Medicaid & Medicare Advantage Services for States & Health Plans

Operations

Every aspect of our work is driven by our three corporate values: do the right thing, people count, and we hold ourselves to high standards. This is particularly true for our government operations team, made up of nearly 550 U.S.-based employees who manage core administrative functions like claims processing, utilization review, multi-lingual contact center, and HIPAA-compliant portals.

Clinical

We do the right thing, which means managing dental and eye care benefits to help ensure your  members achieve optimal health. Every day, licensed clinicians in the office and in the field help ensure the care your members receive is compliant with state and federal standards, as well as your benefit plans and clinical goals.

Network

The success of the Medicaid and Medicare Advantage programs we help manage is built on the strength of our provider networks. All are fully compliant with state and federal requirements for government programs, meeting credentialing, access, and appointment standards. With our commercial networks as our starting point, we can build networks in all 50 states.

See Who We Serve with Medicaid & Medicare Advantage Programs

Medicaid and Medicare Advantage dental and eye care services are managed by our wholly owned subsidiary Avēsis in collaboration with our wholly owned subsidiaries Premier Access Insurance Company and Access Dental Plan. These teams came together in 2017 to create a simplified operational model staffed by dedicated leaders who have an average of more than 20 years of market experience.

Today we efficiently manage care for more than 6.8 million covered lives through our contracts with states and health plans. Our team helps ensure our clients meet their regulatory obligations, while satisfying network providers, reducing costs, and contributing to the improvement of the country's overall health.

Through our wholly owned subsidiary, Access Dental Plan, we have held Medicaid contracts with the State of California since 1994. For more than a quarter of a century, we have annually managed dental benefits for more than 250,000 people enrolled in the Sacramento-based Geographic Management Care (GMC) and the LA Prepaid Health Plan (LAPHP).

Our California programs are incubators for the development of innovative and culturally competent outreach strategies intended to connect with the diverse populations that make up our membership such as:

  • Microtargeted, bilingual phone and text messaging that significantly increases appointment completion
  • Virtual dental home programs implemented through school partnerships
  • Value-based quality incentives that result in triple digit increases in preventive utilization

Each of the Medicaid managed care plans we serve in Kentucky trust us to manage both dental and eye care benefits for their members. With more than half of the Kentucky market on our integrated platform, we set the standards for Medicaid dental and eye care processing in the Commonwealth. Examples include:

  • Writing the silver diamine fluoride guidelines and related processes now in use by most Kentucky Medicaid managed care plans
  • Advising the Commonwealth on the implementation of telehealth regulations
  • Introducing telehealth initiatives to help federal qualified community health centers expand their ancillary care capacities
  • Introducing a dental opioid prescription monitoring program that reduced non-compliant prescription rates by 70 percent in six months
  • Increasing annual diabetic retinopathy exam (DRE) completion rates through portable, home-based care

More than 1,500 Guardian employees live in Pennsylvania, making this an important market for our team. We currently manage dental benefits for more than one million Medicaid members, and more than 100,000 Medicare Advantage enrollees. Our accomplishments include:

  • Helping one health plan achieve their HEDIS annual dental visit (ADV) goal using a dental home
  • Ensuring access to care by maintaining a provider to member ratio of 1:114
  • Increasing oral health literacy of 126,000 children in 5,000 K-3 Title I classrooms through our corporate partnership with the Children’s Health Fund and Scholastic

Through our wholly owned subsidiary Premier Access Insurance Company, we have held a contract with the State of Utah since 2010. Today we manage care for more than 150,000 Utahns who qualify for Medicaid or CHIP benefits across the state.

Our accomplishments include:

  • Earning the NCQA HEDIS Compliance™ seal in 2019 and 2020
  • Continuously achieving HEDIS annual dental visits above the state average  
  • Assisting the Utah Department of Health with an expansion of dental managed care statewide without compromising access or operational efficiency
  • Supporting Utah Oral Health Coalition’s efforts to assess and improve oral health literacy of Medicaid and CHIP members statewide

Explore Our Impact in Medicaid & Medicare Advantage

When we ask our state and health plan clients how we can help, they tell us:

  • Engage members in their own care
  • Satisfy network dentists and eye health providers
  • Reduce government healthcare costs
  • Improve oral, ocular, and overall health

These activities make up the Quadruple Aim, a framework we use to build government healthcare programs that help you improve the health of your enrollees and their communities.  

Ensuring that members get the right care at the right time in the right place is our priority. Our teams work together to emphasize the importance of prevention, provide follow-up reminders, and help remove barriers to care such as language and transportation. We keep members with special healthcare needs (SHCN) top of mind, including people with comorbid conditions such as pregnancy and diabetes.

One example is in the Medicaid dental contract we manage for the State of California.

In our California Medicaid dental market, we wanted to improve preventive visits among some of our members with special health care needs. We used automated bilingual calls to reach parents and guardians of Medicaid members who had not visited the dentist recently, according to our records. During this call, the parent or guardian was given the option to receive live, bilingual help with making an appointment. Our results showed that those who take advantage of the live appointment assistance were more likely to make—and keep— their child’s dental appointment within three months. This increase was seen for children of all ages—from newborn to age 20.

In order to help achieve your goals for member access, we need a stable and satisfied network. Our provider-centric, local network management model puts providers in the hands of our experienced clinical leaders. We also offer peer-to-peer consultation with trained, licensed clinicians and office support delivered by provider relations professionals with real-world clinical and office experience.

One example is in the Medicaid dental contract we manage for the State of Utah.

In 2017, an analysis of our Utah Medicaid/CHIP prior authorization data revealed that the scoring of the required orthodontic index was inconsistent among providers. We engaged in provider outreach with  several rounds of phone calls and emails, and  brought the Clinical Director of Utilization Management, to Utah for two in-person presentations  on index scoring and claims submissions. Providers were then encouraged to participate in the Q&A sessions that followed, allowing participants hands-on experience with the scoring process before the meeting ended. The result was an improvement in prior authorization submissions, which helped increase provider satisfaction and reduced delays in the onset of treatment.

Healthcare costs continue to rise, putting more pressure on our state and health plan clients to be good stewards of the taxpayer dollars that support Medicaid and Medicare. We’re here to help by emphasizing the value of preventive care; reducing fraud, waste, and abuse; and carefully managing high-cost services.

One example is in our Georgia Medicaid market.

Our IV Sedation program provides the option to move dental patients out of the hospital or ambulatory surgical center for surgical procedures and returns them to their communities for lower cost treatment through mobile sedation services arranged in a dental practice setting . In our Georgia Medicaid market, over a three-month period in 2019, 708 dental procedures were arranged out of the hospital and into a dental office setting , saving our health plan clients an average of $6,889 per visit or $4.9M in all.

Dental and eye care are important and only address a small part of the body. We help by integrating our clinical management programs with other disease management and health improvement efforts, like assisting our health plan partners in diagnosing and managing diabetes and reducing opioid prescription rates. 

One example is in our Kentucky Medicaid market.

In our Kentucky Medicaid dental market, where we manage dental benefits for 80 percent of the market, our prescribing program reduced the number of  dentists writing opioid prescriptions at rates that exceed the state’s recommended guidelines. In just six months, we reduced the number of high prescribers by 70 percent.

Discover Our Innovative Medicaid & Medicare Advantage Value-Add Programs

We put people first—from members to providers—to coordinate quality care that can be simple to administer and can help lower overall costs. With 25 years of experience in the government dental and eye care markets, we’ve developed innovative ways to connect enrollees to care, facilitate treatment of complications of diabetes, and expand access for underserved populations. These programs help us help our clients engage members, satisfy providers, save money, and improve overall health.

Download our Innovative Programs Guide to learn more

We connect network dentists and eye care providers to members who may need help getting access to care. Programs we can adapt to your market include:

Learn more

We focus on early diagnosis and prevention to reduce costs and improve member health. Programs we can adapt to your market include:

Learn more

We focus on early diagnosis and prevention to reduce costs and improve member health. Programs we can adapt to your market include:

Learn more

Disclaimer

Medicaid, CHIP, and Medicare Advantage dental, eye care, and hearing care programs are made available through government contracts awarded to Guardian or its subsidiaries. These contracts are administered by Avēsis Third Party Administrators, Inc., for Guardian. Avēsis is a wholly owned subsidiary of Guardian. Guardian® is a registered trademark of The Guardian Life Insurance Company of America, New York, NY.

2021-118366 20230731