companies and dental provider groups.

He can be reached at [email protected].

Medicaid Dental – Really?

by Fred L. Sharpe, DDS, JD

Someone has probably told you that doing Medicaid dental is not for your office. Did you ever look into it? Did you ever consider the details of Medicaid dental in your state? Remember, all state Medicaid programs are not created equal. Since Medicaid dental is the fastest growing segment of dental benefit coverages, you might think again about your decision to avoid it. The key for your office should be: “Can we make money and help people by participating in Medicaid?”



First, let’s understand the varying types of government-sponsored dental benefit programs. We have Medicaid (for individuals and families at or near the federal poverty level), CHIP – Children’s Health Initiative Program (for children in families above the Medicaid qualifying level), Medicare (for older individuals), FEDVIP (for Federal Employees) and TriCare (for military family members). All of these programs provide health benefits, but not always comprehensive dental, for eligible members.

The Medicaid children and CHIP programs are required to provide comprehensive dental benefits. However, the adult coverages under Medicaid vary widely by state. Some states provide almost comprehensive benefits, while others simply provide emergency benefits and little or no preventive benefits. Medicare does not cover dental under the routine benefit programs; however, Medicare Advantage programs may cover dental, but often just preventive and/or preventive and simple restorative benefits. Rarely do Medicare Advantage plans cover comprehensive dental benefits.

It is also important to understand the differences in the program funding before making any decisions to participate. For members in the Medicaid and CHIP programs, the funding is typically 65–70% federal funds and 30–35% state funds. Medicaid plans are administered by the individual States with Federal oversight. Today, a majority of the States have moved the clinical administration to private companies, generally HMOs. While the federal government mandates comprehensive dental benefits for children in Medicaid (up through age 20) and CHIP (through age 18), adult benefits vary widely by state.


Medicare programs are administered directly by the federal government (under CMS – the Commission for Medicare and Medicaid Services) and have no dental benefits included. As always, there are alternative programs called Medicare Advantage plans that may include some dental benefits, but generally a smaller set of covered services than a typical commercial dental plan. FEDVIP and TriCare usually include mostly comprehensive dental benefits administered by a private insurance company. Again, your office may not need to sign a contract to provide dental services under a FEDVIP or TriCare plan, but often these benefits are provided through a PPO network. 


I have heard the standard complaint that the fees under Medicaid and CHIP programs are lower than usual PPO fees. Yes, that is generally true. Since Medicaid and CHIP programs are always State-administered, either directly or through a contracted dental administrator, you need to review the specific fees for the programs in your state. Two things to remember; first, there are usually no copays from the member, so the full fee is paid by the administrator directly to your office and second, most services require no authorization for obtaining payment. In many instances, the payments are made promptly, within several weeks.

In addition, isn’t it true that Medicaid and CHIP members fail many appointments? That can be true, but your office can use your standard dismissal guidelines to dismiss them for failing appointments, if they fail to respect your office time. Offices that have built relationships with their historic patients have better appointment attendance. This is an issue that your office needs to manage more carefully than other patients, but it can be managed.

Again, why should your office participate in Medicaid? I can provide three reasonable answers for that question. First, Medicaid members can fill open chair time. If your office is not completely busy, you are adding paying patients to your schedule. Second, you receive complete payment from the administrator and do not need to rely on patient copayments. The payment schedule that is indicated for Medicaid dental services is totally paid by the government or their administrator – no collection from patients. Third, you are serving patients who have limited financial resources and will benefit from your dental care. The needs are great, and your office can help to serve an underserved population.

The participation in any dental program that requires a contract is up to you as an owner or partner in a dental practice. You need to evaluate the actual Medicaid and CHIP plans in your state, compare fees with your current office schedule and determine if your office would benefit from adding more patients to your office roster. Remember, dental practice can be more rewarding with a wider spectrum of patients. With the changes in our American population, more residents in your community may be in a Medicaid or CHIP program and seeking the dental care you and your team can provide.

~ Fred L. Sharpe, DDS, JD
[email protected]

Tom Limoli

Tom Limoli

“The Nation’s Leading Reimbursement Expert”

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