DAR File No. 32625

Health, Health Care Financing, Coverage and Reimbursement Policy

R414-51

Dental, Orthodontia

NOTICE OF PROPOSED RULE

DAR File No.: 32625
Filed: 04/30/2009, 04:26
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to comply with budget reduction mandates set forth in the 2009 General Session of the Utah Legislature.

Summary of the rule or change:

This change allows only pregnant women and individuals eligible under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program to receive dental and orthodontia services. It also removes one of the limitations for these services.

State statutory or constitutional authorization for this rule:

Sections 26-1-5 and 26-18-3

Anticipated cost or savings to:

the state budget:

The reduction of orthodontia services will result in savings to the General Fund and to the federal budget. Estimates of these savings are listed in the companion filing to this proposed rule (Rule R414-49). (DAR NOTE: The proposed amendment to Rule R414-49 is under DAR No. 32617 in this issue, May 15, 2009, of the Bulletin.)

local governments:

There is no budget impact because local governments do not fund or provide orthodontia services to Medicaid clients.

small businesses and persons other than businesses:

The Department estimates annual losses in revenue to providers of orthodontia services. Estimates of these savings are listed in the companion filing to this proposed rule (Rule R414-49).

Compliance costs for affected persons:

The annual loss in revenue to a single provider of orthodontia services is listed in the companion filing to this proposed rule (Rule R414-49).

Comments by the department head on the fiscal impact the rule may have on businesses:

The 2009 Legislature did not appropriate funds to permit continuation of these services. David N. Sundwall, MD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY UT 84116-3231

Direct questions regarding this rule to:

Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

06/15/2009

Interested persons may attend a public hearing regarding this rule:

5/26/2009 at 1:00 PM, Utah Department of Health, Cannon Health Building, 288 N 1460 W, Room 114, Salt Lake City, UT

This rule may become effective on:

07/01/2009

Authorized by:

David N. Sundwall, Executive Director

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-51. Dental, Orthodontia.

R414-51-1. Introduction and Authority.

(1) The Medicaid Orthodontia Program provides orthodontia services for Medicaid eligible children who have a handicapping malocclusion as a result of birth defects, accident, or abnormal growth patterns, and for Medicaid eligible [adults]pregnant women who have a handicapping malocclusion as a result of a recent accident or disease, of such severity that they are unable to masticate, digest, or benefit from their diet.

(2) Orthodontia services are authorized by 42 CFR 440.100(a), 440.225, 441.56(b)(2), 441.57, October, 1997 ed, which are adopted and incorporated by reference.

 

R414-51-3. Client Eligibility Requirements.

Orthodontia services are available [for Medicaid eligible recipients]only to clients who are pregnant women or who are individuals eligible under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program.

 

R414-51-4. Program Access Requirements.

(1) Orthodontia services are available to children who meet the requirements of having a handicapping malocclusion identified in an Early and Periodic Screening, Diagnosis and Treatment (EPSDT) exam.

(2) The Department shall determine the medical necessity for orthodontia services for each individual whether a child or [adult]a pregnant woman based upon:

(a) the evaluation of the malocclusion using the Salzmann's Index from models of the teeth submitted by the dentist or orthodontist; and

(b) evidence of medical necessity provided by the primary dentist, the orthodontist, or the physician.

(3) The primary care physician, or the physician or dentist who completes the EPSDT screening examination, may contribute information pertaining to the medical necessity for services.

(4) Qualified Providers.

Dentists, oral and maxillofacial surgeons, and orthodontists may provide any part of the orthodontic services for which they are qualified.

 

R414-51-6. Limitations.

Orthodontia is not a Medicaid benefit for:

(1) cosmetic or esthetic reasons;

(2) treatment of any temporo-mandibular joint condition or dysfunction;

(3) conditions in which radiographic evidence of bone loss has been documented[;].[

(4) an adult whose handicapping malocclusion resulted from an accident or disease occurring more than one year from the date of request for services.]

 

KEY: Medicaid, dental, orthodontia

Date of Enactment or Last Substantive Amendment: [January 28, 2004]2009

Notice of Continuation: May 19, 2008

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3