02-031-835 Me. Code R. § 5

Current through 2024-46, November 13, 2024

Section 031-835-5 - Activities That Improve Dental Care Quality

1. A carrier that offers a dental plan shall receive credit under Subparagraph 6(1)(A)(2) for implementing and maintaining activities that improve dental care quality, and updating them in light of evidence-based developments in treatment. To qualify for recognition as activities that improve dental care quality, these activities must:

A. Improve oral and overall health and advance oral health quality, including increasing the likelihood of desired outcomes compared to a baseline; reducing dental disparities among specified populations; and improving patient safety, reducing medical errors, or lowering infection in ways that are capable of being objectively measured and of producing verifiable results;

B. Be directed toward individual enrollees, are incurred for the benefit of specified segments of enrollees, or provide oral health improvements to the population beyond those enrolled in coverage, as long as no credit is taken for additional costs incurred for the benefit of non-enrollees; and

C. Be grounded in the implementation, development, or improvement of evidence-based dental care, widely accepted best clinical practice, or criteria issued by recognized professional dental associations, accreditation bodies, government agencies, or other nationally recognized health care quality organizations.

2. Activities that improve dental care quality shall not include the following:

A. Activities relating to lines of business or products other than dental, including the pro rata share of expenditures relating to both dental and non-dental business;

B. Activities paid for with grant money or other funding separate from premium revenue;

C. Activities that can be billed or allocated by a provider for care delivery and are reimbursed as clinical services;

D. Activities giving rise to administrative cost expenditures, including, but not limited to:

(1) Activities designed primarily to control or contain costs;

(2) Establishing or maintaining a claims adjudication system, including upgrades in information technology that are designed primarily or solely to improve claims payment capabilities or to meet regulatory requirements for processing claims;

(3) Retrospective and concurrent utilization review, and any prospective utilization review that cannot be specifically justified as meeting the definition of "activities that improve dental care quality";

(4) Fraud prevention activities;

(5) Developing and executing provider contracts, including establishing or managing a provider network;

(6) Provider credentialing;

(7) Payroll, except for positions dedicated to activities that improve oral and overall health and the pro rata share of payroll for positions substantially involved in such activities;

(8) Marketing expenses; and

(9) Calculating and administering individual enrollee or employee incentives unless used in the promotion of activities that improve oral and overall health.

02-031 C.M.R. ch. 835, § 5