No. 28618 (Amendment): R414-49. Dental Service

DAR File No.: 28618
Filed: 04/14/2006, 04:03
Received by: NL

 

RULE ANALYSIS

Purpose of the rule or reason for the change:

Funding was not provided for the adult dental program by the 2006 Utah Legislature. This rulemaking is necessary to reflect that action.

 

Summary of the rule or change:

In Section R414-49-3, additional wording is added that defines who can receive treatment. In Section R414-49-5, the wording about specific services is deleted and "covered dental services" is added. In Subsection R414-49-5(6)(a), the stipulation for adults and children is deleted.

 

State statutory or constitutional authorization for this rule:

Section 26-18-3

 

Anticipated cost or savings to:

the state budget:

This rulemaking saves the general fund $3,278,625 and matching federal funds of $7,756,800 for a total of $11,035,425.

 

local governments:

Local governments do not provide dental services therefore there is no impact to local governments.

 

other persons:

Providers may lose up to $11,035,425 in Medicaid reimbursements for services they may no longer provide as a result of this rulemaking. Medicaid clients, if they obtain the same services and pay out-of-pocket will be required to pay $27,000,000 for those services because of the higher, non-Medicaid rates they will have to pay.

 

Compliance costs for affected persons:

There is an average annual loss of $19,463 in Medicaid reimbursements to a single dental provider for services that the provider may no longer provide to Medicaid clients. This is based on the total number of 567 Medicaid dentists and the estimate of one visit per year by a single client. The average Medicaid cost per client for dental care is about $250. The result of this rulemaking will require each Medicaid client who obtains the service and pays out-of-pocket to pay about $600 for the same care.

 

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

This rule will reduce the number of Medicaid recipients eligible to receive dental services and is necessary to stay within appropriations. 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:

Ross Martin at the above address, by phone at 801-538-6592, by FAX at 801-538-6099, or by Internet E-mail at [e-mail]

 

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:

05/31/2006

 

This rule may become effective on:

06/01/2006

 

Authorized by:

David N. Sundwall, Executive Director

 

 

RULE TEXT

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

R414-49. Dental Service.

R414-49-3. Client Eligibility Requirements.

Dental services are available to categorically and medically needy clientsage 20 and younger or who are pregnant.

 

R414-49-5. Service Coverage.

[Specific services are identified for adults and for children eligible for the EPSDT (CHEC) program, since program covered services may differ. Specific program covered services for residents of ICFs/MR are detailed in this section.]Covered dental services:

(1) Diagnostic services are covered as follows:

(a) Each provider may perform a comprehensive oral evaluation one time only for either a child or an adult.

(b) A limited problem-focused oral evaluation for a child or an adult.

(c) Each provider may perform either two periodic oral evaluations, or a comprehensive and a periodic oral evaluation per calendar year.

(d) A choice of panoramic film, a complete series of intraoral radiographs, or a bitewing series of radiographs of diagnostic quality.

(e) Study models or diagnostic casts for children.

(2) Preventive services are covered as follows:

(a) Child:

(i) Two prophylaxis treatments in a calendar year by a provider, with or without fluoride.

(ii) Occlusal sealants are a benefit on the permanent molars of children under age 18.

(iii) Space maintainers.

(b) Adult: Two prophylaxis treatments in a calendar year by a provider.

(3) Restorative services are covered as follows:

(a) Amalgam restorations, composite restorations on anterior teeth, stainless steel crowns, crown build-up, prefabricated post and core, crown repair, and resin or porcelain crowns on permanent anterior teeth for children.

(b) Amalgam restorations, and composite restorations on anterior teeth for adults.

(4) Endodontics services are covered as follows:

(a) Therapeutic pulpotomy for primary teeth.

(b) Root canals, except for permanent third molars or primary teeth, or permanent second molars for adults.

(c) Apicoectomies.

(5) Periodontics services are covered as follows:

(a) Root planing or periodontal treatment for children.

(b) Gingivectomies for patients who use anticonvulsant medication, as verified by their physician.

(6) Oral Surgery services are covered as follows:

(a) Extractions[ for adults and children].

(b) Surgery for emergency treatment of traumatic injury.

(c) Emergency oral and maxillofacial services provided by dentists or oral and maxillofacial surgeons.

(7) Prosthodontics services are covered as follows:

Initial placement of dentures, including the relining to assure the desired fit.

(a) Full Dentures

(i) Child: Complete dentures.

(ii) Adult: "Initial" dentures.

(b) Partial dentures may be provided if the denture replaces an anterior tooth or is required to restore mastication ability where there is no mastication ability present on either side.

(c) Relining, rebasing, or repairing of existing full or partial dentures.

(8) Medicaid covered dental services are available to residents of an ICF/MR on a fee-for-service basis, except for the annual exam, which is part of the per diem paid to the ICF/MR.

(9) Patients who receive total parenteral or enteral nutrition may not receive dentures.

(10) The provider must mark all new placements of full or partial dentures with the patient's name to prevent lost or stolen dentures in facilities licensed under Title 26, Chapter 21.

(11) General anesthesia and I.V. sedation are covered services.

(12) Fixed bridges, osseo-implants, sub-periosteal implants, ridge augmentation, transplants or replants are not covered services.

(13) pontic services, vestibuloplasty, occlusal appliances, or osteotomies are not covered services.

(14) Consultations or second opinions not requested by Medicaid are not covered services.

(15) Treatment for temporomandibular joint syndrome, its prevention or sequela, subluxation, therapy, arthrotomy, meniscectomy, condylectomy are not covered services.

(16) Prior authorization is required for gingivectomies, full mouth debridements, dentures, partial dentures, porcelain to metal crowns and general anesthesia procedures.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [July 1, 2005]2006

Notice of Continuation: November 12, 2004

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