Texas Health and Human Services Provider Finance has released its fees for dental Medicaid codes for 2025, according to an Oct. 23 report by Texas Dentists for Medicaid Reform.
Here are five things to know:
1. The fee for code D0145: oral evaluation will be $54.58 in 2025, down from $142.07 in 2024.
2. The fee for code D0160: exam will be $41.25 in 2025, up from $35.32 in 2024.
3. Other commonly used codes, including D1110, D1120, D2391, D2392, D0210 and D2930, will remain the same in 2025 as they were in 2024.
4. The updated fees take effect March 1, 2025.
5. View the full report here.
Source: Texas dental Medicaid program announces 2025 rates: 5 things to know / Becker’s Dental + DSO Review
This past week was rough for Texas Medicaid Providers.
First hearing that Dentaquest is violating the mandate for full “Access to care” for children was rough. Second hearing the fee’s for 2025 did not move and many respects despite record inflation were reduced.
A few thoughts and concerns that I think the Medicaid provider community needs to address.
First: When decisions are made by Texas HHSC, where are the dental voices. Every time a decision by HHSC is made, it seems the treating dental community nor the patients receiving the care are consulted. It appears the only voices heard or sought after are the DMO’s. The DMO’s are not in the trenches and have no idea the concerns and struggles of the providers and their patients.
For HHSC to reduce the D0145 fee to $54 from $152 is criminal. Not because the fee went down by 200%, but because years ago providers and the state sought desperately to treat the under 3 population better and to get them better dental care and more comprehensive care. The first dental home visit was created because if you teach kids early, and catch early childhood caries early, you can help prevent a lifetime of dental problems. There are forms and a long list of criteria that is addressed on each visit. The program has not only been a comprehensive preventive stroke of genius, but has been very effective . It gave the provider a fair fee and the ability to spend the time necessary to provide comprehensive care to those under three. All this work has been forgotten, because the only voice HHSC is hearing is the voice of DMO’s.
Second: It is my understanding the manifesto, goal, and aim of the program is dental access to care, and utilization of dental preventive services. It is a given that quality of care, and medical necessity of care also goes hand in hand with these objectives. If the number one goal of the program is access to care, and the utilization rates still are not 100%, how does any intermediary begin to limit number of providers, thus automatically reducing access to care. Does Texas have 100% utilization every six months? No. Was HHSC consulted on this decision? Were the dental providers consulted on this decision? How was this decision made when it violates the very purpose of the Medicaid dental program and the legislative mandates of the state. The very dentists who helped bring the utilization numbers up over the past few years, are now being punished for executing the states stated and mandated goals and objectives. The very DMO who has pushed us to increase access to care and utilization of preventive services no reverses on those legal mandates in Texas? How does that happen?
Third: When providers invest in Texas Medicaid dentistry they are making a huge commitment. A commitment to invest and spend hundreds of thousands of dollars and even millions to serve in low income and underserved areas. This is risky because fees are low and generally multi-provider offices are a must to survive the lower fees. The risk is exacerbated when companies like Dentaquest come in and do the bait and switch.
The bait and switch is please sign up we need you, please commit to us, invest heavily in these areas, and then when you are fully invested the veiled threats come through targeted reduced fee’s, down-coding procedures, audits, rejected pre-authorizations, their expert stating treatment not medically necessary, and frequent changes like not paying for appropriate two surface restorations.
Providers have had eighteen years of consistent, inconcistency. The program can be a win/win, certainly not a windfall. If a company like Dentaquest comes in and penalizes all these dental investments and providers in these low income areas, the long-term trust is broken and providers will disappear and the program will suffer. Dentists will always come in, but with embarrassing fee’s there will be fraud and the quality of care will bottom out. This is the ebb and flow when DMO’s only see the need to fatten their pockets and forget about the real goals of the program. Don’t penalize good providers who have helped the state to meet their stated goals.
Fourth: The realistic. Fee’s are bad. This doesn’t mean start over. It means get a committee of providers and get experts (not DMO’s). DMO’s continue to show HHSC that some fee’s are great, when they really are not (like fees on gold crowns, which cost more to make than than you get paid, and you have to do them because the PFM fee is so low: how has that gone on so long). There simply is an ignorance with HHSC, when they have no provider voices on their committee’s. We need more communication. We are out of the loop.
HHSC needs to approach providers with a win/win and adjust the fee’s at least with inflation. We have suffered for the last four years. There is mounds of evidence on that. To come in with no positive adjustment in fee’s just shows an agency that is out of touch with their program and providers and legislative goals. Can the providers please have a voice at the Texas table so that we can operate at least at a win/second place instead of a win/lose?
It has become increasingly difficult to provide proper basic care for individuals on Medicaid due to a reduction in coverage benefits. More than ever, patients have been unable to afford extractions during pregnancy or afford an incision and drainage, which can lead to life-threatening events such as endocarditis, Ludwig angina, etc. I have seen patients with reduced bone and inability to receive proper dentures and not wear their denture due to lack of coverage of implants. Patients, as a result, have lost excessive weight where they basic need of nutrition is compromised. DHMO plans due not provide access to care. Instead, they make dentistry look like we have not invested time, effort, and money just to learn how to treat these patients