DAR File No. 38134

Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-50

Dental, Oral and Maxillofacial Surgeons

Notice of Proposed Rule

(Repeal)

DAR File No.: 38134
Filed: 11/13/2013 11:50:04 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this rule repeal is to streamline and consolidate the scope of dental, oral, and maxillofacial services for Medicaid recipients. The services that are repealed in this rule are consolidated in the companion filing of Rule R414-49. (DAR NOTE: The proposed amendment to Rule R414-49 is under DAR No. 38133 in this issue, December 1, 2013, of the Bulletin.)

Summary of the rule or change:

This rule is repealed in its entirety.

State statutory or constitutional authorization for this rule:

• Section 26-18-3
• 42 CFR 440.100
• Section 26-1-5

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because the services that are repealed in this rule are consolidated in the companion filing of Rule R414-49.

local governments:

There is no impact to local governments because they do not fund or provide dental, oral, and maxillofacial services to Medicaid recipients.

small businesses:

There is no impact to small businesses because the services that are repealed in this rule are consolidated in the companion filing of Rule R414-49.

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

There is no impact to Medicaid providers and to Medicaid recipients because the services that are repealed in this rule are consolidated in the companion filing of Rule R414-49.

Compliance costs for affected persons:

There is no impact to a single Medicaid provider or to a Medicaid recipient because the services that are repealed in this rule are consolidated in the companion filing of Rule R414-49.

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

This makes no change in eligibility or benefits so it has no 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
• Nina Baker at the above address, by phone at 801-538-9127, by FAX at 801-538-6412, or by Internet E-mail at nabaker@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:

12/31/2013

This rule may become effective on:

01/07/2014

Authorized by:

David Patton, Executive Director

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

[R414-50. Dental, Oral and Maxillofacial Surgeons.

R414-50-1. Introduction and Authority.

(1) The Medicaid Oral and Maxillofacial Surgery Program provides a scope of oral and maxillofacial surgery services to meet the basic needs of Medicaid clients. This includes services by both oral and maxillofacial surgeons and general dentists if surgery is performed by a general dentist in an emergency situation and an oral and maxillofacial surgeon is not available.

(2) Oral and maxillofacial surgery services are authorized by 42 USC 1396d(a)(5).

 

R414-50-2. Definitions.

Definitions for this rule are found in R414-1-1. In addition:

(1) "Oral and Maxillofacial Surgeons" means those individuals who have completed a post-graduate curriculum from an accredited institution of higher learning and are board-certified or board-eligible in oral and maxillofacial surgery.

(2) "Oral and maxillofacial surgery" means that part of dental practice which deals with the diagnosis and surgical and adjunctive treatment of diseases, injuries, and defects of the oral and maxillofacial regions.

 

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 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.

 

R414-50-4. Program Access Requirements.

Oral and maxillofacial surgery services are available only from an oral and maxillofacial surgeon who is a Medicaid provider. These services are available from a dentist provider if an oral and maxillofacial surgeon is unavailable.

 

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 to non-pregnant clients 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.

 

R414-50-6. Reimbursement.

(1) Fees for services for which the Department will pay dentists are established from the physician's fees for CPT codes as described in the State Plan, Attachment 4.19-B, Section D Physicians. Fee schedules were initially established after consultation with provider representatives. Adjustments to the schedule are made in accordance with appropriations and to produce efficient and effective services.

(2) The Department pays the lower of the amount billed and the rate on the schedule. A provider shall not charge the Department a fee that exceeds the provider's usual and customary charges for the provider's private-pay patients.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: August 10, 2012

Notice of Continuation: October 21, 2009

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