PROPOSED RULES
SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)
Original Notice.
Preproposal statement of inquiry was filed as WSR 06-21-067 and 05-20-086.
Title of Rule and Other Identifying Information: Part 4 of 4: Amending WAC 388-535-1100 Dental-related services not covered for clients through age twenty, 388-535-1220 Obtaining prior authorization for dental-related services for clients through age twenty, 388-535-1245 Access to baby and child dentistry (ABCD) program; and repealing WAC 388-535-1200 Dental-related services requiring prior authorization -- Children, 388-535-1230 Crowns for children, and 388-535-1240 Dentures, partial dentures, and overdentures for children.
Hearing Location(s): Blake Office Park East, Rose Room, 4500 10th Avenue S.E., Lacey, WA 98503 (one block north of the intersection of Pacific Avenue S.E. and Alhadeff Lane, behind Goodyear Tire. A map or directions are available at http://www1.dshs.wa.gov/msa/rpau/docket.html or by calling (360) 664-6097), on January 9, 2007, at 10:00 a.m.
Date of Intended Adoption: Not earlier than January 10, 2007.
Submit Written Comments to: DSHS Rules Coordinator, P.O. Box 45850, Olympia, WA 98504, delivery 4500 10th Avenue S.E., Lacey, WA 98503, e-mail fernaax@dshs.wa.gov, fax (360) 664-6185, by 5:00 p.m. on January 9, 2007.
Assistance for Persons with Disabilities: Contact Stephanie Schiller, DSHS Rules Consultant, by January 5, 2007, TTY (360) 664-6178 or (360) 664-6097 or by e-mail at schilse@dshs.wa.gov.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The amended sections clarify and update policies for dental-related services for clients through age twenty; ensure that department policies are applied correctly and equitably; replace the terms "medical assistance administration" and "MAA" with "the department"; update policy regarding prior authorization requirements; clarify policy on covered versus noncovered benefits; clarify additional benefits and limitations associated with those services for clients through age twenty; clarify policy for the ABCD program; and repeal WAC 388-535-1200, 388-535-1230, and 388-535-1240 and incorporate updated policy into new sections.
Reasons Supporting Proposal: To clarify new dental-related services covered and the limitations associated with those services; to make HRSA's rules regarding covered and noncovered dental-related services for clients through age twenty clearer and easier to understand for clients and dental providers; and to identify the requirements and criteria that must be met in order to obtain covered dental-related services.
Statutory Authority for Adoption: RCW 74.04.050, 74.08.090, 74.09.500, 74.09.520.
Statute Being Implemented: RCW 74.04.050, 74.08.090, 74.09.500, 74.09.520.
Rule is not necessitated by federal law, federal or state court decision.
Name of Proponent: Department of social and health services, governmental.
Name of Agency Personnel Responsible for Drafting: Kathy Sayre, 626 8th Avenue, Olympia, WA 98504-5504, (360) 725-1342; Implementation and Enforcement: Dr. John Davis, 626 8th Avenue, Olympia, WA 98504-5504, (360) 725-1748.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The proposed rules do not create more than minor costs to small businesses.
A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Dr. John Davis, P.O. Box 45506, Olympia, WA 98504-5506, phone (360) 725-1748, TYY/TDD 1-800-848-5429, fax (360) 586-1590, e-mail davisjd@dshs.wa.gov.
November 30, 2006
Andy Fernando, Manager
Rules and Policies Assistance Unit
3807.4(a) Required by a physician as a result of an EPSDT screen as provided under chapter 388-534 WAC; or
(b) Included in an MAA waivered program.
(2) MAA does not cover the following services for children:
(a) Any service specifically excluded by statute;
(b) More costly services when less costly, equally effective services as determined by the department are available;
(c) Services, procedures, treatment, devices, drugs, or application of associated services which the department or the Centers for Medicare and Medicaid Services (CMS) (formerly known as the Health Care Financing Administration (HCFA)) consider investigative or experimental on the date the services were provided;
(d) Routine fluoride treatments (gel or varnish) for clients age nineteen through twenty, unless the clients are:
(i) Clients of the division of developmental disabilities; or
(ii) Diagnosed with xerostomia, in which case the provider must request prior authorization.
(e) Crowns, as follows:
(i) For wisdom and peg teeth;
(ii) Laboratory processed crowns for posterior teeth;
(iii) Temporary crowns, including stainless steel crowns placed as temporary crowns; and
(iv) Post and core for crowns.
(f) Root canal services for primary or wisdom teeth;
(g) Root planing, unless they are clients of the division of developmental disabilities;
(h) Bridges;
(i) Transitional or treatment dentures;
(j) Teeth implants, including follow up and maintenance;
(k) Cosmetic treatment or surgery, except for medically necessary reconstructive surgery to correct defects attributable to an accident, birth defect, or illness;
(l) Porcelain margin extensions (also known as crown lengthening), due to receding gums;
(m) Extraction of asymptomatic teeth;
(n) Minor bone grafts;
(o) Nonemergent oral surgery performed in an inpatient hospital setting, except for the following:
(i) For clients of the division of developmental disabilities, or for children eighteen years of age or younger whose surgeries cannot be performed in an office setting. This requires written prior authorization for the inpatient hospitalization; or
(ii) As provided in WAC 388-535-1080(4).
(p) Dental supplies such as toothbrushes (manual, automatic, or electric), toothpaste, floss, or whiteners;
(q) Dentist's time writing prescriptions or calling in prescriptions or prescription refills to a pharmacy;
(r) Educational supplies;
(s) Missed or canceled appointments;
(t) Nonmedical equipment, supplies, personal or comfort items or services;
(u) Provider mileage or travel costs;
(v) Service charges or delinquent payment fees;
(w) Supplies used in conjunction with an office visit;
(x) Take-home drugs;
(y) Teeth whitening; or
(z) Restorations for anterior or posterior wear with no evidence of decay.
(3) MAA evaluates a request for any service that is listed as noncovered under the provisions of WAC 388-501-0165)) department does not cover the following for clients through age twenty:
(a) The dental-related services described in subsection (2) of this section unless the services include those medically necessary services and other measures provided to correct or ameliorate conditions discovered during a screening performed under the early periodic screening, diagnosis and treatment (EPSDT) program. See WAC 388-534-0100 for information about the EPSDT program.
(b) Any service specifically excluded by statute.
(c) More costly services when less costly, equally effective services as determined by the department are available.
(d) Services, procedures, treatment, devices, drugs, or application of associated services:
(i) Which the department or the Centers for Medicare and Medicaid Services (CMS) considers investigative or experimental on the date the services were provided.
(ii) That are not listed as covered in one or both of the following:
(A) Washington Administrative Code (WAC).
(B) The department's current published documents.
(2) The department does not cover dental-related services listed under the following categories of service for clients through age twenty (see subsection (1)(a) of this section for services provided under the EPSDT program):
(a) Diagnostic services. The department does not cover:
(i) Extraoral radiographs.
(ii) Comprehensive periodontal evaluations.
(b) Preventive services. The department does not cover:
(i) Nutritional counseling for control of dental disease.
(ii) Tobacco counseling for the control and prevention of oral disease.
(iii) Removable space maintainers of any type.
(iv) Sealants placed on a tooth with the same-day occlusal restoration, pre-existing occlusal restoration, or a tooth with occlusal decay.
(v) Space maintainers for clients ages nineteen through twenty.
(c) Restorative services. The department does not cover:
(i) Gold foil restorations.
(ii) Metallic, resin-based composite, or porcelain/ceramic inlay/onlay restorations.
(iii) Crowns for cosmetic purposes (e.g., peg laterals and tetracycline staining).
(iv) Crowns for third molars one, sixteen, seventeen, and thirty-two.
(v) Temporary or provisional crowns (including ion crowns).
(vi) Labial veneer resin or porcelain laminate restorations.
(vii) Any type of coping.
(viii) Crown repairs.
(ix) Polishing or recontouring restorations or overhang removal for any type of restoration.
(d) Endodontic services. The department does not cover:
(i) Any endodontic therapy on primary teeth, except as described in WAC 388-535-1086 (3)(a).
(ii) Apexification/recalcification for root resorption of permanent anterior teeth.
(iii) Any apexification/recalcification procedures for bicuspid or molar teeth.
(iv) Any apicoectomy/periradicular services for bicuspid or molar teeth.
(v) Any surgical endodontic procedures including, but not limited to, retrograde fillings (except for anterior teeth), root amputation, reimplantation, and hemisections.
(e) Periodontic services. The department does not cover:
(i) Surgical periodontal services including, but not limited to:
(A) Gingival flap procedures.
(B) Clinical crown lengthening.
(C) Osseous surgery.
(D) Bone or soft tissue grafts.
(E) Biological material to aid in soft and osseous tissue regeneration.
(F) Guided tissue regeneration.
(G) Pedicle, free soft tissue, apical positioning, subepithelial connective tissue, soft tissue allograft, combined connective tissue and double pedicle, or any other soft tissue or osseous grafts.
(H) Distal or proximal wedge procedures.
(ii) Nonsurgical periodontal services including, but not limited to:
(A) Intracoronal or extracoronal provisional splinting.
(B) Full mouth or quadrant debridement.
(C) Localized delivery of chemotherapeutic agents.
(D) Any other type of nonsurgical periodontal service.
(f) Removable prosthodontics. The department does not cover:
(i) Removable unilateral partial dentures.
(ii) Any interim complete or partial dentures.
(iii) Precision attachments.
(iv) Replacement of replaceable parts for semi-precision or precision attachments.
(g) Implant services. The department does not cover:
(i) Any type of implant procedures, including, but not limited to, any tooth implant abutment (e.g., periosteal implant, eposteal implant, and transosteal implant), abutments or implant supported crown, abutment supported retainer, and implant supported retainer.
(ii) Any maintenance or repairs to procedures listed in (g)(i) of this subsection.
(iii) The removal of any implant as described in (g)(i) of this subsection.
(h) Fixed prosthodontics. The department does not cover:
(i) Any type of fixed partial denture pontic or fixed partial denture retainer.
(ii) Any type of precision attachment, stress breaker, connector bar, coping, cast post, or any other type of fixed attachment or prosthesis.
(i) Oral and maxillofacial surgery. The department does not cover:
(i) Any oral surgery service not listed in WAC 388-535-1094.
(ii) Any oral surgery service that is not listed in the department's list of covered Current Procedural Terminology (CPT) codes published in the department's current rules or billing instructions.
(j) Adjunctive general services. The department does not cover:
(i) Anesthesia, including, but not limited to:
(A) Local anesthesia as a separate procedure.
(B) Regional block anesthesia as a separate procedure.
(C) Trigeminal division block anesthesia as a separate procedure.
(D) Medication for oral sedation, or therapeutic intramuscular (IM) drug injections, including antibiotic and injection of sedative.
(E) Application of any type of desensitizing medicament or resin.
(ii) Other general services including, but not limited to:
(A) Fabrication of an athletic mouthguard.
(B) Occlusion analysis.
(C) Occlusal adjustment or odontoplasties.
(D) Enamel microabrasion.
(E) Dental supplies such as toothbrushes, toothpaste, floss, and other take home items.
(F) Dentist's or dental hygienist's time writing or calling in prescriptions.
(G) Dentist's or dental hygienist's time consulting with clients on the phone.
(H) Educational supplies.
(I) Nonmedical equipment or supplies.
(J) Personal comfort items or services.
(K) Provider mileage or travel costs.
(L) Fees for no-show, cancelled, or late arrival appointments.
(M) Service charges of any type, including fees to create or copy charts.
(N) Office supplies used in conjunction with an office visit.
(O) Teeth whitening services or bleaching, or materials used in whitening or bleaching.
[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 2003 1st sp.s. c 25, P.L. 104-191. 03-19-078, § 388-535-1100, filed 9/12/03, effective 10/13/03. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.500, 74.09.520, 42 U.S.C. 1396d(a), 42 C.F.R. 440.100 and 440.225. 02-13-074, § 388-535-1100, filed 6/14/02, effective 7/15/02. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 USC 1396d(a), CFR 440.100 and 440.225. 99-07-023, § 388-535-1100, filed 3/10/99, effective 4/10/99. 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.]
(1) MAA)) (1) The department uses the determination process for payment described in WAC 388-501-0165 for covered dental-related services for clients through age twenty that require prior authorization.
(2) The department requires a dental provider who is
requesting prior authorization to submit sufficient objective
clinical information to establish medical necessity. The
request must be submitted in writing on an American Dental
Association (ADA) claim form, which may be obtained by writing
to the American Dental Association, 211 East Chicago Avenue,
Chicago, Illinois 60611. ((The request must include at least
all of the following:))
(3) The department may request additional information as follows:
(a) ((Physiological description of the disease, injury,
impairment, or other ailment;
(b))) Additional radiographs (x-rays)(refer to WAC 388-535-1080(2)).;
(((c) Treatment plan;
(d))) (b) Study models ((, if requested)); ((and
(e))) (c) Photographs((, if requested)); and
(d) Any other information as determined by the department.
(4) The department may require second opinions and/or consultations before authorizing any procedure.
(((2) MAA authorizes requested services that meet the
criteria in WAC 388-535-1080.
(3) MAA denies a request for dental services when the requested service is:
(a) Not medically necessary; or
(b) A service, procedure, treatment, device, drug, or application of associated service which the department or the Centers for Medicare and Medicaid Services (CMS) (formerly known as the Health Care Financing Administration (HCFA)) consider investigative or experimental on the date the service is provided.
(4) MAA may require second opinions and/or consultations before authorizing any procedure.
(5) Authorization is valid only if the client is eligible for covered services on the date of service)) (5) When the department authorizes a dental-related service for a client, that authorization indicates only that the specific service is medically necessary; it is not a guarantee of payment. The authorization is valid for six months and only if the client is eligible for covered services on the date of service.
(6) The department denies a request for a dental-related service when the requested service:
(a) Is covered by another department program;
(b) Is covered by an agency or other entity outside the department; or
(c) Fails to meet the program criteria, limitations, or restrictions in chapter 388-535 WAC.
[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 2003 1st sp.s. c 25, P.L. 104-191. 03-19-078, § 388-535-1220, filed 9/12/03, effective 10/13/03. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.500, 74.09.520, 42 U.S.C. 1396d(a), 42 C.F.R. 440.100 and 440.225. 02-13-074, § 388-535-1220, filed 6/14/02, effective 7/15/02. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 USC 1396d(a), CFR 440.100 and 440.225. 99-07-023, § 388-535-1220, filed 3/10/99, effective 4/10/99.]
(1) Client eligibility for the ABCD program is as follows:
(a) Clients must be age five ((years of age or)) and
younger ((and reside in targeted areas selected by the medical
assistance administration (MAA))). Once enrolled in the ABCD
program, ((an)) eligible clients ((is)) are covered until
((reaching age six)) their sixth birthday.
(b) ((Eligible clients enrolled in a managed care plan
are eligible for the ABCD program under fee-for-service.
(c) Eligible)) Clients ((enrolled in)) eligible under one
of the following medical assistance programs are eligible for
the ABCD program:
(i) Categorically needy program (((CN or)) CNP);
(ii) Limited casualty program((/))-medically needy
program (LCP((/))-MNP); ((and))
(iii) Children's health program; or
(iv) State children's health insurance program (SCHIP).
(c) ABCD program services for eligible clients enrolled in a managed care organization (MCO) plan are paid through the fee-for-service payment system.
(2) Health care providers and community service programs
((in the targeted areas)) identify and refer eligible clients
to the ABCD program. If enrolled, the client and an adult
family member may receive:
(a) ((An ABCD program identification card;
(b))) Oral health ((information)) education;
(((c))) (b) "Anticipatory guidance" (expectations of the
client and the client's family members, including the
importance of keeping appointments); and
(((d))) (c) Assistance with ((obstacles to care, such as
lack of)) transportation((; and
(e) Case management services, for families who do not cooperate with the training(s) in this subsection.
(3) Families who do not cooperate with the training(s) in subsection (2) of this section may be disqualified from the ABCD program. The client remains eligible for MAA dental coverage as described in this chapter.
(4) The)), interpreter services, and other issues related to dental services.
(3) Dentists must be certified through the continuing
education program in the University of Washington School of
Pediatric Dentistry(('s continuing education program certifies
dental providers)) to furnish ABCD program services.
(((5) MAA)) (4) The department pays enhanced fees to
ABCD-certified participating providers for furnishing ABCD
program services. ((In addition to services provided under
MAA's dental care program, the ABCD program provides family
oral health education, which is allowed twice per year, per
family, and must include)) ABCD program services include, when
appropriate:
(a) ((Risk assessment;
(b))) Family oral health ((instruction/training;
(c) Dietary counseling;
(d) Fluoride supplements, if appropriate; and
(e) Documentation in)) education. An oral health education visit:
(i) Must have a duration of at least twenty minutes for each visit;
(ii) Is limited to one visit per day per family, up to two visits per calendar year; and
(iii) Must include all of the following:
(A) "Lift lip" training;
(B) Oral hygiene training;
(C) Risk assessment for early childhood caries;
(D) Dietary counseling;
(E) Topical application of gel or varnish;
(F) Discussion of fluoride supplements; and
(G) Documentation in the client's file or the client's designated adult member's (family member or other responsible adult) file to record the activities provided and duration of the oral education visit.
(b) Comprehensive and periodic oral evaluation, up to two visits per client, per calendar year;
(c) Amalgam and resin restorations on primary teeth, as specified in current department-published documents;
(d) Therapeutic pulpotomy;
(e) Prefabricated stainless steel crowns on primary teeth, as specified in current department-published documents;
(f) Resin-based composite crowns on anterior primary teeth; and
(g) Other dental-related services, as specified in current department-published documents.
(5) The client's file must show documentation of the ABCD program services provided.
[Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.500, 42 U.S.C. 1396d(a), 42 C.F.R. 440.100 and .225. 02-11-136, § 388-535-1245, filed 5/21/02, effective 6/21/02.]
The following sections of the Washington Administrative Code are repealed:
| WAC 388-535-1200 | Dental-related services requiring prior authorization -- Children. |
| WAC 388-535-1230 | Crowns for children. |
| WAC 388-535-1240 | Dentures, partial dentures, and overdentures for children. |