Incurred Medical Expenses - Association of State and Territorial

Welcome and Introductions
Linda Ferraro, RDH, BS
Director, Office of Oral Health, Connecticut
Department of Public Health
Chair, ASTDD Healthy Aging Committee
General Reminders
• Please mute your phone by pressing *6 or
your “Mute” button;
• Webinar will be recorded and archived on
the ASTDD website;
• Questions may be entered into the chat
box and will be addressed after the
speakers are done;
• Please respond to the 3 polling questions
at the conclusion of the webinar.
Purpose of the Webinar
• Nursing facility residents enrolled in Medicaid
can pay for non-covered dental services. This
webinar will provide information about how this
can work using the Incurred Medical Expense
(IME) regulations.
• You may find How-to Guides at:
Today’s Topics
What is IME and how does it work?
IME in practice – case examples
Who needs to be at the table?
Audience questions and comments
Three Related Webinars:
• September 2012 – ADA webinar for dentists
• Today’s webinar – State Dental Directors and
State Medicaid Directors
• Spring 2013 – American Health Care Assoc.
webinar for long-term care administrators and
IME Collaboration
• Mary E. Foley, MPH
Executive Director
Medicaid-CHIP State Dental Assoc.
Medicaid & State Oral Health Programs
Incurred Medical Expense
• Contact your state Medicaid Dental
Program Director/Manager;
• Identify the IME Program lead;
• Explore current program guidelines;
• Identify any policies specific to dental care;
• Collaborate with both the Medicaid dental
and IME programs in establishing next
steps and opportunities for promotion.
Mary Foley
Importance of Dentistry
in Long-term Care
• Sandra Fitzler, RN
Senior Director of Clinical Service
American Health Care Association
Why is dental care needed in nursing facilities?
1. Residents in nursing homes need care
Long-term care facilities are aware of this
They are actually required to provide that care
Dental services can be considered an “incurred
medical expense” under federal regulations
2. Dentists want to provide residents with care
3. However, limited finances are a significant
barrier to care
Federal Regulations related to IME
Go to:
There are financial solutions!
• Incurred Medical Expense (IME) is a
reimbursement mechanism that can be
used for dental services.
• Most nursing facility residents who are
enrolled in Medicaid can pay for dental care
using their Social Security or other
retirement income.
• This mechanism has been in use in many
states for more than a decade.
What is “IME”
how does it work?
• Michael Helgeson, DDS
Chief Executive Officer
Apple Tree Dental
What is the definition of “IME?”
• Incurred Medical Expenses
• IME include medically necessary health
services that are NOT covered by Medicaid,
such as glasses, hearing aides and dental care.
• Laws governing IME permit Medicaid
recipients to use their Social Security income
to pay for Incurred Medical Expenses through
an approval process involving county case
How does this payment process work?
• Residents’ Social Security and other
retirement income arrives monthly even
when they are enrolled in Medicaid.
• This income is generally used to pay the
nursing facility’s bill each month, with
Medicaid paying any remaining balance.
• Under federal laws, this monthly income can
be used to pay for medically necessary
health care, including dental care.
How-to guide for Incurred Medical
• ADA’s How-to Guide:
The How-to Guides target three audiences
 Dental professionals
 Nursing facility
residents and their
 State and county
Medicaid caseworkers
How does IME work for dental professionals?
IME provides a way for dental professionals to
be paid for dental services NOT covered by their
state’s adult dental Medicaid program.
How does IME work for county case workers?
•IME approval processes are usually in place, but
may not be routinely used for dental services in
some states or counties. Education and/or training
may be needed.
IME: Two Sample Cases
Gregory Folse, DDS
Outreach Dentistry
Case #1: Miss Sylvia Simple
• For her income and insurance
– She receives $1,200 per month from Social
Security and has no other retirement income.
– She is on Medicaid, but in her state Medicaid
doesn’t cover adult dental benefits.
– This makes all medically necessary dental
benefits eligible to be paid using IME
• Her dental needs are simple…
– She needs only an exam and preventive care.
– Her total dental bill is $200.
Case #1: Miss Sylvia Simple
• The Dentist:
– Performs the services;
– Creates a dental bill for the balance of $200
and provides it to Miss Simple’s financial
overseer; (Miss Simple, her responsible party,
or the nursing facility.)
– Forwards the dental bill to her Medicaid case
Case #1: Miss Sylvia Simple
• The Case Worker:
– Instructs Miss Simple’s financial overseer
(Miss Simple, her responsible party, or the
nursing facility) to pay $200 to the dentist and
$1,000 to the nursing facility from the next
$1,200 Social Security check;
– Authorizes Medicaid to pay the facility $200
more, so the nursing facility bill is paid in full.
Case #2: Miss Cathy Complex
• For Her Income and Insurance:
– She receives $1,000 per month from Social
Security and other retirement income;
– She is on Medicaid, and her state has
LIMITED adult dental Medicaid benefits
(extractions only);
– The services not covered by Medicaid can be
billed using the IME mechanism;
– The services covered by Medicaid must be
billed to Medicaid.
Case #2: Miss Cathy Complex
• Her dental need are more complex:
– She needs diagnostic, preventive, restorative,
surgical and denture services;
– Her total dental bill is $3,000
• $2,500 are IME eligible
• $500 are Medicaid eligible services
Case #2: Miss Cathy Complex
• To Bill
– Requires the dentist to use two different billing
• Non-covered services through IME
• Covered services through Medicaid
– IME eligible fees totaling $2,500 are greater
than one month of her retirement income
($1,000 per month) so these fees will be paid
over time.
Case #2: Miss Cathy Complex
• To Bill
– For Medicaid services the dentist:
• Must be enrolled as a Medicaid provider or,
• May provide those covered services pro-bono.
– Medicaid eligible fees are billed directly to
Dental Medicaid.
Case #2: Miss Cathy Complex
• The Dentist:
– Performs the services;
– For IME services, creates a dental bill for
$2,500 and provides it to Cathy’s financial
overseer (Cathy, her responsible party, or the
nursing facility);
– Forwards the IME eligible dental bill to her
Medicaid case worker;
– Bills $500 directly to Medicaid for Medicaid
eligible services.
Case #2: Miss Cathy Complex
• The Case Worker:
– Instructs Cathy’s financial overseer to pay
$1,000 for 2 months and $500 for one month
to the dentist in order to pay the entire $2,500
IME bill;
– Authorizes Medicaid to pay the facility $1,000
more for 2 months and $500 more for one
month so the nursing facility bill is paid in full.
Who Needs to be Engaged
in the IME Process?
• Sarah J. Dirks, DDS
Geriatric Dental Group of South Texas, PA
Who Can Assist You With IME
• Dentists Currently Using IME To Fund
Dental Service
• Nursing Facility Staff
• Nursing Facility Medicaid Case Workers
• State IME Procedural Contacts
• State Dental Director
• State Medicaid Dental Director
What Nursing Facility (NF) Staff
Need To Know To Support Oral
Health Services Through IME
Adjustments (IME A’s)
NF administrators, social workers and
business managers should understand:
• IME A’s can provide critical oral health
services to their residents.
• IME A’s are critical to Regulatory
Compliance and Survey Success.
NF Administrators:
• Should realize IME A’s improve both the
oral health of their residents and the
regulatory compliance of their facility.
• The business manager and social worker
will need time to work on the IME A’s.
NF Social Workers:
• Should be able to communicate the IME
process to residents and their families.
NF Business Managers:
• Will need to provide income information to
dentists prior to treatment.
• Will need to assist dentists, patients, and
families with processing IME A’s.
Considerations in Moving
• The IME process is Federal Law and likely
being used for other medical expenses
such as glasses, wheelchairs, hearing
aids, etc.
• Your state may be using Federal IME
policy or may have it’s own protocols.
To Identify Current IME State
• Nursing facility business managers and
state Medicaid case workers are the best
people to answer existing protocol
questions such as:
– What is our state’s specific
procedures/policies to utilize the IME process
for other medically necessary expenses such
as glasses and hearing aids?
– Has our state utilized the IME process for
medically necessary dental expenses?
Questions to Ask the Nursing
Facility Business Manager to
Start Care for a Patient:
• Does Ms. Jones have income available for
IME A’s?
• Who is Ms. Jones’ Medicaid Case
Questions to Ask the Medicaid
Case Worker to Start Care for a
• What specific paperwork is needed in
order to process a resident’s IME A for
their needed medically necessary dental
• How does our state notify the LTC facility
and dentist that the IME adjustments have
been made?
Practical Issues:
• High turnover of NF staff can complicate
the continuity of the IME process.
• Payment of dental bill is not “guaranteed.”
– NF residents must be “current” with their
monthly payments to nursing facility.
– If NF residents leave the NF or expire before
IME A is processed and paid; no payments
will be received as no income is available to
pay for the care provided.
Final Thoughts:
• The determination of the medical
necessity of dental care is best done by a
• All medically appropriate dental services
for NF residents are medically necessary.
• If problems arise with the IME process a
meeting of all IME stakeholders in a given
state may be advised.
Frequently Asked Questions
• Is this IME billing process a “burden” or an
“opportunity” for dentists and facilities?
• How long does it typically take for the
dentist to receive payment?
• How can the billing workflow be optimized
for the nursing facility and dental staff
Thank You!
• Our speakers will now respond to
questions submitted via the chat box.
• Please remember to respond to the 3
survey questions at the conclusion of the
session so that we may better serve you.

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