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 and 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).