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

     Purpose: The rule updates the definition for "craniofacial team," clarifies who is eligible for orthodontic treatment and orthodontic-related services, replaces "MAA's orthodontic consultant" with "department," removes language regarding limitation extensions, extends the time period HRSA covers comprehensive full orthodontic treatment, removes references to specific medical conditions, updates cross-references, and clarifies, simplifies, and omits redundant language.

     Citation of Existing Rules Affected by this Order: Amending WAC 388-535A-0010, 388-535A-0020, 388-535A-0030, 388-535A-0040, 388-535A-0050, and 388-535A-0060.

     Statutory Authority for Adoption: RCW 74.04.050, 74.08.090.

      Adopted under notice filed as WSR 08-12-073 on June 3, 2008.

     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) 586-1590, e-mail davisjd@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     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 6, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 6, Repealed 0.

     Date Adopted: August 8 [7], 2008.

Robin Arnold-Williams

Secretary

     "Appliance placement" means the application of orthodontic attachments to the teeth for the purpose of correcting dentofacial abnormalities.

     "Cleft" means an opening or fissure involving the dentition and supporting structures, especially one occurring in utero. These can be:

     (1) Cleft lip;

     (2) Cleft palate (involving the roof of the mouth); or

     (3) Facial clefts (e.g., macrostomia).

     "Comprehensive full orthodontic treatment" means utilizing fixed orthodontic appliances for treatment of the permanent dentition leading to the improvement of a client's severe handicapping craniofacial dysfunction and/or dentofacial deformity, including anatomical and functional relationships.

     "Craniofacial anomalies" means abnormalities of the head and face, either congenital or acquired, involving disruption of the dentition and supporting structures.

     "Craniofacial team" means a ((department of health- and medical assistance administration-recognized)) cleft palate/maxillofacial team or an American Cleft Palate Association-certified craniofacial team. These teams are responsible for the management (review, evaluation, and approval) of patients with cleft palate craniofacial anomalies to provide integrated ((case)) management, promote parent-professional partnership, and make appropriate referrals to implement and coordinate treatment plans.

     "Dental dysplasia" means an abnormality in the development of the teeth.

     "EPSDT" means the department's early and periodic screening, diagnosis, and treatment program for clients twenty years of age and younger as described in chapter 388-534 WAC.

     "Hemifacial microsomia" means a developmental condition involving the first and second brachial arch. This creates an abnormality of the upper and lower jaw, ear, and associated structures (half or part of the face appears smaller sized).

     "Interceptive orthodontic treatment" means procedures to lessen the severity or future effects of a malformation and to affect or eliminate the cause. Such treatment may occur in the primary or transitional dentition and may include such procedures as the redirection of ectopically erupting teeth, correction of isolated dental cross-bite, or recovery of recent minor space loss where overall space is adequate.

     "Limited transitional orthodontic treatment" means orthodontic treatment with a limited objective, not involving the entire dentition. It may be directed only at the existing problem, or at only one aspect of a larger problem in which a decision is made to defer or forego more comprehensive therapy.

     "Malocclusion" means improper alignment of biting or chewing surfaces of upper and lower teeth.

     "Maxillofacial" means relating to the jaws and face.

     "Occlusion" means the relation of the upper and lower teeth when in functional contact during jaw movement.

     "Orthodontics" means treatment involving the use of any appliance, in or out of the mouth, removable or fixed, or any surgical procedure designed to redirect teeth and surrounding tissues.

     "Orthodontist" means a dentist who specializes in orthodontics, who is a graduate of a postgraduate program in orthodontics that is accredited by the American Dental Association, and who meets the licensure requirements of the department of health.

[Statutory Authority: RCW 74.08.090, 74.09.520 and 74.09.035, 74.09.500. 05-01-064, § 388-535A-0010, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520, 74.09.500, 42 U.S.C. 1396d(a), C.F.R. 440.100 and 225. 02-01-050, § 388-535A-0010, filed 12/11/01, effective 1/11/02.]

     (a) Clients in the categorically needy program (((CN) or)) (CNP) and the medically needy program (MNP) may receive orthodontic treatment and orthodontic-related services through age twenty. Any orthodontic treatment plan that extends beyond the client's twenty-first birthday will not be approved by the department.

     (b) ((Clients in the medically needy program (MNP) receive orthodontic services through age twenty.

     (c))) Clients in the state children's health insurance program (CHIP) may receive orthodontic treatment and orthodontic-related services through age eighteen. ((See WAC 388-416-0015 for when certification periods may be extended.

     (d))) (c) Clients who are eligible for services under the EPSDT program may receive orthodontic treatment and orthodontic-related services under the provisions of WAC 388-534-0100.

     (2) ((MAA does not cover orthodontic services for adults.

     (3))) Eligible clients may receive the same orthodontic treatment and orthodontic-related services in ((designated border)) recognized out-of-state bordering cities on the same basis as if provided in-state. See WAC 388-501-0175.

[Statutory Authority: RCW 74.08.090, 74.09.520 and 74.09.035, 74.09.500. 05-01-064, § 388-535A-0020, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520, 74.09.500, 42 U.S.C. 1396d(a), C.F.R. 440.100 and 225. 02-01-050, § 388-535A-0020, filed 12/11/01, effective 1/11/02.]

     (1) Orthodontists;

     (2) Pediatric dentists;

     (3) General dentists; and

     (4) Department recognized craniofacial teams or other orthodontic specialists approved by ((MAA's orthodontic consultant)) the department.

[Statutory Authority: RCW 74.08.090, 74.09.520 and 74.09.035, 74.09.500. 05-01-064, § 388-535A-0030, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520, 74.09.500, 42 U.S.C. 1396d(a), C.F.R. 440.100 and 225. 02-01-050, § 388-535A-0030, filed 12/11/01, effective 1/11/02.]

     (a) ((Cleft lip, cleft palate, or other craniofacial anomalies when the client is treated by and receives follow-up care from a department-recognized craniofacial team for:

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

     (((ii))) (b) The following craniofacial anomalies((, including but not limited to)):

     (A) Hemifacial microsomia;

     (B) Craniosynostosis syndromes;

     (C) Cleidocranial dental dysplasia;

     (D) Arthrogryposis; or

     (E) Marfan syndrome.

     (((iii) Other medical conditions with significant facial growth impact (e.g., juvenile rheumatoid arthritis (JRA)); or

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

     (b) Other severe handicapping malocclusions, including one or more of the following:

     (i) Deep impinging overbite when lower incisors are destroying the soft tissues of the palate;

     (ii) Crossbite of individual anterior teeth when destruction of the soft tissue is present;

     (iii) Severe traumatic malocclusion (e.g., loss of a premaxilla segment by burns or by accident, the result of osteomyelitis, or other gross pathology);

     (iv) Overjet greater than 9mm with incompetent lips or reverse overjet greater than 3.5mm with reported masticatory and speech difficulties; or

     (v) Medical conditions as indicated on the)) (2) Subject to prior authorization requirements and the limitations in this section and other applicable WAC, the department covers orthodontic treatment and orthodontic-related services for severe malocclusions with a Washington Modified Handicapping Labiolingual Deviation (HLD) Index Score ((that result in a score)) of twenty-five or higher. ((On a case-by-case basis, the department reviews all requests for treatment for conditions that result in a score of less than twenty-five, based on medical necessity.

     (2))) (3) The department may cover ((requests for)) orthodontic treatment for dental malocclusions other than those listed in subsection (1) and (2) of this section ((when the department determines that the treatment is medically necessary)) on a case-by-case basis and when prior authorized.

     (((3))) (4) The department does not cover the following orthodontic treatment or orthodontic-related services:

     (a) Replacement of lost or repair of broken orthodontic appliances;

     (b) Orthodontic treatment for cosmetic purposes;

     (c) Orthodontic treatment that is not medically necessary (see WAC 388-500-0005);

     (d) Out-of-state orthodontic treatment, except as stated in WAC 388-501-0180 (see also WAC 388-501-0175 for medical care provided in bordering cities); or

     (e) Orthodontic treatment and orthodontic-related services that do not meet the requirements of this section or other applicable WAC.

     (((4))) (5) The department covers the following orthodontic treatment and orthodontic-related services, subject to the limitations listed (providers must bill for these services according to WAC 388-535A-0060):

     (a) Panoramic radiographs (((X rays)) x-rays)((, once per client in a three-year period)) when medically necessary.

     (b) Interceptive orthodontic treatment, once per ((the)) a client's lifetime.

     (c) Limited transitional orthodontic treatment, ((up to one year from)) once per a client's lifetime. The treatment must be completed within twelve months of the date of the original appliance placement (see subsection (((5))) (6)(a) of this section for information on limitation extensions).

     (d) Comprehensive full orthodontic treatment((, up to two years from)) once per a client's lifetime. The treatment must be completed within thirty months of the date of the original appliance placement (see subsection (((5))) (6)(a) of this section for information on limitation extensions).

     (e) Orthodontic appliance removal only when:

     (i) The client's appliance was placed by a different provider or dental clinic; and

     (ii) The provider has not furnished any other orthodontic treatment or orthodontic-related services to the client.

     (f) Other medically necessary orthodontic treatment and orthodontic-related services as determined by the department.

     (((5) A request to exceed stated limitations or other restrictions on covered services is called a limitation extension (LE), which is a form of prior authorization. The department evaluates and approves requests for LE for orthodontic services when medically necessary, under the provisions of WAC 388-501-0165.))

     (6) The department evaluates a request for ((any)) orthodontic ((service not listed as covered in this section under the provisions of WAC 388-501-0160)) treatment or orthodontic-related services:

     (a) That are in excess of the limitations or restrictions listed in this section, according to WAC 388-501-0169; and

     (b) That are listed as noncovered according to WAC 388-501-0160..

     (7) The department reviews requests for orthodontic treatment or orthodontic-related services for clients who are eligible for services under the EPSDT program according to the provisions of WAC 388-534-0100.

[Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 06-24-036, § 388-535A-0040, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.520 and 74.09.035, 74.09.500. 05-01-064, § 388-535A-0040, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520, 74.09.500, 42 U.S.C. 1396d(a), C.F.R. 440.100 and 225. 02-01-050, § 388-535A-0040, filed 12/11/01, effective 1/11/02.]

     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.
AMENDATORY SECTION(Amending WSR 05-01-064, filed 12/8/04, effective 1/8/05)

WAC 388-535A-0050   Authorization and prior authorization for orthodontic treatment and orthodontic-related services.   (1) When the ((medical assistance administration (MAA))) department authorizes an interceptive orthodontic treatment, limited orthodontic treatment, ((or)) full orthodontic treatment, or orthodontic-related services for a client, including a client eligible for services under the EPSDT program, that authorization indicates only that the specific service is medically necessary; it is not a guarantee of payment. The client must be eligible for the covered service at the time the service is provided.

     (2) For orthodontic treatment of a client with cleft lip, cleft palate, or other craniofacial anomaly, prior authorization((:

     (a))) is not required if the client is being treated by a department-recognized craniofacial team, or an orthodontic specialist who has been approved by ((an MAA dental consultant)) the department to treat cleft lip, cleft palate, or other craniofacial anomalies((; and

     (b) Is required if the client is not being treated by a provider listed in (a) of this subsection)).

     (3) Subject to the conditions and limitations of this section and other applicable WAC, ((MAA)) the department requires prior authorization for orthodontic treatment and/or orthodontic-related services for other dental ((malocculusions)) malocclusions that are not listed in WAC 388-535A-0040(1).

[Statutory Authority: RCW 74.08.090, 74.09.520 and 74.09.035, 74.09.500. 05-01-064, § 388-535A-0050, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520, 74.09.500, 42 U.S.C. 1396d(a), C.F.R. 440.100 and 225. 02-01-050, § 388-535A-0050, filed 12/11/01, effective 1/11/02.]

     (2) ((MAA)) The department considers that a provider who furnishes covered orthodontic treatment and orthodontic-related services to an eligible client has accepted ((MAA's rates and)) the department's fees as published in the department's fee schedules.

     (3) ((To be reimbursed for providing limited transitional orthodontic treatment, providers must bill MAA in intervals during the treatment and complete treatment within twelve months of the date of appliance placement:)) Interceptive orthodontic treatment. The department pays for interceptive orthodontic treatment as follows:

     (a) The first three months of treatment starts the date the initial appliance is placed and includes active treatment for the first three months.

     (b) Treatment must be completed within twelve months of the date of appliance placement.

     (4) Limited transitional orthodontic treatment. The department pays for limited transitional orthodontic treatment as follows:

     (a) The first three months of treatment starts the date the initial appliance is placed and includes active treatment for the first three months. The provider ((should)) must bill ((MAA)) the department with the date of service that the initial appliance is placed.

     (b) Continuing follow-up treatment must be billed after each three-month treatment interval during the treatment.

     (c) Treatment must be completed within twelve months of the date of appliance placement. Treatment provided after one year from the date the appliance is placed requires a limitation extension. See WAC ((388-535A-0040(5))) 388-535A-0040(6).

     (((4) To be reimbursed for providing comprehensive full orthodontic treatment, providers must bill MAA in intervals during the treatment and complete treatment within twenty-four months of the date of the appliance placement)) (5) Comprehensive full orthodontic treatment. The department pays for comprehensive full orthodontic treatment as follows:

     (a) The first six months of treatment starts the date the initial appliance is placed and includes active treatment ((within)) for the first six months. The provider ((should)) must bill ((MAA)) the department with the date of service that the initial appliance is placed.

     (b) Continuing follow-up treatment must be billed after each three-month treatment interval, with the first three-month interval beginning six months after the initial appliance placement.

     (c) Treatment must be completed with thirty months of the date of appliance placement. Treatment provided after ((two years)) thirty months from the date the appliance is placed requires a limitation extension. See WAC ((388-535A-0040(5))) 388-535A-0040(6).

     (((5))) (6) Payment for orthodontic treatment and orthodontic-related services is based on ((MAA's)) the department's published fee schedule ((of maximum allowances; fees listed in the fee schedule are the maximum allowable fees)).

     (((6))) (7) Orthodontic providers who are in department-designated bordering cities must:

     (a) Meet the licensure requirements of their state; and

     (b) Meet the same criteria for payment as in-state providers, including the requirements to contract with ((MAA)) the department.

     (((7))) (8) If the client's eligibility for orthodontic treatment under WAC 388-535A-0020 ends before the conclusion of the orthodontic treatment, payment for any remaining treatment is the individual's responsibility((; MAA)). The department does not ((reimburse)) pay for these services.

     (((8))) (9) The client is responsible for payment of any orthodontic service or treatment received during any period of ineligibility, even if the treatment was started when the client was eligible((; MAA)). The department does not ((reimburse)) pay for these services.

     (((9))) (10) See WAC 388-502-0160 and 388-501-0200 for when a provider or a client is responsible to pay for a covered service.

[Statutory Authority: RCW 74.08.090, 74.09.520 and 74.09.035, 74.09.500. 05-01-064, § 388-535A-0060, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520, 74.09.500, 42 U.S.C. 1396d(a), C.F.R. 440.100 and 225. 02-01-050, § 388-535A-0060, filed 12/11/01, effective 1/11/02.]

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