Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-50

Dental, Oral and Maxillofacial Surgeons

Notice of Proposed Rule

(Amendment)

DAR File No.: 36103
Filed: 04/27/2012 11:52:13 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to comply with mandates set forth in the 2012 General Session of the Utah Legislature reinstating emergency dental to non-pregnant adult Medicaid clients.

Summary of the rule or change:

This change allows non-pregnant adults 21 years and older to receive limited emergency dental services. It also clarifies that services performed by an oral surgeon are still available to all categorically and medically needy clients.

State statutory or constitutional authorization for this rule:

• Section 26-18-3
• Section 26-1-5

Anticipated cost or savings to:

the state budget:

Estimates are listed in the companion filing to this proposed rule (Rule R414-49). (DAR NOTE: The proposed amendment to Section R414-39-3 is under DAR No. 36105 in this issue, May 15, 2012, of the Bulletin.)

local governments:

Estimates are listed in the companion filing to this proposed rule (Rule R414-49).

small businesses:

Estimates are listed in the companion filing to this proposed rule (Rule R414-49).

persons other than small businesses, businesses, or local governmental entities:

Estimates are listed in the companion filing to this proposed rule (Rule R414-49).

Compliance costs for affected persons:

Dental providers will see an increase in revenues and emergency room providers will see a decrease in revenues resulting from this amendment. It is difficult to quantify the specific compliance costs for any specific provider as the future utilization is unknown.

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

Providers of dental service will benefit from having this a covered service.

David Patton, PhD, 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:

06/14/2012

This rule may become effective on:

07/01/2012

Authorized by:

David Patton, Executive Director

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

R414-50. Dental, Oral and Maxillofacial Surgeons.

R414-50-3. Client Eligibility Requirements.

(1) Oral and maxillofacial surgery services are available only to clients who are pregnant women or who are individuals eligible under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program. Nevertheless, physician, medical and surgical services performed by an oral surgeon are available to all categorically and medically needy clients.

(2) Dental services to non-pregnant adults ages 21 and older are limited to emergency services only as defined in the Utah Medicaid State Plan Attachment 3.1-A, Attachment #10 and Attachment 3.1-B, Attachment #10.

 

R414-50-5. Service Coverage.

Emergency services outlined in this section are covered services for clients who are pregnant women or who are individuals eligible under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program. Services for non-pregnant adults ages 21 and older are noted in the Utah Medicaid State Plan Attachment 3.1-A, Attachment #10 and Attachment 3.1-B, Attachment #10.

(1) [Emergency services are covered services. ]Emergency services provided by a dentist in areas where an oral and maxillofacial surgeon is unavailable are covered services.

(2) Appropriate general anesthesia necessary for optimal management of the emergency is a covered service.

(3) Hospitalization of patients for dental surgery may be a covered service if a patient's physician, at the time of the proposed hospitalization, verifies that the patient's general health status dictates that hospitalization is necessary for the health and welfare of the patient.

(4) Treatment of temporomandibular joint fractures is a covered service. All other temporomandibular joint treatments are not covered services.

(5) For procedures requiring prior approval, Medicaid shall deny payment if the services are rendered before prior approval is obtained. Exceptions may be made for emergency services, or for recipients who obtain retroactive eligibility. The provider must apply for approval as soon as is practicable after the service is provided.

(6) Extraction of primary teeth at or near the time of exfoliation, as evidenced by mobility or loosening of the teeth, is not a covered service.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [November 1, 2010]2012

Notice of Continuation: October 21, 2009

Authorizing, and Implemented or Interpreted Law: 26-1-4.1; 26-1-5; 26-18-3