The Louisiana Department of Health (LDH) may have a requirement for a Medicaid Dental Benefit Third Party Administrator (TPA).

The following information was sourced from the Request for Information (RFI) document and is subject to change upon the release of a formal solicitation.

The Louisiana Department of Health (LDH) is responsible for the administration of the Louisiana Medicaid program, serving over 1.6 million individuals across the state. Medicaid’s philosophy is to operate the Medicaid Program in a manner that achieves the Triple Aim of optimizing health system performance by improving patient experience of care, overall health and reduce the per capita cost. LDH envisions a future where everyone in Louisiana has the best care and health possible. Currently, dental services are administered through risk bearing Dental Benefit Program Managers. The State is evaluating the feasibility of transitioning to a centralized non-risk bearing Third Party Administrator (TPA) model. LDH seeks to explore this alternative model for the administration of State directed fee-for-service dental benefits for approximately 1.4 million eligible beneficiaries.

Medicaid’s dental program provides dental services to four populations:

1. EPSDT Dental – comprehensive dental benefits to individuals under the age of 21, as specified in LAC 50:XV.6901;
2. Adult Waiver – comprehensive dental benefits to individuals over 21 with intellectual/developmental disabilities (IDD) enrolled in the New Opportunities Waiver, Residential Options Waiver or Supports Waiver Programs, as specified in LAC 50:XXI.5721, LAC 50:XXI.16309 and LAC 50:XXI.13941;
3. Adult Intermediate Care Facility (ICF/IDD) – comprehensive dental services for individuals over 21 who reside in an ICF due to intellectual disability, as specified in LAC 50:VII.31105; and
4. Adult Denture Program – denture benefits for adults 21 and older, as specified in LAC 50:XXV.303.

The following information was sourced from the Request for Information (RFI) document and is subject to change upon the release of a formal solicitation.

LDH is considering contracting with a TPA to administer dental benefits for eligible Medicaid enrollees. Interested parties are requested to respond to the following items. Additional context is referenced in Section 2.3 Response Content:

Organizational Overview

• Executive Summary
• Corporate background and experience
• Brief history, ownership structure, and experience in administering Medicaid dental programs
• States currently serving as a dental TPA

Scope of Work

• Description of available services related to dental benefit administration
• Capacity to implement and manage large-scale dental programs
• Timeline to implement with a state Medicaid agency

Network Management

• Approach to recruiting and retaining dental providers, including specialists
• Strategies for increasing provider participation in underserved areas

Enrollee Services

• Description of administrative functionality to address beneficiary concerns and awareness of dental benefits.
• Describe resources for beneficiaries to access plan information, benefits, locate dentist and review claim history
• Capabilities to operate a beneficiary call center for the above-mentioned services and care coordination.

Claims Processing and Utilization Management

• Capabilities for timely and accurate claims adjudication
• Utilization review and cost containment strategies
• Description of service authorization process including clinical staffing requirements
• Capabilities to operate a provider call center for assisting with the above-mentioned services.

Care Coordination

• Approaches to integrate care coordination for medically complex, high-need, or special needs beneficiaries

Data and Technology

• Overview of data systems and interoperability with state systems
• Reporting capabilities and performance monitoring tools

Quality Improvement

• Experience with quality assurance programs and dental health outcomes
• Metrics used to evaluate program success

Compliance and Program Integrity

• Strategies for fraud, waste, and abuse prevention
• Mechanisms for regulatory compliance and audit readiness

Implementation and Transition Planning

• Timeline and methodology for transitioning from current administration to a TPA-led model
• Risk mitigation strategies

Cost Estimate

• Provide a general overview of your pricing model (e.g., subscription-based, per user, per transaction).
• Include any information regarding typical implementation and operations costs, as well as factors influencing them.
• Whenever possible, provide the responders proposed reimbursement structure broken out by programmatic component as stipulated in Attachment I.
• Cost consideration should be general and non-binding