Medicaid must improve network adequacy standards, ADA council says

New assessment includes recommendations for follow-up activity

A report released by the ADA Council on Advocacy for Access and Prevention says that only seven states are meeting network adequacy for Medicaid and recommends the Association lead the charge to establish standards.

The report, along with its recommendations, were approved by the ADA Board of Trustees at its August board meeting

Network adequacy is a term commonly used to describe whether a plan has a sufficient number of providers that are in-network within the plan’s coverage area. In the case of Medicaid, this refers to a state’s or managed care organization’s ability to have a sufficient number of credentialed Medicaid providers that can provide services for all eligible Medicaid beneficiaries.

The report came as a result of a House Resolution 520H approved at the 2024 House of Delegates that asked the ADA Board of Trustees to determine whether the Center for Medicare and Medicaid Services had failed to enforce compliance with the portion of the Medicaid Act that says payments should be sufficient to enlist enough providers so that care and services are available under the plan. In response, the council worked with an external entity to complete a comprehensive survey of Medicaid networks for dental service and analyze the Centers for Medicare & and Medicaid Services’ enforcement of the Medicaid Act to present to the ADA Board of Trustees.

The report’s conclusion was that CMS has not enforced compliance. This is largely due to different interpretations of the law between presidential administrations and managed care organizations, according to the council.

 “We have known for many years that access to dental care has been hindered for Medicaid beneficiaries due to the lack of providers who are able to serve and treat Medicaid beneficiaries,” said Jessica Robertson, D.M.S., council chair. “Remedies such as increased reimbursement and reducing undue administrative burden can help incentivize providers to participate in the program. This report demonstrates that these remedies are often not pursued by states to fix network adequacy as there is a lack of enforcement at the federal level.”

The council recommended a series of future actions for the ADA, which included:

• The ADA leading the establishment of scientifically sound network adequacy standards that can be enforced to avoid “ghost networks”/insufficient networks. Adequacy can be assessed by how long it takes a patient to travel to their dentist; the distance to the provider; appointment wait times; the percentage of beneficiaries receiving an exam; or validated access measures.

• The ADA advocating through legislative action that CMS adopt ADA’s developed network adequacy standards given the mixed interpretation by differing administrations.

• The ADA continuing its Medicaid Pilot Project to address the implementation of ADA-developed network adequacy standards and increase the number of states meeting network adequacy increases from seven to 15 by 2030.

• The ADA working with state dental associations to establish Medicaid provider public policy advocates to support a roster across all 50 states.

• The ADA ensuring medical loss ratio reporting, with managed care organizations clearly distinguishes dental from medical services, requiring that 85% of Medicaid dental funds are spent on dental care.

The report’s finding and recommendations is available at ADA.org/networkadequacy.