Current through 2024-38, September 18, 2024
Specific reimbursement rates are listed on the dental fee
schedule, which is posted on the Department's website in accordance with
22 MRSA
§3173-J(7).
Reimbursement for covered services may be inclusive of, but is not limited to,
local anesthesia, sutures, materials, supplies, and routine postoperative
care.
Reimbursement rates are based on the following
methodology:
A.
Benchmarks
The Department calculates reimbursement rates for covered
CDT codes using either the Commercial Median Benchmark or the All-States
Medicaid Average Benchmark.
1. The
Commercial Median Benchmark for each CDT code is the median of
Maine commercial payer dental claim allowed amounts when the claim is paid as
primary with an allowed amount greater than zero (0) based on data from the
Maine Health Data Organization's All Payer Claims Database. The Commercial
Median Benchmark rate for a CDT code must have equal to or greater than
one-hundred (100) claims billed in the source data used to set the benchmarks
in order for the Department to consider it reliable. Benchmarks are assessed
every two (2) years utilizing claims from the most recent Maine state fiscal
year.
2. The Medicaid State
Average Benchmark (Medicaid Benchmark) is the average of all other
states' Medicaid rates for a CDT code, where rates are available and reliable.
The Department excludes any rates as unreliable in the determination of the
Medicaid Benchmark when they represent outliers in comparison to the other
state rates, or when there is excessive variation across all state rates
available. If a Medicaid agency uses different child and adult rates, the
Department uses the average of the rates. Benchmarks are assessed every two (2)
years utilizing the most current rates available as of the time of the rate
schedule update.
B.
Determination of Benchmark and Percent of Benchmark
The Department determines which Benchmark and percent of
Benchmark to use in setting rates using the following methodology:
1. The Department sets rates for diagnostic,
endodontic, periodontic, preventive, and limited orthodontic treatment services
based on 67% of the Commercial Median Benchmark or 133% of the Medicaid State
Average Benchmark, if the Commercial Median Benchmark rate is unavailable or
unreliable as defined in Section 25.06(A)(1).
2. The Department sets rates for adjunctive,
oral and maxillofacial surgery, orthodontics (except for limited orthodontic
treatment), prosthodontics, and restorative services based on 50% of the
Commercial Median Benchmark, or 100% of the Medicaid State Average Benchmark if
the Commercial Median Benchmark rate is unavailable or unreliable as defined in
Section 25.06(A)(1).
3. Temporary
Exceptions: The following methodologies will be in effect through June 30,
2026.
a. The methodology set forth in B.1 will
also apply to codes for extraction of an erupted or exposed root; and
b. The Department will default codes for
medicament application to 133% of the Medicaid State Average
Benchmark.
C.
Adaptation of Methodology for Related Codes
In alignment with common practice by commercial payers
and other state Medicaid agencies, for codes in the same series and/or for the
same service, differentiated only by time increment for the code or age of
patient, etc., the methodology outlined above applies to the base service;
other CDT codes are set in relation to the base service proportional to the
amount of time or factor of difficulty of the related service.
1. Orthodontic Treatment: For limited and
comprehensive orthodontic treatment, after calculation of the initial rates by
code in alignment with the methodology above, the Department then sets the
final MaineCare rates at the adolescent dentition rate for the codes in the
same series (limited and orthodontic).
In order to identify claims that reflect a bundled rate
for orthodontic treatment, the Department only includes claims that are paid as
primary and that have a rate greater than $300 and $1000 for limited and
comprehensive orthodontic treatment codes, respectively. The Department
excludes claims when the code was billed more than once per person.
2. Sedation: The Department sets
rates for deep and intravenous moderate sedation service codes at 50% of the
Commercial Median Benchmark for the CDT code that represents the first fifteen
(15) minutes of deep sedation.
D.
Inflation Adjustment
The Department applies an inflation adjustment to all
rates based on the Consumer Price Index (CPI) for dental services in U.S. city
average, all urban consumers, seasonally adjusted (CUSR0000SEMC02) to adjust
rates to the current year.
