No. 32617 (Amendment): R414-49. Dental Service.

DAR File No.: 32617
Filed: 04/30/2009, 04:17
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to comply with budget reduction mandates set forth in the 2009 General Session of the Utah Legislature.

Summary of the rule or change:

This change allows only pregnant women and individuals eligible under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program to receive dental services.

State statutory or constitutional authorization for this rule:

Sections 26-1-5 and 26-18-3

Anticipated cost or savings to:

the state budget:

There is a savings of approximately $2,000,000 to the General Fund and approximately $5,000,000 in federal dollars.

local governments:

There is no budget impact because local governments do not fund or provide dental services to Medicaid clients.

small businesses and persons other than businesses:

The providers of dental services lose approximately $7,000,000 in annual revenue as a result of this change. However, the total out-of-pocket expense to Medicaid clients who elect to pay out-of-pocket is difficult to estimate because it is impossible to know how many clients would elect to obtain these services.

Compliance costs for affected persons:

A single provider of dental services loses approximately $14,009 in annual revenue, based on the total number of providers and client visits per year. The average Medicaid cost per client for dental care is about $250. This change will require each Medicaid client who obtains this service to pay out-of-pocket about $600 for the same care.

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

The 2009 Legislature did not appropriate funds to permit continuation of these services. 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:

Craig Devashrayee at the above address, by phone at 801-538-6641, 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:

06/15/2009

Interested persons may attend a public hearing regarding this rule:

5/26/2009 at 1:00 PM, Utah Department of Health, Cannon Health Building, Room 114

This rule may become effective on:

07/01/2009

Authorized by:

David N. Sundwall, Executive Director

RULE TEXT

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

R414-49. Dental Services.

R414-49-3. Client Eligibility Requirements.

Dental services are available [to categorically and medically needy clients]only to clients who are pregnant women or who are individuals eligible under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program.

 

R414-49-5. Service Coverage.

Specific services are identified for [adults]pregnant women 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.

(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]Pregnant Women: 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]pregnant women.

(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]Pregnant Women: "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]2009

Notice of Continuation: November 12, 2004

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