DAR File No. 43536

Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-49

Dental, Oral and Maxillofacial Surgeons and Orthodontia

Notice of Proposed Rule

(Amendment)

DAR File No.: 43536
Filed: 02/25/2019 08:29:24 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of these changes are to update and implement, by rule, Medicaid policy for dental and orthodontic services, and to implement the provisions of H.B. 435, which passed during the 2018 General Session, which provide dental benefits to certain adults in the Medicaid program.

Summary of the rule or change:

These amendments define the scope of dental services available to members under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program. They also define the scope of dental services available to pregnant members, blind or disabled members, and includes provisions for Targeted Adult Medicaid (TAM) members who receive treatment in a substance abuse treatment program. This rule text also includes provisions for emergency dental.

Statutory or constitutional authorization for this rule:

• Section 26-18-3
• Section 26-1-5

Anticipated cost or savings to:

the state budget:

There is an expected cost of $3,194,171 through State Fiscal Year (SFY) 2021, with the expansion of dental services to certain adults in the Medicaid program.

local governments:

There is no impact on local governments because they neither fund nor provide dental services under the Medicaid program.

small businesses:

Small businesses may see a share of revenue up to $3,194,171 through SFY 2021, with the expansion of dental services to certain adults in the Medicaid program.

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

Medicaid providers may see a share of revenue up to $3,194,171 through SFY 2021, with the expansion of dental services to certain adults in the Medicaid program. Likewise, Medicaid members who become eligible for these services may see out-of-pocket savings based on that amount.

Compliance costs for affected persons:

There are no compliance costs to a single Medicaid provider or to a Medicaid member because these changes can only result in increased revenue and out-of-pocket savings.

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

Businesses will see an increase in revenue with the expanded availability of adult dental services.

Joseph K. Miner, MD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Office 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:

04/15/2019

This rule may become effective on:

04/22/2019

Authorized by:

Joseph Miner, Executive Director

Appendix 1: Regulatory Impact Summary Table*

Fiscal Costs	FY 2019	FY 2020	FY 2021
State Government	$600,000	$1,263,600	$1,330,571
Local Government	$0	$0	$0
Small Businesses	$0	$0	$0
Non-Small Businesses	$0	$0	$0
Other Person	$0	$0	$0
Total Fiscal Costs:	$600,000	$1,263,600	$1,330,571
Fiscal Benefits
State Government	$0	$0	$0
Local Government	$0	$0	$0
Small Businesses	$600,000	$1,263,600	$1,330,571
Non-Small Businesses	$600,000	$1,263,600	$1,330,571
Other Persons	$600,000	$1,263,200	$1,330,571
Total Fiscal Benefits:	$600,000	$1,263,200	$1,330,571
Net Fiscal Benefits:	$600,000	$1,263,200	$1,330,571

 

*This table only includes fiscal impacts that could be measured. If there are inestimable fiscal impacts, they will not be included in this table. Inestimable impacts for State Government, Local Government, Small Businesses and Other Persons are described in the narrative. Inestimable impacts for Non-Small Businesses are described in Appendix 2.

 

Appendix 2: Regulatory Impact to Non-Small Businesses

About 1,600 non-small business providers of dental and orthodontic services may see a share of revenue that totals $3,194,171 through State Fiscal Year 2021.

 

 

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

R414-49. Dental, Oral and Maxillofacial Surgeons and Orthodontia.

R414-49-1. Introduction.

The Medicaid Dental Program provides a scope of dental services for Medicaid recipients in accordance with the Dental, Oral Maxillofacial, and Orthodontia Services Utah Medicaid Provider Manual and Attachment 4.19-B of the Medicaid State Plan, as incorporated into Section R414-1-5.

 

[ R414-49-2. Dental Services for the Blind or Disabled.

(1) Introduction and Authority.

(a) This section defines the scope of dental services available to blind or disabled Medicaid members who are 18 years of age or older.

(b) Dental services are authorized by 42 CFR 440.100, 440.120, and 483.460. This rule is also authorized under Sections 26-1-5 and 26-18-3.

(2) Definitions.

(a) "Dental services" whether furnished in the office, a hospital, a skilled nursing facility, or elsewhere, means covered services performed within the scope of the Medicaid dental provider's license as defined in Title 58, Occupations and Professions.

(b) "Blind or disabled" is as defined in Subsection 1614(a) of the Social Security Act.

(3) Client Eligibility Requirements.

(a) Dental Services are available to blind or disabled members who are 18 years of age or older.

(4) Program Access Requirements.

(a) Dental services are available only from a dental provider who has a current Utah Medicaid provider agreement, and has complied with all relevant laws and policy.

(5) Covered Services.

(a) Covered Services and limitations are maintained in the Utah Medicaid Coverage and Reimbursement Code Lookup and the Dental, Oral Maxillofacial, and Orthodontia Services Utah Medicaid Provider Manual.]

R414-49-2. Definitions.

In addition to the definitions in Rule R414-1 and the Utah Medicaid Provider Manual, Section I: General Information, the following definitions apply to this rule:

(a) "Anterior tooth" means tooth numbers 6 through 11; 22 through 27; C through H; and M through R.

(b) "Dental services" whether furnished in the office, a hospital, a skilled nursing facility, or elsewhere, means covered services performed within the scope of the Medicaid enrolled dental provider's license as defined in Title 58, Occupations and Professions.

(c) "Posterior tooth" means tooth numbers 1 through 5; 12 through 21; 28 through 32; A through B; I through L; and S through T.

 

R414-49-3. Early and Periodic Screening, Diagnostic and Treatment (EPSDT).

This section defines the scope of dental services available to members who are eligible under the EPSDT program, and includes comprehensive and preventive health care services.

(1) Program Access Requirements.

(a) Dental services are available only through an enrolled dental provider that complies with all relevant laws and policy.

(2) Coverage and Limitations.

(a) Dental services are provided only within the parameters of generally accepted standards of dental practice and are subject to limitations and exclusions established by Medicaid.

(b) Dental services are subject to limitations and exclusions of medical necessity and utilization control considerations or conditions.

(c) Additional service limitations and exclusions are maintained in the Coverage and Reimbursement Code Look-up Tool and the Dental, Oral Maxillofacial, and Orthodontia Services Utah Medicaid Provider Manual. These limitations and exclusions are updated in the Medicaid Information Bulletin.

(d) Medicaid will reimburse one evaluation per member per day, even if more than one provider is involved from the same office or clinic. Multiple exams for the same date of service are not covered.

(e) Medicaid includes in the global payment, and does not reimburse separately, denture adjustments performed by the original provider within six months of a member receiving a denture.

(f) Medicaid may cover third-molar extractions when at least one of the third molars has documented pathology that requires extraction. By discretion, a provider may remove the remaining third molars during the same procedure.

(g) Medicaid covers the treatment of temporomandibular joint fractures, but does not cover other temporomandibular joint treatments.

(h) The laboratory or pathologist must submit claims directly to Medicaid for payment of laboratory services.

(3) Medicaid does not cover the following types of dental services:

(a) Composite resin fillings on posterior teeth;

(b) Cast crowns (porcelain fused to metal) on posterior permanent teeth or on primary teeth;

(c) Pulpotomies or pulpectomies on permanent teeth, except in the case of an open apex;

(d) Fixed bridges or pontics;

(e) All types of dental implants;

(f) Tooth transplantation;

(g) Ridge augmentation;

(h) Osteotomies;

(i) Vestibuloplasty;

(j) Alveoloplasty;

(k) Occlusal appliances, habit control appliances, or interceptive orthodontic treatment;

(l) Treatment for temporomandibular joint syndrome, sequela, subluxation, or other therapies;

(m) Procedures such as arthrostomy, meniscectomy, or condylectomy;

(n) Nitrous oxide analgesia;

(o) House calls;

(p) Consultation or second opinions not requested by Medicaid;

(q) Services provided without prior authorization;

(r) General anesthesia for removal of an erupted tooth;

(s) Oral sedation for behavior management;

(t) Temporary dentures or temporary stayplate partial dentures;

(u) Limited orthodontic treatment, including removable appliance therapies;

(v) Removable appliances in conjunction with fixed banded treatment; and

(w) Extraction of primary teeth at or near the time of exfoliation, as evidenced by mobility or loosening of the teeth.

(4) Dental Spend-Ups.

(a) A Medicaid member may choose to upgrade a covered service to a non-covered service if the member assumes the responsibility for the difference in fees for the following dental procedures:

(i) Covered amalgam fillings to non-covered composite resin fillings;

(ii) Covered stainless steel crowns to non-covered porcelain or cast gold crowns; or

(iii) Covered anterior stainless steel crowns (deciduous) to non-covered anterior stainless steel crowns with facings (composite facings added or commercial or lab-prepared facings).

 

R414-49-4. Pregnant Members.

This section defines the scope of dental services available to pregnant members who are eligible for Traditional Medicaid. Dental services extend for a 60-day period after the pregnancy ends and any remaining days in the month in which the 60 days lapse.

(1) Program Access Requirements.

(a) Dental services are available only through an enrolled dental provider that complies with all relevant laws and policy.

(2) Coverage and Limitations.

(a) Dental services are provided only within the parameters of generally accepted standards of dental practice and are subject to limitations and exclusions established by Medicaid.

(b) Dental services are subject to limitations and exclusions of medical necessity and utilization control considerations or conditions.

(c) Additional service limitations and exclusions are maintained in the Coverage and Reimbursement Code Look-up Tool and the Dental, Oral Maxillofacial, and Orthodontia Services Utah Medicaid Provider Manual. These limitations and exclusions are updated in the Medicaid Information Bulletin.

(d) Medicaid will reimburse one evaluation per member per day, even if more than one provider is involved from the same office or clinic. Multiple exams for the same date of service are not covered.

(e) Medicaid includes in the global payment, and does not reimburse separately, denture adjustments performed by the original provider within six months of a member receiving a denture.

(f) Medicaid may cover third molar extractions when at least one of the third molars has documented pathology that requires extraction. By discretion, a provider may remove the remaining third molars during the same procedure.

(g) Medicaid covers the treatment of temporomandibular joint fractures, but does not cover other temporomandibular joint treatments.

(h) The laboratory or pathologist must submit claims directly to Medicaid for payment of laboratory services.

(3) Medicaid does not cover the following types of dental services:

(a) Composite resin fillings on posterior teeth;

(b) Cast crowns (porcelain fused to metal) on posterior permanent teeth or on primary teeth;

(c) Pulpotomies or pulpectomies on permanent teeth, except in the case of an open apex;

(d) Fixed bridges or pontics;

(e) All types of dental implants;

(f) Tooth transplantation;

(g) Ridge augmentation;

(h) Osteotomies;

(i) Vestibuloplasty;

(j) Alveoloplasty;

(k) Occlusal appliances, habit control appliances, or interceptive orthodontic treatment;

(l) Treatment for temporomandibular joint syndrome, sequela, subluxation, or other therapies;

(m) Procedures such as arthrostomy, meniscectomy, or condylectomy;

(n) Nitrous oxide analgesia;

(o) House calls;

(p) Consultation or second opinions not requested by Medicaid;

(q) Services provided without prior authorization;

(r) General anesthesia for removal of an erupted tooth;

(s) Oral sedation for behavior management;

(t) Temporary dentures or temporary stayplate partial dentures;

(u) Limited orthodontic treatment, including removable appliance therapies;

(v) Removable appliances in conjunction with fixed banded treatment; and

(w) Extraction of primary teeth at or near the time of exfoliation, as evidenced by mobility or loosening of the teeth.

(4) Dental Spend-Ups.

(a) A Medicaid member may choose to upgrade a covered service to a non-covered service if the member assumes the responsibility for the difference in fees for the following dental procedures:

(i) Covered amalgam fillings to non-covered composite resin fillings;

(ii) Covered stainless steel crowns to non-covered porcelain or cast gold crowns; or

(iii) Covered anterior stainless steel crowns (deciduous) to non-covered anterior stainless steel crowns with facings (composite facings added or commercial or lab-prepared facings).

 

R414-49-5. Blind or Disabled Members.

This section defines the scope of dental services available to blind or disabled members eligible for Traditional Medicaid who are 18 years of age or older, as defined in Subsection 1614(a) of the Social Security Act. Services are authorized by a federal waiver of Medicaid requirements approved by the Centers for Medicare & Medicaid Services, and allowed under Section 1115 of the Social Security Act.

(1) Program Access Requirements.

(a) Dental services are available only through an enrolled dental provider that complies with all relevant laws and policy.

(2) Coverage and Limitations.

(a) Dental services are provided only within the parameters of generally accepted standards of dental practice and are subject to limitations and exclusions established by Medicaid.

(b) Dental services are subject to limitations and exclusions of medical necessity and utilization control considerations or conditions.

(c) Additional service limitations and exclusions are maintained in the Coverage and Reimbursement Code Look-up Tool and the Dental, Oral Maxillofacial, and Orthodontia Services Utah Medicaid Provider Manual. These limitations and exclusions are updated in the Medicaid Information Bulletin.

(d) Medicaid will reimburse one evaluation per member per day, even if more than one provider is involved from the same office or clinic. Multiple exams for the same date of service are not covered.

(e) Medicaid includes in the global payment, and does not reimburse separately, denture adjustments performed by the original provider within six months of a member receiving a denture.

(f) Medicaid may cover third molar extractions when at least one of the third molars has documented pathology that requires extraction. By discretion, a provider may remove the remaining third molars during the same procedure.

(g) Medicaid covers the treatment of temporomandibular joint fractures, but does not cover other temporomandibular joint treatments.

(h) The laboratory or pathologist must submit claims directly to Medicaid for payment of laboratory services.

(3) Medicaid does not cover the following types of dental services:

(a) Composite resin fillings on posterior teeth;

(b) Cast crowns (porcelain fused to metal) on posterior permanent teeth or on primary teeth;

(c) Pulpotomies or pulpectomies on permanent teeth, except in the case of an open apex;

(d) Fixed bridges or pontics;

(e) All types of dental implants;

(f) Tooth transplantation;

(g) Ridge augmentation;

(h) Osteotomies;

(i) Vestibuloplasty;

(j) Alveoloplasty;

(k) Occlusal appliances, habit control appliances, or interceptive orthodontic treatment;

(l) Treatment for temporomandibular joint syndrome, sequela, subluxation, or other therapies;

(m) Procedures such as arthrostomy, meniscectomy, or condylectomy;

(n) Nitrous oxide analgesia;

(o) House calls;

(p) Consultation or second opinions not requested by Medicaid;

(q) Services provided without prior authorization;

(r) General anesthesia for removal of an erupted tooth;

(s) Oral sedation for behavior management;

(t) Temporary dentures or temporary stayplate partial dentures;

(u) Limited orthodontic treatment, including removable appliance therapies;

(v) Removable appliances in conjunction with fixed banded treatment; and

(w) Extraction of primary teeth at or near the time of exfoliation, as evidenced by mobility or loosening of the teeth.

(4) Dental Spend-Ups.

(a) A Medicaid member may choose to upgrade a covered service to a non-covered service if the member assumes the responsibility for the difference in fees for the following dental procedures:

(i) Covered amalgam fillings to non-covered composite resin fillings;

(ii) Covered stainless steel crowns to non-covered porcelain or cast gold crowns; or

(iii) Covered anterior stainless steel crowns (deciduous) to non-covered anterior stainless steel crowns with facings (composite facings added or commercial or lab-prepared facings).

 

R414-49-6. Targeted Adult Medicaid (TAM).

This section defines the scope of dental services available to eligible Targeted Adult Medicaid members who are actively receiving treatment in a substance abuse treatment program as defined in Section 62A-2-101, licensed under Title 62A, Chapter 2, Licensure of Programs and Facilities. Services are authorized by a federal waiver of Medicaid requirements approved by the Centers for Medicare & Medicaid Services, and allowed under Section 1115 of the Social Security Act.

(1) Program Access Requirements.

(a) Dental services are available only through an enrolled dental provider that complies with all relevant laws and policy.

(b) Dental services for this population are provided through the University of Utah School of Dentistry (SOD).

(c) Before performing any dental services, SOD shall obtain verification of active treatment for substance use disorder (SUD) from the substance abuse treatment program. The SOD shall then submit an SUD verification form to Medicaid for each eligible TAM member. The SUD verification form is available in "All Providers General Attachments" on the Utah Medicaid website at https://medicaid.utah.gov.

(2) Coverage and Limitations.

(a) Dental services are provided only within the parameters of generally accepted standards of dental practice and are subject to limitations and exclusions established by Medicaid.

(b) Dental services are subject to limitations and exclusions of medical necessity and utilization control considerations or conditions.

(c) Additional service limitations and exclusions are maintained in the Coverage and Reimbursement Code Look-up Tool and the Dental, Oral Maxillofacial, and Orthodontia Services Utah Medicaid Provider Manual. These limitations and exclusions are updated in the Medicaid Information Bulletin.

(d) Medicaid will reimburse one evaluation per member per day, even if more than one provider is involved from the same office or clinic. Multiple exams for the same date of service are not covered.

(e) Medicaid includes in the global payment, and does not reimburse separately, denture adjustments performed by the original provider within six months of a member receiving a denture.

(f) Medicaid may cover third molar extractions when at least one of the third molars has documented pathology that requires extraction. By discretion, a provider may remove the remaining third molars during the same procedure.

(g) Medicaid covers the treatment of temporomandibular joint fractures, but does not cover other temporomandibular joint treatments.

(h) The laboratory or pathologist must submit claims directly to Medicaid for payment of laboratory services.

(3) Medicaid does not cover the following types of dental services:

(a) Composite resin fillings on posterior teeth;

(b) Cast crowns (porcelain fused to metal) on posterior permanent teeth or on primary teeth;

(c) Pulpotomies or pulpectomies on permanent teeth, except in the case of an open apex;

(d) Fixed bridges or pontics;

(e) All types of dental implants;

(f) Tooth transplantation;

(g) Ridge augmentation;

(h) Osteotomies;

(i) Vestibuloplasty;

(j) Alveoloplasty;

(k) Occlusal appliances, habit control appliances or interceptive orthodontic treatment;

(1) Treatment for temporomandibular joint syndrome, sequela, subluxation, or other therapies;

(m) Procedures such as arthrostomy, meniscectomy, or condylectomy;

(n) Nitrous oxide analgesia;

(o) House calls;

(p) Consultation or second opinions not requested by Medicaid;

(q) Services provided without prior authorization;

(r) General anesthesia for removal of an erupted tooth;

(s) Oral sedation for behavior management;

(t) Temporary dentures or temporary stayplate partial dentures;

(u) Limited orthodontic treatment, including removable appliance therapies;

(v) Removable appliances in conjunction with fixed banded treatment; and

(w) Extraction of primary teeth at or near the time of exfoliation, as evidenced by mobility or loosening of the teeth.

(4) Dental Spend-Ups.

(a) A Medicaid member may choose to upgrade a covered service to a non-covered service if the member assumes responsibility for the difference in fees for the following dental procedures:

(i) Covered amalgam fillings to non-covered composite resin fillings;

(ii) Covered stainless steel crowns to non-covered porcelain or cast gold crowns; and

(iii) Covered anterior stainless steel crowns (deciduous) to non-covered anterior stainless steel crowns with facings (composite facings added or commercial or lab prepared facings).

 

R414-49-7. Emergency Dental.

This section defines the scope of dental services available to members who are otherwise eligible under the Medicaid program.

(1) Program Access Requirements.

(a) Dental services are available only through an enrolled dental provider that complies with all relevant laws and policy.

(2) Coverage and Limitations.

(a) Emergency dental services are the treatment of a sudden and acute onset of a dental condition that requires immediate treatment, where delay in treatment would jeopardize or cause permanent damage to a person's dental or medical health.

(b) Emergency dental service limitations and exclusions are maintained in the Coverage and Reimbursement Code Look-up Tool and the Dental, Oral Maxillofacial, and Orthodontia Services Utah Medicaid Provider Manual. These limitations and exclusions are updated in the Medicaid Information Bulletin.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [July 1, 2017]2019

Notice of Continuation: June 17, 2014

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