WSR 14-02-080 EMERGENCY RULES HEALTH CARE AUTHORITY (Medicaid Program) [Filed December 30, 2013, 12:47 p.m., effective January 1, 2014] Effective Date of Rule: January 1, 2014.
Purpose: Restore adult dental benefit for eligible clients beginning January 1, 2014.
Citation of Existing Rules Affected by this Order: Amending WAC 182-535-1060.
Statutory Authority for Adoption: RCW 41.05.021; 3ESSB 5034 (section 213, chapter 4, Laws of 2013).
Under RCW 34.05.350 the agency for good cause finds that immediate adoption, amendment, or repeal of a rule is necessary for the preservation of the public health, safety, or general welfare, and that observing the time requirements of notice and opportunity to comment upon adoption of a permanent rule would be contrary to the public interest; that state or federal law or federal rule or a federal deadline for state receipt of federal funds requires immediate adoption of a rule; and that in order to implement the requirements or reductions in appropriations enacted in any budget for fiscal years 2009, 2010, 2011, 2012 or 2013, which necessitates the need for the immediate adoption, amendment, or repeal of a rule, and that observing the time requirements of notice and opportunity to comment upon adoption of a permanent rule would be contrary to the fiscal needs or requirements of the agency.
Reasons for this Finding: These emergency rules are necessary to meet the requirements in 3ESSB 5034, section 213, chapter 4, Laws of 2013, 63rd legislature, effective January 1, 2014.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 1, Amended 1, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 1, Amended 1, Repealed 0.
Date Adopted: December 31, 2013.
Kevin M. Sullivan
Rules Coordinator
AMENDATORY SECTION (Amending WSR 12-09-081, filed 4/17/12, effective 5/18/12)
WAC 182-535-1060 Clients who are eligible for dental-related services.
(1) ((The clients described in this section are eligible to receive the dental-related services described in this chapter, subject to limitations, restrictions, and client-age requirements identified for a specific service. (a) Clients who are eligible under one of the following medical assistance programs: (i) Categorically needy (CN); (ii) Children's health care as described in WAC 388-505-0210; (iii) Medically needy (MN); (iv) Medical care services (MCS) as described in WAC 182-508-0005; (v) Alcohol and Drug Abuse Treatment and Support Act (ADATSA). (b) Clients who are eligible under one of the medical assistance programs in subsection (a) of this section and are one of the following: (i) Twenty years of age and younger; (ii) Twenty years of age and younger enrolled in an agency-contracted managed care organization (MCO). MCO clients are eligible under fee-for-service for covered dental-related services not covered by their MCO plan, subject to the provisions of this chapter and other applicable agency rules; (iii) For dates of service on and after July 1, 2011, clients who are verifiably pregnant; (iv) For dates of service on and after July 1, 2011, clients residing in one of the following: (A) Nursing home; (B) Nursing facility wing of a state veteran's home; (C) Privately operated intermediate care facility for the intellectually disabled (ICF/ID); or (D) State-operated residential habilitation center (RHC). (v) For dates of service on and after July 1, 2011, clients who are eligible under an Aging and Disability Services Administration (ADSA) 1915 (c) waiver program; (vi) For dates of service prior to October 1, 2011, clients of the division of developmental disabilities; or (vii) For dates of service on and after October 1, 2011, clients of the division of developmental disabilities who also qualify under (b)(i), (iii), (iv), or (v) of this subsection.)) Refer to WAC 182-501-0060 to see which Washington apple health programs include dental-related services in their benefit package. (2) Managed care clients are eligible under Washington apple health fee-for-service for covered dental-related services not covered by their MCO plan, subject to the provisions of this chapter and other applicable agency rules. (3) See WAC ((388-438-0120)) 182-507-0115 for rules for clients eligible under an alien emergency medical program. (((3) The dental services discussed in this chapter are excluded from the benefit package for clients not eligible for comprehensive dental services as described in subsection (1) of this section. Clients who do not have these dental services in their benefit package may be eligible only for the emergency oral health care benefit according to WAC 182-531-1025.)) (4) Exception to rule procedures as described in WAC 182-501-0169 are not available for services that are excluded from a client's benefit package.
NEW SECTION
WAC 182-535-1066 Dental-related services—Medical care services clients.
(1) The agency covers the following dental-related services for a medical care services client as listed in WAC 182-501-0060 when the services are provided by a dentist to assess and treat pain, infection, or trauma of the mouth, jaw, or teeth, including treatment of post-surgical complications, such as dry socket: (a) Limited oral evaluation; (b) Periapical or bite-wing radiographs (X rays) that are medically necessary to diagnose only the client's chief complaint; (c) Palliative treatment to relieve dental pain; (d) Pulpal debridement to relieve dental pain; and (e) Tooth extraction. (2) Tooth extractions require prior authorization when: (a) The extraction of a tooth or teeth results in the client becoming edentulous in the maxillary arch or mandibular arch; or (b) A full mouth extraction is necessary because of radiation therapy for cancer of the head and neck. (3) Each dental-related procedure described under this section is subject to the coverage limitations listed in this chapter.
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