Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-50

Dental, Oral and Maxillofacial Surgeons

Notice of Proposed Rule

(Amendment)

DAR File No.: 36378
Filed: 06/15/2012 10:25:14 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to clarify that limited emergency dental services, as mandated by the Legislature, are based on the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program.

Summary of the rule or change:

This change clarifies that limited emergency dental services, as mandated by the Legislature, are based on the EPSDT Program.

State statutory or constitutional authorization for this rule:

• Section 26-1-5
• Section 26-18-3

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because this amendment simply clarifies that the provision of limited emergency dental services is based on the EPSDT Program.

local governments:

There is no impact to local governments because this amendment simply clarifies that the provision of limited emergency dental services is based on the EPSDT Program.

small businesses:

There is no impact to small businesses because this amendment simply clarifies that the provision of limited emergency dental services is based on the EPSDT Program.

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

There is no impact to Medicaid providers and to Medicaid clients because this amendment simply clarifies that the provision of limited emergency dental services is based on the EPSDT Program.

Compliance costs for affected persons:

There is no impact to a single Medicaid provider or to a single Medicaid client because this amendment simply clarifies that the provision of limited emergency dental services is based on the EPSDT Program.

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

Clarifying that services are available through the EPSDT program is expected to have no fiscal impact on business.

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:

07/31/2012

This rule may become effective on:

08/07/2012

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 are available to clients who are pregnant women or who are individuals eligible under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program. Dental services to non-pregnant clients[adults ages 21 and older] and to non-EPSDT clients 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]to non-pregnant clients[adults ages 21 and older] and to non-EPSDT clients are noted in the Utah Medicaid State Plan Attachment 3.1-A, Attachment #10 and Attachment 3.1-B, Attachment #10.

(1) 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: 2012

Notice of Continuation: October 21, 2009

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