Texas Health and Human Services Provider Finance quietly posted its much anticipated legislated biennial review of Medicaid dental fees early last week. Well, maybe it was earlier, but it was only noticed early last week. It was found tucked into a document (download direct from their website) that included the review of collaborative care, Q codes, sleep studies and certified family partners.
These fees are to take effect on March 1, 2025.
Coincident with DentaQuest limiting its network
The review’s release coincides with DentaQuest informing dental providers that it was limiting its network as of October 15. Good investigators don’t believe in coincidence. At least Inspector Gordon told John Blake that in “The Dark Knight Rises.”
But, in all seriousness, DentaQuest limiting its network sends the message that current dental fees have been adequate to attract enough dentists to serve all its Medicaid clients.
Therefore, there is no need to increase fees.
ADA releases report comparing state Medicaid fees to private practice
In another coincidence, the American Dental Association’s Health Policy Institute released a report this month (download) entitled “Medicaid Reimbursement for Dental Care Services – 2024 data update.” The ADA report compares each state’s Medicaid fee for service schedule for 14 procedures against charges for the same service in private dental insurance plans aggregated to the state level. So, for each state, a percentage figure is obtained for Medicaid /Private practice.
The ADA calculates the national average to be 39.2% for child dental services, and the Texas average is 42.1%.
This report is a redux of a previously flawed version.
Criteria for Texas review
These calculations play into the hands of the Provider Finance review because the department uses “the median or mean of the Medicaid fees from 14 states (the ten most populous and the 4 bordering Texas) or the median or mean of the states that cover the service. (from the review document)”
The ADA calculations for those states are:
- California 36.9%
- Florida 22.2%
- New York 34.0%
- Pennsylvania 30.9%
- Illinois 23.9%
- Ohio 53.3%
- Georgia 39.8%
- North Carolina 34.3%
- Michigan 52.0%
- New Jersey 50.0%
- New Mexico 34.7%
- Oklahoma 38%
- Arkansas 36.1%
- Louisiana 59.1%
So you can see where Texas stacks up — even though fees haven’t been increased since 2007, those fees are still higher than 11 of those 14 other states. As a point, this comparison is useful for DMOs as we have been told that dental insurers try to use the Medicaid rate as a standard to reduce private practice payments.
What does the biennial fee review show?
The complete dental fee comparison table PDF file below is taken from the Provider Finance document showing all fee changes. There are some hefty increases in certain codes. But, unfortunately, most of these aren’t heavily used codes.
Here are some commonly utilized fees compared:
| 2007 | 2024 | 2025 | Percentage change | |
| D0145 – oral evaluation | $144.97 | $142.07 | $54.58 | -61.58% |
| D0150 – exam | $36.04 | $35.32 | $41.25 | 16.79% |
| D1110 – cleaning (13 years +) | $56.00 | $54.88 | $54.88 | 0 |
| D1120 – child cleaning | $37.50 | $36.75 | $36.75 | 0 |
| D2391 – 1 surface posterior Permanent | $84.04 | $80.34 | $80.34 | 0 |
| D1351 – sealant | $28.82 | $27.24 | $30.88 | 9.35% |
| D2392 – 2 surface posterior Permanent | $110.20 | $105.30 | $105.30 | 0 |
| D0210 – full mouth x-ray | $72.08 | $70.64 | $70.64 | 0 |
| D7140 – extract primary tooth | $66.37 | $64.06 | $68.79 | 7.38% |
| D2930 – stainless steel crown primary | $156.06 | $149.12 | $149.12 | 0 |
| D3220 – pulpotomy | $87.96 | $84.05 | $88.96 | 5.84% |
The lack of fee increases in these codes does not help the pain dental providers feel right now.
Complaints starting to flow to HHS
One provider has already sent a complaint to HHS about the fee review and sent us a copy.
Date: 10/16/2024
To: Provider Finance Acute Care Services
Texas Health and Human Services Commision
To Whom It May Concern:
Please be advised we found the following information visiting the TEXAS Health and Human Services website: https://pfd.hhs.texas.gov/rate-packets
After reading the Proposed Medicaid rates increment document, we have some doubts and questions because they are not reflecting the reality that all Medicaid dentists and dental offices are facing on a daily basis with inflation and high operations costs.
1) Are you guys proposing to reduce the D0145 Oral Evaluation fee from $142,07 to $54.58?
W D0145 ORAL EVALUATION, PT < 3YRS 6-35 N $144.97 $142.07 $54.58 $54.58 -61.58% (decreased)
Note: The D0145 is one of the most effective procedures to educate kids and parents and fight against bottle decay.
2) Are Our Texas Legislators and Finance Office proposing a little 2% increment of most of the dental fees after many years ( more than 15 years) working with the same fees to see kids in Texas?
See a couple of samples of your proposed dental fee increments below:
W D1120 DENTAL PROPHYLAXIS CHILD 6-155 N/F $37.50 $36.75 $36.75 $36.75 2.00%
W D1351 DENTAL SEALANT PER TOOTH 0-20 N/F $28.82 $28.24 $30.99 $30.88 2%
W D2391 RESIN-BASED COMPOSITE – 1 SURFACE, POSTERIOR 0-20 N/F $80.34 $80.34 $80.34 $80.34 2.00%
3) Is the notice of proposed adjustments to fees, Rates of Charges for the Medicaid Policy review of the B(2) Dental (Targeted Policy; Comprehensive Fee Review) pending to be still reviewed or not? We would like to confirm if there is not a mistake made by the Provider Finance Department, with the fees, because if the proposed adjustment to fees is real, they are showing poor treatment and an injustice with the dental providers network who have treated TX Medicaid kids in a responsible and professional manner over all these years.
Our Dental Director Dr. … requested to write this message and send it to your office as soon as possible.
Notice of Proposed Adjustments to Fees, Rates or Charges for the Medical Policy Fee Review of the following: B(1) Collaborative Care Model – G0512, B(2) Dental, B(4) Q Codes, B(5) Sleep Studies, B(6) Certified Family Partners March 01, 2025
Notice of Proposed Adjustments to Fees, Rates or Charges for the Medical Policy Fee Review of the following: B(1) Collaborative Care Model – G0512, B(2) Dental, B(4) Q Codes, B(5) Sleep Studies, B(6) Certified Family Partners
03-01-2025-adj-fee-cocm-dental-qcodes-sleepstudies-cert-fam-part.pdf (602.89 KB)
We hope all this is only informative for the coming fees review meeting – November 12, 2024 – and your office and our TEXAS Legislators have a different plan already in mind to give us a great positive outcome with a substantial fee increment in order to balance our operational costs and to help to fight against Inflation same as other States legislators have approved and informed their providers for the well being of their patients.
As general information the inflation rate over the last 10 years has been 45.51%. How come Medicaid providers are going to survive/operate with an overall 2% increment on dental Fees? Source: http://www.data.bls.gov.
We look forward to hearing from you soon and we pray to God to guide our legislators and Texas Health and Human Services Commision to do and make their best to take a clever decision for the good of the State, patients, and dentists.
Cordially,
What can you do
There is a public hearing coming up on November 12. You can read about this in the review document introduction below.
We will do a separate article on this later in the week.
Both the House and the Senate of the great state of Texas are controlled by Republicans who don’t give a hoot about health care for the lower income people. Their only concern seems to be tax cuts for the rich. Texas has a surplus does it not? Then what do the legislature do with all that money? Oh yeah, Abbott spent $148 millions since 2022 flying immigrants to other states. That money could have been better use for the citizen of Texas, no? I do hospital dentistry in North Texas. They have flown patient in from as far as Midland/Odessa for me to evaluate for dental rehab. But then they denied coverage. Then why fly them all the way here? Just to show that “oh we did something”??? What a bunch of crock! This had happened more than a few times. So frustrated with the system, and feel so bad for the families of special needs patients/medically compromised patients.
The prices paid by dental insurers for Medicaid have not risen in many years, but our taxes, supplies, staff salaries sure have. I certainly have felt the pinch of the policies over the last few years. Insurance companies are making money but not enough in their minds to warrant increasing useable fees that are used daily in my office. It’s no wonder many dentists don’t want to accept Medicaid.
I’m closing my rural Medicaid pediatric office next year. It’s become impossible to run a dental practice in this environment. Supply costs have doubled, staff are demanding higher wages, and while they raise select fees by a mere 4-9%, they’ve lowered D0145 by 61%. Message received. I’m closing my doors.
It would be nice if your comments were not politically damning. It takes away from the topic at hand and leads readers to believe your message is less than credible.
There were no political comments in the article.
She is referring to the first comment by CT
She is referring to the first comment by CT