WSR 99-01-169

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES

(Medical Assistance Administration)

[Filed December 23, 1998, 10:46 a.m.]



Original Notice.

Preproposal statement of inquiry was filed as WSR 98-08-074.

Title of Rule: Chapter 388-535 WAC, Dental-related services.

Purpose: The department is amending these rules per the Governor's Executive Order 97-02 which requires rules to be rewritten for clarity, concision, foundation in law, fairness, readability, and with public involvement. In addition, the department is expanding the geographic of the access to baby and child dentistry (ABCD) program, and requiring more prior authorization requirements of certain high-cost crowns for back teeth.

Statutory Authority for Adoption: RCW 74.08.090, 74.09.035, 74.09.520, and 74.09.700; 42 USC 1396d(a); 42 CFR 440.100 and 42 CFR 440.225.

Statute Being Implemented: RCW 74.09.035, 74.09.520, and 74.09.700; 42 USC 1396d(a); 42 CFR 440.100 and 42 CFR 440.225.

Summary: Medicaid clients may receive dental-related services, under limitations, including evaluations, cleaning, extractions, crowns, dentures, orthodontics, and referrals. Dentists, denturists, dental laboratories, and related professionals are paid for these services under specific limitations including medical/dental necessity, prior authorization from MAA in some cases, adequate record keeping, and post-pay reviews. State-funded clients receive a more limited range of services, including dentures and hospital-based dental services for emergencies and major trauma. Preventive services are offered to children.

Reasons Supporting Proposal: Congress and the state legislature authorized the department to offer these services, to protect the general health of Washington's noninsured population that is eligible for Medicaid or state-funded medical programs.

Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Carree Moore, DSHS/MAA/Family Services, Mailstop 45530, (360) 586-2763.

Name of Proponent: Department of Social and Health Services, Medical Assistance Administration, governmental.

Rule is not necessitated by federal law, federal or state court decision.

Explanation of Rule, its Purpose, and Anticipated Effects: Medicaid clients may receive dental-related services, under limitations, including evaluations, cleaning, extractions, crowns, dentures, orthodontics, and referrals. Dentists, denturists, dental laboratories, and related professionals are paid for these services under specific limitations including medical/dental necessity, prior authorization from MAA in some cases, adequate record keeping, and post-pay reviews. State-funded clients receive a much more limited range of services, including dentures and hospital-based dental services for emergencies and major trauma. Preventive services are offered to children.

Proposal Changes the Following Existing Rules: Expands the access to baby and child dentistry (ABCD) program for infants and toddlers from just Spokane County, to any area targeted by MAA as needing that program.

Requires prior authorization from MAA for crowns, except for stainless steel crowns (any teeth) and resin crowns (for primary teeth).

No small business economic impact statement has been prepared under chapter 19.85 RCW. The department has determined that no small businesses will be significantly affected.

RCW 34.05.328 applies to this rule adoption. A cost-benefit analysis (CBA) was prepared. A copy of that CBA is available from Allen Richards, Regulatory Improvement, Medical Assistance Administration, P.O. Box 45530, Olympia, WA 98504-5530, phone (360) 586-1008, fax (360) 753-7315, e-mail richaa@dshs.wa.gov.

Hearing Location: Lacey Government Center (behind Tokyo Bento Restaurant), 1009 College Street S.E., Room 104-B, Lacey, WA 98503, on February 9, 1999, at 10:00 a.m.

Assistance for Persons with Disabilities: Contact Paige Wall by January 29, 1999, phone (360) 902-7540, TTY (360) 902-8324, e-mail pwall@dshs.wa.gov.

Submit Written Comments to: Identify WAC Numbers, Paige Wall, Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 902-8292, by February 9, 1999.

Date of Intended Adoption: February 24, 1999.

December 18, 1998

Marie Myerchin-Redifer, Manager

Rules and Policies Assistance Unit

SHS-2500.5

GENERAL



NEW SECTION



WAC 388-535-1010  Dental-related program introduction. This chapter describes:

(1) The dental-related services that the medical assistance administration (MAA) offers to its eligible clients;

(2) Limitations to those services;

(3) Provider requirements, including prior authorizations; and

(4) MAA's methods for paying providers for dental-related services.



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AMENDATORY SECTION (Amending Order 3931, filed 12/6/95, effective 1/6/96)



WAC 388-535-1050  Dental-related definitions. This section contains definitions of words and phrases in bold that the department uses in ((rules for the medical assistance administration dental program)) this chapter. See also chapter 388-500 WAC for other definitions and abbreviations.. Further dental definitions used by the department may be found in the Current Dental Terminology (CDT-2) and the Current Procedural Terminology (CPT). Where there is any discrepancy between the CDT-2 or CPT and this section, this section prevails.

(((1))) "Access to baby and child dentistry (ABCD)" is a ((Spokane County pilot initiative)) demonstration project to increase access to dental services in targeted areas for Medicaid eligible infants, toddlers, and preschoolers up through the age of five. See WAC 388-535-1300 for specific information.

(((2))) "Adult" means a client nineteen years of age or older.

"Anterior" means teeth in the front of the mouth. In relation to crowns, only these permanent teeth are anterior:

(1) "Lower anterior," teeth twenty-two, twenty-three, twenty-four, twenty-five, twenty-six, and twenty-seven; and

(2) "Upper anterior," teeth six, seven, eight, nine, ten, and eleven.

"Arch" means the curving structure formed by the crowns of the teeth in their normal position, or by the residual ridge after loss of the teeth.

(((3))) "Asymptomatic" means having no symptoms.

"Banding" means the application of orthodontic brackets to the teeth ((and/or face)) for the purpose of correcting dentofacial abnormalities.

(((4))) "Base metal" means dental alloy containing no precious metals.

"Behavior management" means managing the behavior of a client during treatment using the assistance of additional professional staff, and professionally accepted restraints ((such as a papoose board)) or sedative agent, to protect the client from self-injury.

(((5) "Buccal" means pertaining to or directed toward the cheek.)) "Bicuspid" means teeth four, five, twelve, thirteen, twenty, twenty-one, twenty-eight, and twenty-nine.

(((6))) "By report" - a method of payment for a covered service, supply, or equipment ((for which the medical assistance administration has not established a maximum allowable, either because the service or supply is new and its use is not yet considered standard, or it)) which:

(1) Has no maximum allowable established by MAA,

(2) Is a variation on a standard practice, or

(3) Is rarely provided. ((Payment for a "by report" service or item is made on a case-by-case basis.

(7))) "Caries" means ((a disease of the calcified tissues of the teeth resulting from the action of microorganisms on carbohydrates, characterized by a decalcification of the inorganic portion of the tooth and accompanied or followed by disintegration of the organic portion)) tooth decay.

(((8))) "Child"(( - for purposes of the dental program, a child is defined as a person zero through)) means a client eighteen years of age or younger.

(((9))) "Cleft" means ((a longitudinal)) an opening or fissure involving significant dental processes, especially one occurring in the embryo. ((Also see "facial cleft."

(10))) These can be:

(1) Cleft lip,

(2) Cleft palate (at the roof of the mouth), or

(3) Transverse facial cleft (macrostomia).

"Comprehensive oral evaluation" means a thorough evaluation and recording of the ((extraoral and intraoral)) hard and soft tissues((. Includes)) in and around the mouth, including the evaluation and recording of the patient's dental and medical history and a general health assessment.

(((11))) "Corona" is the portion of a tooth that is covered by enamel, and is separated from the root or roots by a slightly constricted region, known as the ((neck)) cemento-enamel junction.

(((12))) "Craniofacial anomalies" means abnormalities of the head and face, either congenital or acquired, involving significant dental processes.

(((13))) "Craniofacial team" means a department of health and MAA recognized cleft palate/maxillofacial team which is: Responsible for management (review, evaluation, and approval) of patients with cleft palate craniofacial anomalies to provide integrated case management, promote parent-professional partnership, making appropriate referrals to implement and coordinate treatment plans.

"Current dental terminology (CDT), second edition (CDT-2)," a systematic listing of descriptive terms and identifying codes for reporting dental services and procedures performed by dental practitioners. CDT is published by the Council on Dental Benefit Programs of the American Dental Association (ADA).

(((14) "Dental analgesia" means the use of agents to induce insensibility to or relief from dental pain without loss of consciousness)) "Current procedural terminology (CPT)," means a description of medical procedures and is available from the American Medical Association of Chicago, Illinois.

(((15))) "Dental general anesthesia" means the use of agents to induce loss of feeling or sensation, a controlled state of unconsciousness, in order to allow dental services to be rendered to the client. ((The term is applied especially to the loss of sensation of pain through general anesthesia)).

(((16))) "Dentally necessary" means diagnostic, preventive, or corrective services that are accepted dental procedures appropriate for the age and development of the client to prevent the incidence or worsening of conditions that endanger teeth or periodontium (tissues around the teeth) or cause significant malfunction or impede reasonable development or homeostatis (health) in the stomatognathic (mouth and jaw) system:

(1) Which may include simple observation with no treatment, if appropriate; and

(2) Includes use of less costly, equally effective services.

"Dentin" is the ((chief substance or)) mineralized tissue of the teeth, which surrounds the tooth pulp and is covered by enamel on the crown and by cementum on the roots of the teeth.

(((17) "Dental prosthesis" means a replacement for one or more of the teeth or other oral structure, ranging from a single tooth to a complete denture.

(18))) "Dentures" are a set of ((natural or)) prosthetic artificial teeth((; ordinarily used to designate an artificial replacement for the natural teeth)). See WAC 388-535-1240 for specific information.

(((19))) "Dysplasia" means an abnormality ((of)) in the development of the teeth.

(((20))) "Enamel" is the white, compact, and very hard substance that covers and protects the dentin of the crown of a tooth.

(((21) "Facial clefts" are the clefts between the embryonic processes which normally unite to form the face. Failure of such union, depending on its site, causes such developmental defects as cleft lip (harelip), cleft mandible, oblique facial cleft, and transverse facial cleft (macrostomia).

(22))) "Endodontic" means a root canal treatment and related follow-up.

"EPSDT/healthy kids" means the department's early periodic screening, diagnosis, and treatment program for clients twenty years of age and younger as described in WAC 388-86-027.

"Fluoride varnish" means a substance containing dental fluoride, for painting onto teeth. When painted onto teeth, it sticks to tooth surfaces.

"Gingiva" means the gums.

"Hemifacial microsomia" means half or part of the face is smaller-sized.

"High noble metal" means dental alloy containing at least sixty percent pure gold.

"High risk child" means any child who has been identified through an oral evaluation or assessment as ((having)) being at a high risk for developing dental disease because of caries in the child's dentin; or a child identified by the department as developmentally disabled.

(((23))) "Hypoplasia" means the incomplete or defective development of the enamel of the teeth.

(((24) "Limited oral evaluation" means an evaluation or reevaluation limited to a specific oral health situation or problem.

(25) "Limited visual oral assessment" - A service preformed by dentists which involves assessing the need for sealants to be placed by dental hygienists; screening children in Head Start or ECEAP programs; providing triage services; or in circumstances referring a child to another dentist for treatment. These assessments are also used by dental hygienists performing intraoral screening of soft and hard tissues to assess the need for prophylaxis, sealants, fluoride varnish, or refers to a dentist for other dental treatment.

(26))) "Low risk child" means any child who has been identified through an oral evaluation or assessment as ((having)) being at a low risk for dental disease because of the absence of white spots or caries in the enamel or dentin. This category includes children with restorations who are otherwise without disease.

(((27) "Macrostomia" means a greatly exaggerated width of the mouth, resulting from failure of union of the maxillary and mandibular processes, with extension of the oral orifice to the ear. The defect may be unilateral or bilateral.

(28))) "Major bone grafts" means a transplant of solid bone tissue(s), such as buttons or plugs.

"Malocclusion" means the contact between the ((maxillary and mandibular)) upper and lower teeth ((as will)) that interferes with the highest efficiency during the ((excursive)) movements of the jaw that are essential to ((mastication)) chewing. The abnormality is categorized into four classes, graded by Angle's classification. For coverage , see WAC 388-535-1250.

(((29))) "Maxillofacial" means relating to the jaws and face.

"Minor bone grafts" means a transplant of nonsolid bone tissue(s), such as powdered bone.

"Moderate risk child" means a child who has been identified through an oral evaluation or assessment as ((having)) being at a moderate risk for dental disease, based on presence of white spots, enamel caries or hypoplasia.

(((30))) "Molars" means:

(1) Permanent teeth one, two, three, fourteen, fifteen, sixteen, seventeen, eighteen, nineteen, thirty, thirty-one, and thirty-two; and

(2) Primary teeth A, B, I, J, K, L, S and T.

"Noble metal" means a dental alloy containing at least twenty-five percent but less than sixty percent pure gold.

"Occlusion" means the relation of the ((maxillary and mandibular)) upper and lower teeth when in functional contact during ((activity of the mandible)) jaw movement.

(((31))) "Oral evaluation" is ((an evaluation performed on a client, new or established, to determine the patient's dental and/or medical health status, or changes to that status.

(32) "Oral health assessment or screening" is)) a comprehensive oral health and developmental history; an assessment of physical and oral health development and nutritional status; and health education, including anticipatory guidance.

(((33))) "Oral health assessment or screening" means a screening of the hard and soft tissues in the mouth.

"Oral health status" refers to the client's risk or susceptibility to dental disease at the time an oral evaluation is done by a dental practitioner. This risk is designated as low, moderate or high based on the presence or absence of certain indicators.

(((34) "Oral sedation" means the use of oral agents to produce a sedative or calming effect.

(35) "Orthodontia")) "Orthodontic" is a treatment involving the use of any appliance, ((intraoral or extraoral)) in or out of the mouth, removable or fixed, or any surgical procedure designed to ((move)) redirect teeth and surrounding tissues.

(((35))) "((Partial dentures)) Partials" means a prosthetic appliance replacing one or more missing teeth in one jaw, and receiving its support and retention from both the underlying tissues and some or all of the remaining teeth. See WAC 388-535-1240 for specific information.

(((36))) "Posterior" means teeth and tissue towards the back of the mouth. Specifically, only these permanent teeth: one, two, three, four, five, twelve, thirteen, fourteen, fifteen, sixteen, seventeen, eighteen, nineteen, twenty, twenty-one, twenty-eight, twenty-nine, thirty, thirty-one, and thirty-two.

"Prophylaxis" ((is a preventive)) means intervention which includes the scaling and polishing of teeth to remove coronal plaque, calculus, and stains.

(((37) "Rebase" means to replace the base material of a denture without changing the occlusal relations of the teeth.

(38))) "Reline" means to resurface the tissue side of a denture with new base material in order to achieve a more accurate fit.

(((39) "Restorative services" means services or treatments to restore a tooth to its original condition by the filling of a cavity and replacement of lost parts, or the material used in such a procedure.

(40))) "Root planing" is a procedure designed to remove microbial flora, bacterial toxins, calculus, and diseased cementum or dentin from the teeth's root surfaces and pockets.

(((41))) "Scaling" means the removal of calculous material from the exposed tooth surfaces and that part of the teeth covered by the marginal gingiva.

(((42))) "Sealant" is a material applied to teeth to prevent dental caries.

(((43) "Space management therapy" is a treatment to hold space for missing first and/or second primary molars and maintain position for permanent teeth.

(44))) "Sequestrectomy" means removal of dead or dying bone that has separated from healthy bone.

"Therapeutic pulpotomy" means the surgical removal of a portion of the pulp (inner soft tissue of a tooth), to retain the healthy remaining pulp.

"Usual and customary" means the fee that the provider usually charges ((his or her)) non-Medicaid customers for ((a)) the same service or item. This is the maximum amount that the provider may bill MAA ((for the same service or item)).

"Wisdom teeth" means teeth one, sixteen, seventeen, and thirty-two.



[Statutory Authority: Initiative 607, 1995 c 18 2nd sp.s. and 74.08.090. 96-01-006 (Order 3931), 388-535-1050, filed 12/6/95, effective 1/6/96.]



Reviser's note: RCW 34.05.395 requires the use of underlining and deletion marks to indicate amendments to existing rules. The rule published above varies from its predecessor in certain respects not indicated by the use of these markings.



Reviser's note: The typographical errors in the above section occurred in the copy filed by the agency and appear in the Register pursuant to the requirements of RCW 34.08.040.



COVERAGE



NEW SECTION



WAC 388-535-1060  Eligible dental-related clients. (1) Subject to the specific limitations described in WAC 388-535-1080, Covered services, clients of the following MAA programs are eligible for the dental-related services described in this chapter:

(a) Categorically needy (CN or CNP), including:

(i) Children's health; and

(ii) Pregnant undocumented aliens.

(b) Medically needy (MN).

(2) Clients with the following state-only funded eligibility programs receive the coverage described in WAC 388-535-1260:

(a) General assistance unemployable (GAU); and

(b) Alcohol and drug abuse treatment and support act (ADATSA).

(3) Clients of the medically indigent (MI) program are limited to emergency hospital-based services only.



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NEW SECTION



WAC 388-535-1080  Covered dental-related services. (1) MAA pays only for covered dental and dental-related services, equipment, and supplies listed in this section when they are:

(a) Within the scope of an eligible client's medical care program;

(b) Dentally necessary;

(c) Within accepted dental or medical practice standards and are:

(i) Consistent with a diagnosis of dental disease or condition; and

(ii) Reasonable in amount and duration of care, treatment, or service.

(2) The following dental-related services are covered:

(a) Oral health evaluations and assessments.

(i) Oral health evaluations no more than once every six months.

(ii) The evaluation services must be documented in the client's dental file.

(iii) These evaluations must include:

(A) A comprehensive oral health and developmental history;

(B) An assessment of physical and oral health development status;

(C) Health education, including anticipatory guidance; and

(D) Oral health status.

(b) Dentally necessary services for the identification of dental problems or the prevention of dental disease subject to limitations of this chapter;

(c) Prophylaxis treatment is allowed:

(i) Once every twelve months for adults including nursing facility clients.

(ii) Once every six months for children.

(iii) Three times a calendar year for clients of the division of developmental disabilities.

(d) Dental services or treatment necessary for the relief of pain and infections, including removal of symptomatic wisdom teeth. Routine removal of asymptomatic wisdom teeth without justifiable medical indications is not covered;

(e) Restoration of teeth and maintenance of dental health subject to limitations of WAC 388-535-1100, Dental services not covered;

(f) Complex orthodontic treatment for severe handicapping dental needs as specified in WAC 388-535-1250, Orthodontic coverage for DSHS clients;

(g) Complete and partial dentures, and necessary modifications, repairs, rebasing, relining and adjustments of dentures subject to the limitations of WAC 388-535-1240, Dentures;

(h) Dentally necessary oral surgery when coordinated with the client's managed care plan (if any);

(i) Endodontic (root canal) therapies for permanent teeth;

(j) Nitrous oxide only when medically justified and a component of behavior management;

(k) Crowns as described in WAC 388-535-1230, Crowns;

(l) Therapeutic pulpotomies, once per tooth; and

(m) Sealants for:

(i) Occlusal surfaces of teeth, two, three, four, fourteen, fifteen, eighteen, nineteen, thirty and thirty-one;

(ii) Lingual pits of teeth seven and ten;

(iii) Teeth with no decay;

(iv) Children only; and

(v) Once per tooth in a three-year period.

(3) For clients identified by the department as developmentally disabled, the following preventive services may be allowed more frequently than the limits listed in (3) of this section:

(a) Fluoride application, varnish or gel;

(b) Root planing; and

(c) Prophylaxis scaling and coronal polishing.

(4) Panoramic radiographs are allowed only for oral surgical or orthodontic purposes.

(5) The department covers dentally necessary services provided in a hospital under the direction of a physician or dentist for:

(a) The care or treatment of teeth, jaws, or structures directly supporting the teeth if the procedure requires hospitalization; and

(b) Short stays when the procedure cannot be done in an office setting. See WAC 388-550-1100(4), Hospital coverage.

(6) For clients residing in nursing facilities or group homes:

(a) Dental services must be requested by the client or a referral for services made by the attending physician, facility nursing supervisor, or the client's legal guardian;

(b) Mass screening for dental services of clients residing in a facility is not permitted; and

(c) Nursing facilities must provide dental-related necessary services per WAC 388-97-225, Nursing facility care.



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AMENDATORY SECTION (Amending Order 3931, filed 12/6/95, effective 1/6/96)



WAC 388-535-1100  ((Noncovered)) Dental-related services not covered. (1) Dental-related services described in subsection (2) of this section are not covered unless:

(a) Required by a physician as a result of ((a)) an EPSDT/Healthy Kids screen((,included as part of a managed care plan service package;)):

(i) Except that all of the orthodontic limitations of WAC 388-535-1250, Orthodontic coverage for DSHS clients, still apply; and

(ii) Such services must be dentally necessary

(b) Included in a waivered program; or

(c) Part of one of the Medicare programs for ((the)) qualified Medicare beneficiaries((; the)) (QMB) except for QMB-only which is not covered.

(2) MAA ((may exclude from the scope of covered dental-related services)) does not cover:

(a) Services, procedures, treatment, devices, drugs, or application of associated services which MAA or the Health Care Financing Administration (HCFA) consider investigative or experimental on the date the services are provided;

(b) Cosmetic treatment or surgery, except for medically or dentally necessary reconstructive surgery to correct defects attributable to an accident, birth defect, or illness;

(c) ((Orthodontia)) Teeth whitening;

(d)Orthodontic care for adults((, except that Medicaid eligible clients nineteen and twenty years of age who meet the criteria in WAC 388-535-1250 shall be covered));

(((d) Orthodontia))

(e) Orthodontic care for cosmetic reasons and for children who do not meet the criteria in WAC 388-535-1250, ((or who request orthodontia for cosmetic reasons)) Orthodontic coverage for DSHS clients;

(((e))) (f) Any service specifically excluded by statute;

(((f))) (g) More costly services when less costly equally effective services as determined by the department are available;

(((g))) (h) Nonmedical equipment, supplies, personal or comfort items and/or services;

(((h) Prophylaxis, for children seven years of age or younger, unless developmentally disabled;))

(i) Root planing for children(( eighteen years of age or younger)) unless clients of the division of developmental disabilities;

(j) ((Molar endodontics for clients nineteen years of age or older;

(k) Endodontic)) Root canal services for ((anterior)) primary teeth((, except that new therapeutic pulpotomy shall be covered; and

(l) For a persons nineteen years of age and older, unless developmentally disabled:

(i)));

(k) Routine fluoride treatments for adults, unless developmentally disabled;

(((ii) Molar endodontics; or

(iii) Orthognathic surgery))

(l) Extraction of asymptomatic teeth:

(i) Except as a necessary part of orthodontic treatment, or (ii) Unless their removal is the most cost effective dental procedure related to dentures;

(m) Crowns for wisdom teeth; and

(n) Amalgam or acrylic build-up for wisdom teeth.

(((2))) (3) MAA does not pay for the following services/supplies:

(a) Missed or canceled appointments;

(b) Provider mileage or travel costs;

(c) Take-home drugs;

(d) Dental supplies such as toothbrushes((,)) (manual ((or)), automatic, or electric), toothpaste, floss, or whiteners;

(e) Educational supplies;

(f) Reports, client charts, insurance forms, copying expenses;

(g) Service charges/delinquent payment fees;

(h) Dentist's time writing prescriptions or calling in prescriptions or prescription refills to a pharmacy; ((and))

(i) ((Medical)) Supplies used in conjunction with an office visit;

(j) Transitional/immediate dentures;

(k) Teeth implants including follow up and maintenance;

(l) Bridges;

(m) Nonemergent oral surgery for adults performed in an inpatient setting;

(n) Minor bone grafts; or

(o) Temporary crowns.



[Statutory Authority: Initiative 607, 1995 c 18 2nd sp.s. and 74.08.090. 96-01-006 (Order 3931), 388-535-1100, filed 12/6/95, effective 1/6/96.]



AMENDATORY SECTION (Amending Order 3931, filed 12/6/95, effective 1/6/96)



WAC 388-535-1150  ((Eligible)) Becoming a DSHS dental provider((s defined)). (1) The following providers ((shall be)) are eligible for enrollment to provide and be ((reimbursed)) paid for dental-related ((medical)) services to eligible clients:

(a) Persons currently licensed by the state of Washington to:

(i) Practice dentistry or specialties of dentistry;

(ii) Practice medicine and osteopathy((,)) for:

(A) Oral surgery procedures;

(((b) Persons currently licensed by the state of Washington to practice dentistry;

(c) Persons currently licensed by the state of Washington to)) or

(B) Fluoride varnish under EPSDT/Healthy Kids.

(iii) Practice as dental hygienists;

(((d) Persons currently licensed by the state of Washington to)) (iv) Provide denture services (((denturists)));

(((e))) (v) Practice anesthesiology; or

(vi) Provide conscious sedation, when providing that service in dental offices for dental treatments and when certified by the department of health.

(b) Facilities which are:

(i) Hospitals currently licensed by the department of health;

(((f))) (ii) Federally-qualified health centers;

(((g) Participating health departments;

(h))) (iii) Medicare-certified ambulatory surgical centers;

(((i))) (iv) Medicare-certified rural health clinics;

(((j) Public health providers of dental screening services who have a signed agreement with the department to provide such services to persons eligible for EPSDT/healthy kids services)) or

(v) Community health centers.

(c) Participating local health jurisdictions; and

(((k))) (d) Border area or out-of-state providers of dental-related services qualified in their states to provide these services.

(2) ((A)) Licensed providers participating in the MAA dental program may be ((reimbursed)) paid only for those services that are within ((his or her)) their scope of practice.

(((3) The provider shall bill the department and its clients according to WAC 388-87-010 and 388-87-015.))



[Statutory Authority: Initiative 607, 1995 c 18 2nd sp.s. and 74.08.090. 96-01-006 (Order 3931), 388-535-1150, filed 12/6/95, effective 1/6/96.]



AMENDATORY SECTION (Amending Order 3931, filed 12/6/95, effective 1/6/96)



WAC 388-535-1200  Dental services requiring prior authorization. (((1))) The following services require prior approval:

(((a) Nonemergent surgical procedures as described under WAC 388-86-095;

(b))) (1) Nonemergent inpatient hospital dental admissions as described under WAC ((388-86-050 and 388-87-070)) 388-550-1100(1) Hospital coverage;

(((c))) (2) Orthodontic treatment as described under WAC ((388-535-1000 (3)(f))) 388-535-1250;

(((d) Cast base partial))

(3) Dentures as described in WAC 388-535-1240;

(((e) Coronal polishing and scaling for children seven years of age and under; or

(f))) (4) Crowns as described in WAC 388-535-1230; and

(5) Selected procedures ((determined by the department)) identified by MAA, published in its current dental billing instructions, available from MAA at Olympia, Washington.

(((2) When requesting prior approval, the department shall require the dental provider to submit, in writing, sufficient objective clinical information to establish medical necessity including, but not limited to:

(a) A physiological description of the disease, injury, impairment, or other ailment;

(b) Pertinent laboratory findings;

(c) X-ray reports; and

(d) Patient profiles.

(3) The department shall approve a request when the requested service meets the criteria in WAC 388-535-1000(2), Scope of coverage.

(4) The department shall deny a request for dental services when the requested service is:

(a) Not medically necessary as defined under WAC 388-500-0005; or

(b) A service, procedure, treatment, device, drug, or application of associated service which MAA or the Health Care Financing Administration (HCFA) consider investigative or experimental on the date the service is provided.

(5) The department may require a second opinion and/or consultation before the approval of any elective oral surgical procedure.))



[Statutory Authority: Initiative 607, 1995 c 18 2nd sp.s. and 74.08.090. 96-01-006 (Order 3931), 388-535-1200, filed 12/6/95, effective 1/6/96.]



NEW SECTION



WAC 388-535-1220  Obtaining prior authorization for dental services. Authorization by MAA only indicates that the specific treatment is dentally necessary. Authorization for dental services does not guarantee payment.

(1) When requesting prior authorization, the dental provider must submit to MAA, in writing, sufficient objective clinical information to establish dental necessity including, but not limited to:

(a) Physiological description of the disease, injury, impairment, or other ailment;

(b) X-ray(s);

(c) Treatment plan;

(d) Study model, if requested; and

(e) Photographs, if requested.

(2) When the requested service meets the criteria in WAC 388-535-1080, Covered services, it will be authorized.

(3) A request for dental services will be denied when the requested service is:

(a) Not dentally necessary; or

(b) A service, procedure, treatment, device, drug, or application of associated service which MAA or the Health Care Financing Administration (HCFA) consider investigative or experimental on the date the service is provided.

(4) Second opinions and/or consultations may be required before the authorization of any elective procedure.

(5) Authorization is valid only if the client is eligible for the date of service.

(6) Miscellaneous or unspecified procedures may require prior authorization at MAA's discretion.



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NEW SECTION



WAC 388-535-1230  Crowns. (1) The following crowns do not need authorization and are covered:

(a) Stainless steel, and

(b) Nonlaboratory resin for primary anterior teeth.

(2) The following crowns are limited to single restorations for permanent anterior (upper and lower) teeth and require prior authorization by MAA:

(a) Porcelain fused to a high noble metal;

(b) Porcelain fused to a predominately base metal;

(c) Porcelain fused to a noble metal;

(d) Porcelain with ceramic substrate;

(e) Full cast high noble metal;

(f) Full cast predominately base metal;

(g) Full cast noble metal; and

(h) Resin (laboratory).

(3) Criteria for crowns:

(a) Crowns may be authorized when the tooth meets the criteria of dentally necessary.

(b) Coverage is based upon a supportable five year prognosis that the client will retain the tooth if crowned. The provider must submit the following information:

(i) The overall condition of the mouth;

(ii) Oral health status;

(iii) Patient maintenance of good oral health status;

(iv) Arch integrity; and

(v) Prognosis of remaining teeth (that is, no more involved than periodontal case type II).

(c) Anterior teeth must show traumatic or pathological destruction to loss of at least one incisal angle.

(4) The laboratory processed crowns described in subsection (2):

(a) Are covered only once per permanent tooth in a five year period;

(b) Are covered for endodontically treated anterior teeth only after satisfactory completion of the root canal therapy. Post-endodontic treatment X-rays must be submitted for prior authorization of these crowns; and

(c) Including tooth and soft tissue preparation, amalgam or acrylic build-ups, temporary restoration, cement base, insulating bases, impressions, and local anesthesia; and

(d) Are covered when a lesser service will not suffice because of extensive coronal destruction, and treatment is beyond intracoronal restoration.



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NEW SECTION



WAC 388-535-1240  Dentures. (1) Initial dentures do not require prior authorization except as described in subsection (4).

(2) Partial dentures are covered under these limits:

(a) Cast base partials only when replacing three or more teeth per arch excluding wisdom teeth; and

(b) No partials are covered when they replace wisdom teeth only.

(3) Prior authorization for replacement dentures or partials is not required when:

(a) The client's existing dentures or partials are:

(i) No longer serviceable and cannot be relined or rebased;

(ii) Are lost; or

(iii) Are damaged beyond repair.

(b) The client's health would be adversely affected by absence of dentures;

(c) The client has been able to wear dentures successfully; and

(d) The denture meets the criteria of dentally necessary.

(4) Payment (which may be partial) for laboratory and professional fees for dentures and partials requires prior authorization when the client:

(a) Dies;

(b) Moves from the state;

(c) Cannot be located; or

(d) Does not participate in completing the dentures.

(5) The provider must document in the client's medical or dental record:

(a) Justification for replacement of dentures; and

(b) Charts of missing teeth, for replacement of partials.

(6) The impression date may be used as the service date for dentures including partials only when:

(a) Related dental services including laboratory services were provided during a client's eligible period; and

(b) The client is not eligible at the time of delivery.



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AMENDATORY SECTION (Amending Order 3931, filed 12/6/95, effective 1/6/96)



WAC 388-535-1250  Orthodontic coverage for DSHS ((clients)) children. ((The department shall cover orthodontia care when:)) Complex orthodontic treatment for severe handicapping dental needs is covered only for categorically needy children subject to the limits of this section.

(1) Prior ((authorized;)) authorization is not required for cleft lip, cleft palate, or craniofacial anomalies when the client is:

(a) Being treated by a department-recognized cleft lip, cleft palate or craniofacial anomaly team; and

(b) Eligible per WAC 388-535-1060.

(2) ((A client is eligible for EPSDT/healthy kids services; and)) Orthodontic care must be prior authorized for children with severe malocclusions.

(3) A client ((meets)) must meet one of the following categories to be eligible for orthodontic care:

(a) A child with clefts ((and congenital or acquired)) (lip or palate) craniofacial anomalies and severe malocclusions when followed by an MAA-recognized cleft lip, cleft palate, or craniofacial team for:

(i) Cleft lip and palate, cleft palate, ((and)) or cleft lip with alveolar process involvement;

(ii) Craniofacial anomalies, including but not limited to:

(A) Hemifacial microsomia;

(B) Craniosynostosis syndromes;

(C) Cleidocranial dysplasia;

(D) Arthrogryposis;

(E) Marfans syndrome; or

(F) Other syndromes by MAA review;

(iii) Other diseases/dysplasia with significant facial growth impact, e.g., juvenile rheumatoid arthritis (JRA); or

(iv) Post traumatic, post radiation, or post burn jaw deformity.

(b) A child with severe malocclusions which include one or more of the following:

(i) A severe skeletal disharmony;

(ii) A severe overjet resulting in functional impairment;

(iii) A severe vertical overbite resulting in palatal impingement((;)) and/or damage to the mandibular labial tissues.

(((c))) (d) A child with other dental malformations resulting in severe dental functional impairment ((shall be reviewed)). MAA reviews each of these cases for ((medical)) dental necessity.

(4) Interceptive orthodontic treatment is covered once per client's lifetime for clients with cleft palate, craniofacial anomaly, or severe malocclusions.

(5) Limited transitional orthodontic care is covered for a maximum of one year from original placement. Follow up treatment is allowed in three-month increments after the initial treatment.

(6) Full orthodontic care is limited to a maximum of two years from original banding. Six follow up treatments are allowed in three month increments, beginning six months after original bonding.

(7) Lost or broken orthodontics appliances are not covered. (8) Orthodontic removal is covered for a client whose appliance was placed by a provider not participating with MAA, or whose payment was not covered by MAA.



[Statutory Authority: Initiative 607, 1995 c 18 2nd sp.s. and 74.08.090. 96-01-006 (Order 3931), 388-535-1250, filed 12/6/95, effective 1/6/96.]



Reviser's note: The typographical error in the above section occurred in the copy filed by the agency and appears in the Register pursuant to the requirements of RCW 34.08.040.



NEW SECTION



WAC 388-535-1260  Dental-related limits of state-only funded programs. (1) Clients with the following state-funded only eligibility programs receive only the limited coverage described in this section:

(a) General assistance unemployable (GAU); and

(b) Alcohol and drug abuse treatment and support act (ADATSA) (GAU-W).

(2) The dental services described and limited in this chapter are covered for clients eligible for GAU or GAU-W only when provided as part of a medical treatment for:

(a) Apical abscess verified by clinical examination, and treated by:

(i) Open and drain palliative treatment;

(ii) Tooth extraction; or

(iii) Root canal;

(b) Radiation therapy for cancer of the mouth, only for a total dental extraction performed prior to and because of that radiation therapy;

(c) Tooth fractures (limited to extraction);

(d) Maxillofacial fracture;

(e) Systemic or presystemic cancer, only for oral hygiene related to those conditions;

(f) Cysts or tumor therapies; or

(g) Sequestrectomies.

(3) MAA may require prior authorization for any dental treatment provided to a GAU or GAU-W client.



[]



AMENDATORY SECTION (Amending Order 3931, filed 12/6/95, effective 1/6/96)



WAC 388-535-1300  Access to baby and child dentistry (ABCD) program. (1) The access to baby and child dentistry (ABCD) program is a demonstration project ((in Spokane County,)) established to increase access to dental services in targeted areas for Medicaid eligible infants, toddlers, and preschoolers.

(2) Children eligible for the ABCD program ((shall)) must be ((four)) five years of age ((and under)) or younger and residing in ((Spokane County)) targeted areas selected by MAA.

(3) ((Dental providers certified by the University of Washington continuing education program shall provide ABCD services)) MAA pays enhanced fees to ABCD-certified participating providers for the targeted services. The University of Washington continuing education program certifies dental providers for ABDC services.

(4) In addition to services provided under the ((medical assistance administration ())MAA(())) dental care program, the following services are provided:

(a) Family oral health education; and

(b) Case management services.

(5) Clients who do not comply with program requirements may be disqualified from the ABCD program. The client remains eligible for regular MAA dental coverage((.

(6) MAA pays enhanced fees to ABCD-certified participating providers for the targeted services)).



[Statutory Authority: Initiative 607, 1995 c 18 2nd sp.s. and 74.08.090. 96-01-006 (Order 3931), 388-535-1300, filed 12/6/95, effective 1/6/96.]



Reviser's note: RCW 34.05.395 requires the use of underlining and deletion marks to indicate amendments to existing rules. The rule published above varies from its predecessor in certain respects not indicated by the use of these markings.



PAYMENT



AMENDATORY SECTION (Amending Order 3931, filed 12/6/95, effective 1/6/96)



WAC 388-535-1350  ((Payment methodology--)) Dental-related services-Payment methodology. The department uses the dental services described in the Current Dental Terminology, 2nd edition (CDT-2), and the Current Procedure Terminology (CPT). The department uses state-assigned procedure codes to identify services not fully described in the CDT-2 or CPT descriptions.

(1) For covered services provided to eligible clients, MAA ((shall reimburse)) pays dentists and related providers on a fee-for-service or ((contract)) contractual basis, subject to the exceptions and restrictions listed under WAC 388-535-1100, ((Noncovered)) Dental services not covered, and WAC 388-535-1400, Dental payment limits.

(2) ((In general maximum allowable fees (MAFs) for dental services provided to adult clients are based on the department's historical reimbursement rates, updated for legislatively authorized vendor rate increases.

(3))) MAA may pay providers a higher reimbursement rate for selected dental services provided to children ((eighteen years and younger)) in order to increase children's access to dental services.

(((4))) (3) Maximum allowable fees (((MAFs))) for dental services provided to children are set as follows:

(a) The department's historical reimbursement rates for various procedures are compared to usual and customary charges.

(b) The department consults with and seeks input from representatives of the provider community to identify program areas((/)) and concerns that need to be addressed.

(c) The department consults with dental experts and public health professionals to identify and prioritize dental services((/)) and procedures in terms of their effectiveness in improving ((and/))or promoting children's dental health.

(d) Legislatively authorized vendor rate increases and/or earmarked appropriations for children's dental services are allocated to specific procedures based on this priority list and considerations of access to services.

(e) Larger percentage increases ((are)) may be given to those procedures which have been identified as most effective in improving ((and/))or promoting children's dental health.

(f) Budget-neutral rate adjustments are made as appropriate based on the department's evaluation of utilization trends, effectiveness of interventions, and access issues.

(((5))) (4) Dental general anesthesia services for all eligible clients are reimbursed on the basis of base anesthesia units (((BAU))) plus time. Payment for dental general anesthesia is calculated as follows:

(a) Dental procedures are assigned ((five base)) an anesthesia base unit((s)) of five;

(b) Twelve minutes constitute one unit of time. When a dental procedure requiring dental general anesthesia results in multiple time units and a remainder (less than twelve minutes), the remainder or fraction ((shall be)) is considered as one time unit;

(c) Time units are added to the ((five base)) anesthesia base unit((s)) of five and multiplied by the anesthesia conversion factor;

(d) The formula for determining ((reimbursement)) payment for dental general anesthesia is: (5.0 base anesthesia units .+time units) x conversion factor .= payment.

(5) Anesthesiologists may be paid for general dental anesthesia provided in dental offices. Only anesthesiologists specially contracted by MAA will be paid an additional fee for that service.

(6) Dental hygienists ((shall be)) are paid at the same rate as dentists for services allowed under The Dental Hygienist Practice Act available from the department of health, Olympia, Washington.

(7) Licensed denturists or dental laboratories billing independently ((shall be)) are paid at MAA's allowance for ((prosthodontics)) prosthetics (dentures and partials) services.

(8) Fee schedule changes are made whenever vendor rate increases or decreases are authorized by the legislature.

(9) ((The department uses the American Dental Association's Current Dental Terminology, Second Edition (CDT-2) as the basis for identification of dental services. The department supplements this list with state-assigned procedure codes to identify services which do not fit exactly into the CDT-2 descriptions.

(10))) The department may adjust maximum allowable fees to reflect changes in the services or procedure code descriptions.



[Statutory Authority: Initiative 607, 1995 c 18 2nd sp.s. and 74.08.090. 96-01-006 (Order 3931), 388-535-1350, filed 12/6/95, effective 1/6/96.]



AMENDATORY SECTION (Amending Order 3931, filed 12/6/95, effective 1/6/96)



WAC 388-535-1400  Dental payment limits. (1) Provision of covered dental services to ((a client)) an eligible ((for a medical care program)) client constitutes acceptance by the provider of the department's rules and fees.

(2) Participating providers ((shall)) must bill the department their usual and customary fees.

(3) Payment for dental services is based on the department's schedule of maximum allowances. Fees listed in the MAA fee schedule are the maximum allowable fees.

(4) Payment to the provider will be the lesser of the billed charge (usual and customary fee) or the department's maximum allowable fee.

(5) If a covered service is performed for which no fee is listed, the service ((shall be)) is paid "By Report((.))" on a case-by-case basis as determined by MAA

(6) ((Clients shall be responsible for payment as described under WAC 388-087-010 for services not covered under the client's medical care program)) If eligibility for dental services ends before the conclusion of the dental treatment, payment for any remaining treatment is the client's responsibility.

The client is responsible for payment of any dental treatment or service received during any period of ineligibility with the exception described in WAC 388-535-1240(4) even if the treatment was started when the client was eligible.



[Statutory Authority: Initiative 607, 1995 c 18 2nd sp.s. and 74.08.090. 96-01-006 (Order 3931), 388-535-1400, filed 12/6/95, effective 1/6/96.]



AMENDATORY SECTION (Amending Order 3931, filed 12/6/95, effective 1/6/96)



WAC 388-535-1450  ((Payment--)) Denture laboratory services -Payment. (((1))) A dentist using the services of an independent denture laboratory ((shall request services for an MAA client in the same manner he or she requests services for his or her private patient)) must bill MAA for the services of the laboratory.

(((2) An independently practicing denturist may bill the department directly.)) No ((reimbursement shall be)) payment will be made to a dentist for services performed and billed by an independent denturist.



[Statutory Authority: Initiative 607, 1995 c 18 2nd sp.s. and 74.08.090. 96-01-006 (Order 3931), 388-535-1450, filed 12/6/95, effective 1/6/96.]



AMENDATORY SECTION (Amending Order 3931, filed 12/6/95, effective 1/6/96)



WAC 388-535-1500  ((Payment--))Dental-related hospital services--Payment. ((The department shall pay for medically)) Dentally necessary ((dental-related)) hospital inpatient and outpatient services ((according to)) in accord with WAC ((388-87-070 and 388-87-072)) 388-550-1100.



[Statutory Authority: Initiative 607, 1995 c 18 2nd sp.s. and 74.08.090. 96-01-006 (Order 3931), 388-535-1500, filed 12/6/95, effective 1/6/96.]



AMENDATORY SECTION (Amending Order 3931, filed 12/6/95, effective 1/6/96)



WAC 388-535-1550  Dental care provided out-of-state-Payment. (1) ((The department shall authorize and provide comparable dental care services to)) Clients, except those receiving medical care services (state-only funding), who are temporarily outside ((of)) the state ((to the same extent that such)) receive the same dental care services ((are furnished to)) as clients in the state, subject to the same exceptions and limitations ((as in-state clients)).

(2) ((The department shall not provide)) Out-of-state dental care ((to)) received by clients receiving medical care services ((as defined under WAC 388-500-0005. The department shall cover dental services in designated bordering cities for)) (state-only funding) is not covered.

(3) Eligible clients in MAA-designated border areas may receive the same dental services as if provided in state.

(((3) Out-of-state))

(4) Dental providers ((shall)) who are out-of-state must meet the same criteria for payment as in-state providers, including the requirements to contract with MAA.



[Statutory Authority: Initiative 607, 1995 c 18 2nd sp.s. and 74.08.090. 96-01-006 (Order 3931), 388-535-1550, filed 12/6/95, effective 1/6/96.]



REPEALER



The following section of the Washington Administrative Code is repealed:



WAC 388-535-1000 Dental-related services--Scope of coverage.

Legislature Code Reviser 

Register

Washington State Code Reviser's Office