WSR 07-06-042

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)

[ Filed March 1, 2007, 2:40 p.m. , effective April 1, 2007 ]


Effective Date of Rule: Thirty-one days after filing.

Purpose: The new and 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; and 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. Clients and dental providers will be able to identify the requirements and criteria that must be met in order to obtain covered dental-related services.

Citation of Existing Rules Affected by this Order: Repealing WAC 388-535-1200, 388-535-1230 and 388-535-1240; and amending WAC 388-535-1080, 388-535-1100, 388-535-1220, and 388-535-1245.

Statutory Authority for Adoption: RCW 74.08.090, 74.09.500, 74.09.520.

Adopted under notice filed as WSR 06-24-069 (part 1 of 4), 06-24-068 (part 2 of 4), 06-24-071 (part 3 of 4), and 06-24-070 (part 4 of 4) on December 4, 2006.

Changes Other than Editing from Proposed to Adopted Version: Note: Strikeouts and underlines indicate language deleted or added since the proposal.

WAC 388-535-1079 Dental-related services for clients through age twenty--General. (1)(d) Are documented in the client's record in accordance with chapter 388-502 WAC;

(d) (e) Are within...;

(e) (f) Are consistent...;

(f) (g) Are reasonable...; and

(g) (h) Are listed...

(2) Under the Early Periodic Screening and Diagnostic Treatment (EPSDT) program, clients ages twenty and younger may be eligible for the dental-related services listed as noncovered in WAC 388-535-1100, if the services include those medically necessary services and other measures provided to correct or ameliorate conditions discovered during a screening performed under the EPSDT program.

WAC 388-535-1080 Covered dental-related services for clients through age twenty--Diagnostic. (1)(a) Oral health evaluations and assessments. The services must be documented in the client's record in accordance with WAC 388-502-0020.

(2) Radiographs (X-rays). The department: ...(f) Covers a maximum of two four bitewing radiographs once every twelve months for clients through age eleven.

WAC 388-535-1082 Covered dental-related services for clients through age twenty--Preventive services. (1)(a) Which includes scaling and polishing...once every six months for clients through age eighteen twenty. (b) Which includes scaling and polishing procedures to remove coronal plague, calculus, and stains when performed on transitional or permanent dentition, once every twelve months for clients ages nineteen through twenty.

(c) (b) Only when the service is performed six months after periodontal scaling and root planing, or periodontal maintenance services, for clients ages thirteen through eighteen twenty.

(d) Only when the service is performed twelve months after periodontal scaling and root planing, or periodontal maintenance services for clients ages nineteen through twenty.

(e) (c) Only when not performed...scaling and root planing.

(f) (d) For clients of the division of developmental disabilities...

(4)(d) Sealants only if evidence of occlusal or interproximal decay has not penetrated to the dentoenamel junction (DEJ). Sealants on noncarious teeth or teeth with incipient caries.

WAC 388-535-1084 Covered dental-related services for clients through age twenty--Restorative services. (3) Amalgam restorations for primary posterior teeth only. The department: (a) Ccovers amalgam restorations for a maximum of two surfaces for a primary posterior tooth first molar and a maximum of three surfaces for a primary second molar. (See subsection (9)(c) of this section for restorations for a primary posterior tooth requiring a three or more surface restoration. additional surfaces.) The department does not pay for additional amalgam restorations. (b) Does not pay for additional amalgam or composite restoration on the same tooth after two surfaces.

(6)(b) Resin-based composite restorations for a maximum of two surfaces for a primary posterior tooth first molar and a maximum of three surfaces for a primary second molar. (See subsection (9)(c) of this subsection for restorations for a primary posterior tooth requiring a three of [or] more surface restoration additional surfaces.) The department does not pay for additional composite or amalgon restorations on the same tooth after two surfaces.

(6)(c) Glass ionimer restorations only for primary teeth, and only for clients ages four five and younger...

(9)(c) Prefabricated stainless steel crowns for primary posterior teeth once every three years without prior authorization if: decay involves three or more surfaces, of if the tooth had a pulpotomy. (i) Decay involves three or more surfaces for a primary first molar; (ii) Decay involves four or more surfaces for a primary second molar; or (iii) The tooth had a pulpotomy.

WAC 388-535-1090 Covered dental-related services for clients through age twenty--Prosthodontics (removable). (1)(f) Requires a provider to submit the following with a prior authorization request for removable prosthetics for a client residing in a nursing home, group home, or other facility an alternate living facility (ALF) as defined in WAC 388-513-1301 or in a nursing facility.

WAC 388-535-1098 Covered dental-related services for clients through age twenty--Adjunctive general services. (5)(a)(ii) Clients ages...when prior authorized; and (iii) Clients of the division of developmental disabilities according to WAC 388-535-1099.; and

(iv) Clients who reside in an alternate living facility (ALF) as defined in WAC 388-513-1301 or in a nursing facility.

WAC 388-535-1100 Dental-related services not covered for clients through age twenty. (1)(a) The dental-related services described in subsection (2) of this section unless the services are covered 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.

A final cost-benefit analysis is available by contacting Dr. John Davis, P.O. Box 45506, Olympia, WA 98504-5506, phone (360) 725-1748, fax (360) 568-1590, e-mail davisjs@dshs.wa.gov.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 11, Amended 4, Repealed 3.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 11, Amended 4, Repealed 3.

Date Adopted: February 27, 2007.

Robin Arnold-Williams

Secretary

Reviser's note: The material contained in this filing exceeded the page-count limitations of WAC 1-21-040 for appearance in this issue of the Register. It will appear in the 07-08 issue of the Register.

Washington State Code Reviser's Office