SF5230

Purpose

• Delay or pause the full implementation of a single dental administrator for the medical assistance program and set up a contingent process to move dental services under a single administrator if certain performance benchmarks are not met.

Main Provisions

• Contingent administration plan
  • If managed care and county-based purchasing plans (in aggregate) fail to meet the performance benchmark for coverage year 2024, the commissioner will, after requesting information and proposals, contract with a dental administrator to run dental services starting January 1, 2028 to 2030 for:
  • Recipients of medical assistance (MA)
  • MinnesotaCare enrollees who are served under fee-for-service
  • People receiving services through managed care plans
• Roles of the dental administrator
  • Provide administrative services such as:
  • provider recruitment and contracting
  • recipient outreach and assistance
  • utilization management and medical necessity reviews for dental services
  • dental claims processing
  • coordination of dental care with other services
  • fraud and abuse management
  • monitoring statewide access to dental services
  • performance measurement and quality improvement
  • third-party liability management
  • establishment of grievance and appeals processes for providers and enrollees
• Provider payments
  • Payments to contracted dental providers must be based on rates recommended by the dental access working group.
  • If those rates aren’t established in law by July 1, 2027 or 2029, payments must use rates under sections 256B.76 and 256L.11.
• Recipient provider choice
  • Recipients must be able to choose a dental provider, including any provider who agrees to the participation requirements and payment rates set by the commissioner and the dental administrator.
• Network and access requirements
  • The dental administrator must meet network adequacy and geographic access requirements that apply to managed care plans for dental services (per section 62K.14).
• Accountability and performance
  • The contract must include performance benchmarks, accountability measures, and progress rewards based on recommendations from the dental access working group.
• Contract duration and extensions
  • The commissioner may extend the implementation contract for up to three years and may contract with the same dental administrator for up to five years, starting in 2028–2030.

Section 2: Dental Utilization Reporting (Subd.4)

• Annual reporting timeline
  • Reports due March 15 between 2022 and 2026, and then to 2028, with updated data and metrics.
• Contents of the report
  • Utilization metrics by age groups (adults and children ages 1–20) for the most recent calendar year, for both fee-for-service and MA MinnesotaCare populations.
  • Utilization by county.
  • Utilization by children and adults enrolled through fee-for-service and through managed care plans or county-based purchasing plans.
  • Description of corrective action plans for any issues.
• Historical and ongoing metrics
  • The initial report (due March 15, 2022) must include data for 2017–2020.
  • Starting in 2023 reports, include:
  • Number of dentists enrolled with MA/ MinnesotaCare as a dental provider and their congressional districts.
  • Number of enrolled dentists who provided fee-for-service dental services to MA or MinnesotaCare patients in categories (1–9, 10–100, 100+ patients) and the number who provided through a managed care plan or county-based purchasing plan (also categorized by patient counts).
  • Number of dentists who provided services to new MA/MinnesotaCare patients enrolled in the previous year.
• Additional yearly details
  • The 2023 report must include metrics for 2017–2021.

Significant Changes to Existing Law

• Establishment of a contingent path to a single dental administrator
  • Creates a plan to consolidate dental administration under one dental administrator if performance benchmarks are not met by current managed care and county-based purchasing arrangements.
• Expanded administrative responsibilities
  • The dental administrator would handle a broad set of duties (recruitment, contracting, utilization management, fraud control, quality improvement, grievance processes, etc.), shifting many administrative functions away from separate plans to a centralized administrator.
• Rates and pricing changes
  • Ties provider payment rates to a recommended dental access working group; introduces a potential shift to pre-determined state-established rates if the working group’s recommendations are not enacted in law by specified dates.
• Reporting and transparency requirements
  • Adds comprehensive annual utilization reporting and various counts related to enrolled dentists and patient access, intended to improve oversight and data-driven decision-making.

Implementation Considerations

• Timeline sensitivity
  • The plan depends on performance benchmarks for 2024 and legislative timing around rate establishment (by July 1, 2027 or 2029) to determine how payments are set.
• Choice and access
  • Maintains patient choice of providers while requiring alignment with the new administrator’s processes and payment framework.
• Oversight and accountability
  • Incorporates formal benchmarks, accountability measures, and progress rewards to monitor the dental administrator’s performance.

Relevant terms - single dental administrator - medical assistance (MA) - MinnesotaCare - fee-for-service (or fee-for-service) - managed care - county-based purchasing plans - performance benchmark - dental access working group - dental administrator payments - network adequacy - geographic access (section 62K.14) - utilization management - medical necessity - fraud and abuse - grievance and appeals - rates (as recommended by the dental access working group and as established in law under 256B.76 and 256L.11) - third-party liability (TPL) - RFI (request for information) - RFP (request for proposals) - provider recruitment and contracting - provider choice - annual dental utilization report - congressional district (for dentist enrollment)