Oral Care for Residents in Long Term Care Facilities in Texas: Financial Barriers

1. Oral Care for Residents in Long Term Care Facilities in Texas:Financial Barriers Lynn Nolf Estrada, Administrator Geriatric Dental Group of South Texas San Antonio, TX

2. Learning Objectives • To understand who is eligible for each program • To recognize the required forms needed for each program • To understand the required processes for each program • Recognize the pitfalls that can endanger the successful utilization of each program

3. Financial Options for Senior Care • Form H1263-B Medicaid Process • Full Vendor Program • Self-pay

4. Form H1263-B • Receive a completed Form H1263B from the nursing facility social worker • You must have original signature of the MD, DO, NP, PA or Clinical nurse specialist on the first page • The 2nd page needs the signature of the resident or their responsible party (RP) • The form must be entirely filled out. • The resident must reside in and a licensed Nursing Facility

5. Business Manager Checklist • Applied income • Nursing Home Medicaid #14 effective date • Medical POA or RP and their relation to the resident • Who manages the funding/trust • Spouse in the community • Good standing with the facility • Hospice

6. Verified Eligibility • Contact the nurse and request the following: • Face Sheet • MARs (Medical Administration Resources) • Advance Directive • History & Physical • Most recent lab work • Set appointment with the nurse • Courtesy call to the RP

7. Initial dental appointment Develop treatment plan based upon the findings from: • Complete Oral Examination • Full Mouth X-rays / Panorex • Debridement

8. RP Consents • Contact the Responsible Party for consents • Treatment Plan • Oral Surgery Consents • Bisphosphonate Consents • Sedation, etc • Memorandum of Understanding

9. Completed Treatment Once the medically necessary treatment has been completed. Submit the claim to the Nursing Facility ME worker • Mail original Form H1263-B • Itemized Claim form of all completed treatment • Date • ADA Code • Fee *Average processing time is about 30 to 45 days

10. Income Adjustment • The ME worker approves treatment • The adjustment is entered in the MESAV system • The MESAV reflects the increase in funds available • This notifies the nursing facility of an approval • The practice will receive one or two forms showing the approval. This notifies us of the billing direction.

11. 3 possibilities for payments • Form H1259 – Back-dated payments will come from the nursing facility • Forms H1259 AND H4808 – a mixture of back-dated funds from the NF and future monthly payments from the fund manager • Form H4808 – Payments to come in consecutive monthly intervals ** Form H1259 changing to H1053

12. Billing Form H1259 • Bill the nursing facility • Statement • Itemized Invoice • Copy of the 1259 Form H4808 • Bill the Responsible Party • Statement

13. Additional forms • H1052-IME • Action Needed • Signatures missing • Signature not original • Description of signer • Coding incorrect, etc • H1054-IME • Proof Needed • Questionable treatment rendered. State requesting verification that treatment was received.

14. Full Vendor Program Eligibility • There is no applied income (their SSI is =/< $60 per month) • Nursing Facility Medicaid #14 • Must be in dental pain • Reside in a licensed Nursing Facility

15. Necessary Full Vendor Forms • Form 2463 • Physician Order stating “Dental Pain” • Itemized invoice from the dental office ** There is a 1 year submission deadline.

16. Full Vendor fee schedule Dental Codes and Rates D0140 Emergency Oral Exam $19.16 D9110 Emergency Palliative Exam $18.75 D0220 X-Rays First Exam $12.82 D0230 X-Rays Second and Each Film $11.74 D7140 Simple Extraction Single Tooth $67.04 D7250 Extraction Root Removal – Exposed Roots $92.50 D7210 Surgical Removal of Erupted Tooth $102.81 D7220 Removal of Impacted Tooth-Soft Tissue $157.50 D7230 Removal of Impacted Tooth – Partially Bony $180.00 D7240 Removal of Impacted Tooth – Completely Bony $300.00 D7241 Removal of Impacted Tooth – Completely Bony with Complications $156.25 D7250 Surgical Removal of Resident Tooth Roots $92.50 D7510 Incision and Drainage of Abscess-Intraoral Soft Tissue $37.50 D7520 Incision and Drainage of Abscess-Exta oral Soft Tissue $125.00 D9215 Local Anesthesia $12.50 D9220 General Anesthesia – First 30 Minutes $87.50 D9221 General Anesthesia – Each Additional 15 Minutes $31.25

17. Self Pay • Resident has no Medicaid or the Medicaid is pending • Work with the trust fund manager • Credit card/checks • CareCredit • Once Medicaid is approved, if it is retro-dated, you can submit the Form H1263-B for their reimbursement

18. Thank you! Lynn Nolf Estrada, Administrator Phone: 210.617.4446 Fax: 210.617.5572 admin @ geriatricdentalgroup.com www.geriatricdentalgroup.com