No. 37696 (Amendment): Rule R414-51. Dental, Orthodontia

(Amendment)

DAR File No.: 37696
Filed: 06/04/2013 01:40:14 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to clarify access requirements, service coverage, limitations, and reimbursement for orthodontia services.

Summary of the rule or change:

This amendment clarifies access requirements, service coverage, limitations, and reimbursement for orthodontia services. It also makes other technical changes.

State 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 no impact to the state budget because this amendment only clarifies Medicaid policy for orthodontia services.

local governments:

There is no impact to local governments because they neither fund nor provide Medicaid services to Medicaid recipients.

small businesses:

There is no impact to small businesses because this amendment only clarifies Medicaid policy for orthodontia services.

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

There is no impact to Medicaid providers and to Medicaid recipients because this amendment only clarifies Medicaid policy for orthodontia services.

Compliance costs for affected persons:

There is no impact to a single Medicaid provider or to a Medicaid recipient because this amendment only clarifies Medicaid policy for orthodontia services.

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

This change will likely be cost neutral for the majority of providers.

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 [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:

07/31/2013

This rule may become effective on:

08/07/2013

Authorized by:

David Patton, Executive Director

RULE TEXT

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

R414-51. Dental, Orthodontia.

R414-51-1. Introduction and Authority.

(1) The Medicaid Orthodontia Program provides orthodontia services for Medicaid eligible children who have a handicapping malocclusion as a result of birth defects, accident, or abnormal growth patterns, and for Medicaid eligible pregnant women who have a handicapping malocclusion as a result of a recent accident or disease, of such severity that they are unable to masticate, digest, or benefit from their diet.

(2) Orthodontia services are authorized by 42 CFR 440.100(a), 440.225, 441.56(b)(2), 441.57, October, 1997 ed, which are adopted and incorporated by reference.

 

R414-51-2. Definitions.

In addition to the definitions in R414-1, the following definitions also appl[ies]y to this rule:

(1) "Adult" means an individual who is 21 years of age or older[;].

(2) "Child" means an individual who is under 21 years of age[;].

(3) "Salzmann's Index" means the "Handicapping Malocclusion Assessment Record" by J. A. Salzmann, used for assessment of handicapping malocclusion, as adopted by the Board of Directors of the American Association of Orthodontists and the Council on Dental Health of the American Dental Association. This index provides a universal numerical measurement of the total malocclusion.

 

R414-51-3. Client Eligibility Requirements.

Orthodontia 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.

 

R414-51-4. Program Access Requirements.

(1) Orthodontia services are available to children who meet the requirements of having a handicapping malocclusion identified in an Early and Periodic Screening, Diagnosis and Treatment (EPSDT) exam.

(2) The Department shall determine [the ]medical necessity for orthodontia services [for each individual whether a child or a pregnant woman ]based upon:

(a) [the ]evaluation of the malocclusion using the Salzmann's Index from models of the teeth submitted by the dentist or orthodontist; and

(b) evidence of medical necessity provided by the primary dentist, [the ]orthodontist, or [the ]physician.

(3) The primary care physician, or the physician or dentist who completes the EPSDT screening examination, may contribute information pertaining to the medical necessity for services.

(4) Qualified [P]providers[.] include dentists, orthodontists, and oral and maxillofacial surgeons.

[Dentists, oral and maxillofacial surgeons, and orthodontists may provide any part of the orthodontic services for which they are qualified.

]

R414-51-5. Service Coverage.

(1) Medicaid considers a Salzmann's Index score of 30 or [more]higher a level of handicapping malocclusion for which orthodontia is a covered service.

(2) Service coverage includes:

(a) a wax bite and study models of the teeth;

(b) removal of teeth, or other surgical procedures, if necessary to prepare for an orthodontic appliance;

(c) attachment of an orthodontic appliance;

(d) adjustments of an appliance; and

(e) removal of an appliance[;].

[ (3) Dental surgical procedures which are cosmetic only are not covered services even when proposed in conjunction with orthodontia.

]

R414-51-6. Limitations.

[Orthodontia is not a Medicaid benefit]Medicaid does not cover orthodontia for:

(1) cosmetic or esthetic reasons;

(2) dental surgical procedures which are cosmetic even when performed in conjunction with orthodontia;

(2) treatment of any temporo-mandibular joint condition or dysfunction; or

(3) conditions in which radiographic evidence of bone loss has been documented.

 

R414-51-7. Reimbursement.

(1) Fees for services for which the Department will pay [optometrists]orthodontists are established from the physician's fees for CPT or CDT 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.

[(3) The Department shall pay dentists in rural areas 120 percent of the Medicaid established dental fee. The Department shall pay dentist in urban areas 120 percent of the Medicaid established dental fee who agree in writing to treat 100 Medicaid eligible patients per year.

]

KEY: Medicaid, dental, orthodontia

Date of Enactment or Last Substantive Amendment: [July 1, 2009]2013

Notice of Continuation: April 30, 2013

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

 

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