红领巾瓜报 Spotlight
Supporting Medicaid Dental Benefit Administrators: Oral health and dental care are vital for the health of communities听
Whether performing under risk-based prepaid ambulatory health plan (PAHP) contracts or non-risk (administrative service organizations), Medicaid dental managed care organizations (MCOs) and dental benefit administrators (DBAs) face the same challenges as Medicaid MCOs, and state Medicaid agencies, including but not limited to:
Getting into and staying in compliance with state regulatory and contract requirements
Understanding and responding to new federal and state rules and regulations
Growing market share including success in state procurements, in MCO solicitations for DBAs, and attracting and retaining enrollees
Improving utilization to meet quality measure targets, medical loss ratios, and margin expectations including increased utilization of preventive oral health care, and decreased utilization of unnecessary care such as avoidable emergency room care for dental diagnoses
Excelling in benefit administration operations including member services and engagement, provider network development and provider services, claim/encounter administration, reporting, and other functional areas
Managing financial risk including developing or validating capitation rates and developing value-based payment arrangements
The importance of oral health and dental care
Oral health is integral to the overall health and quality of an individual鈥檚 life, and lack of access to oral health care negatively impacts entire populations.
Tooth decay affects 90% of adults 20 to 64 years of age and costs the U.S. about $45.9B in lost productivity in 2015. This frequently results in visits to hospital emergency rooms where care is often palliative but does not treat the root cause of problems1
Gum disease affects almost 50% of adults 45 to 64 years of age and is a risk factor for nearly 60 other adverse health conditions, including Alzheimer鈥檚 disease, diabetes, and heart disease2
More than half of working-age adults living in poverty have untreated caries (52%), whereas only 1 out of 5 adults with incomes of twice the federal poverty guideline or higher have untreated caries (20%)3
Tooth decay is preventable but impacts nearly 46% of U.S. children. Left untreated, tooth decay can cause chronic pain, impaired development, disfiguration, and social isolation. In severe cases, bacteria from a tooth infection can even travel to the brain and cause death. Caries disproportionately affect children who experience poverty, belong to certain racial and ethnic groups, or are affected by other social factors4
OUR EXPERTISE
At 红领巾瓜报, our consultants have led MCOs, state Medicaid agencies, and include senior officials from Medicare, directors of large nonprofit and social services organizations, top-level advisors, C-level executives at hospitals, health systems and health plans, and senior-level physicians. We know that oral health, access to dental care, and oral health literacy play a vital role in the health of communities supported by Medicaid MCOs. 红领巾瓜报 can support the work that DBAs do and the challenges they face in the changing Medicaid environment.
How 红领巾瓜报 can help
红领巾瓜报 has decades of experience working with Medicaid MCOs, DBAs, state Medicaid agency dental policy makers, and oral health providers. 红领巾瓜报 can:
Provide actionable insights into new federal and state regulations and guidance to help clients understand potential impacts and opportunities for their business. We assist clients to determine what must be done, what can be done, and develop recommendations for what should be done, and to implement those activities. DBAs are frequently performing as PAHPs and are subject to many of the federal rules related to interoperability, prior authorization, access, and eligibility that apply to Medicaid MCOs. 红领巾瓜报 provides our Medicaid provider and payer clients with analyses about those rules, which could also benefit DBAs.
Perform validation and compliance support to help clients identify and address any compliance gaps and support clients in validating their own compliance with any state or MCO imposed Corrective Action Plans. We also support clients to grow and strengthen their own capabilities and infrastructure to perform these functions.
Support client growth with end-to-end procurement assistance, including market conditioning and strategy, writing, mock scoring, orals preparation, implementation, and operations stabilization assistance; and with market analysis.
Support delivery system, reimbursement, and provider network design by conducting research and analysis on oral health delivery system approaches, provider reimbursement structures, coverage, and access trends.
Identify, assess, and help implement best practices in oral health care programs related to special populations, including children鈥檚 access to oral health care and dental access in rural communities.
Support quality improvement and utilization management initiatives that increase appropriate and desired utilization and curb inappropriate utilization. This can include help achieving Healthcare Effectiveness Data and Information Set (HEDIS) measure goals and developing oral health literacy programs, achieving accreditation, developing and implementing Performance Improvement Plans (PIPs), and conducting data analysis to understand utilization and evaluate the impact of program changes on utilization.
Provide actuarial services in support of benefit and program design, capitation rate development, and capitation rate validation.
Design and evaluate value-based payment models that tie provider payments to quality and value.
Project spotlight
Minnesota Medicaid Dental Program Study
The 2021 Minnesota Legislature directed the Department of Human Services (DHS) to conduct a review of Medicaid dental program delivery systems in states that have enacted and implemented a 鈥渃arve out鈥� dental delivery system. This legislation also directed DHS to conduct an analysis of dental provider hesitancy to participate in the Medical Assistance (MA) program as an enrolled provider. DHS contracted with 红领巾瓜报 to conduct the analyses mandated in the legislation. 红领巾瓜报 reviewed the Medicaid dental program delivery systems in states that have implemented a carve-out dental delivery system, including comparing state program designs, program costs and rates where available, and quality metrics for children one through 20 years of age with at least one preventive dental service within a year. 红领巾瓜报 also surveyed dental providers to better understand hesitancy to participate in Medicaid and opinions on policy approaches to improve provider participation.
The final report, available at , described the analysis of state dental carve-out experiences and the dental provider survey results.
Contact our experts:
Sarah Arvey
Associate Principal
Rebecca Kellenberg
Principal
Beth Kidder
Managing Principal
Stephen Palmer
Managing Principal
Caroline (Carrie) Rosenzweig
Principal
[1] Oral Health in America – April 2022 Bulletin, National Institute of Dental and Craniofacial Research, accessed 4/1/2025,
[2] Oral Health in America – April 2022 Bulletin, National Institute of Dental and Craniofacial Research, accessed 4/1/2025,
[3] National Institutes of Health. Oral Health in America: Advances and Challenges. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health, National Institute of Dental and Craniofacial Research, 2021,
[4] Big Hopes for Little Teeth, National Institute of Dental and Craniofacial Research, accessed 4/1/2025,
