HEALTH CARE AUTHORITY

[Filed September 20, 2021, 8:57 a.m.]

Preproposal statement of inquiry was filed as WSR 21-13-050.

Title of Rule and Other Identifying Information: WAC 182-535-1245 Access to baby and child dentistry (ABCD) program.

Hearing Location(s): On October 26, 2021, at 10:00 a.m. The health care authority (HCA) remains closed in response to the coronavirus disease 2019 (COVID-19) public health emergency. Until further notice, HCA continues to hold public hearings virtually without a physical meeting place. This promotes social distancing and the safety of the residents of Washington state. To attend the virtual public hearing, you must register in advance for this public hearing https://zoom.us/webinar/register/WN_Ig_1_lBzQ0Oa2h_0Y6Ak0w. After registering, you will receive a confirmation email containing information about joining the public hearing.

Date of Intended Adoption: Not sooner than October 27, 2021.

Submit Written Comments to: HCA Rules Coordinator, P.O. Box 42716, Olympia, WA 98504-2716, email arc@hca.wa.gov, fax 360-586-9727, by October 26, 2021.

Assistance for Persons with Disabilities: Contact Amber Lougheed, phone 360-725-1349, fax 360-586-9727, telecommunication[s] relay service 711, email amber.lougheed@hca.wa.gov, by October 8, 2021.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The agency is amending these rules [to] align with SSB 5976. Specifically, the agency removed the age limitation of five and younger and added coverage for clients under the age of 13 who have one or more disabilities as defined by RCW 74.09.390. The agency is also clarifying that if the client is enrolled in an agency-contracted managed care organization (MCO), dental providers must bill the agency's directly under the fee-for-service payment system for ABCD services. Medical providers must bill the MCO directly for ABCD program services. If the client is not enrolled in an MCO, dental providers and medical providers must bill the agency directly under the fee-for-service payment system for ABCD program services. Only ABCD-certified dental providers and primary care providers certified in ABCD are paid an enhanced fee.

Reasons Supporting Proposal: See purpose.

Statutory Authority for Adoption: RCW 41.05.021, 41.05.160; SSB 5976, chapter 242, Laws of 2020, Access to baby and child dentistry program—Eligibility.

Statute Being Implemented: RCW 41.05.021, 41.05.160; SSB 5976, chapter 242, Laws of 2020, Access to baby and child dentistry program—Eligibility.

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

Agency Comments or Recommendations, if any, as to Statutory Language, Implementation, Enforcement, and Fiscal Matters: Not applicable.

Name of Proponent: HCA, governmental.

Name of Agency Personnel Responsible for Drafting: Valerie Freudenstein, P.O. Box 42716, Olympia, WA 98504-2716, 360-725-1344; Implementation and Enforcement: Janice Tadeo, P.O. Box 45506, Olympia, WA 98504-5506, 360-725-1583.

A school district fiscal impact statement is not required under RCW 28A.305.135.

A cost-benefit analysis is not required under RCW 34.05.328. RCW 34.05.328 does not apply to HCA rules unless requested by the joint administrative rules review committee or applied voluntarily.

The proposed rule does not impose more-than-minor costs on businesses. Following is a summary of the agency's analysis showing how costs were calculated. The proposed rule does not impose any costs on businesses.

AMENDATORY SECTION(Amending WSR 21-14-055, filed 7/1/21, effective 8/1/21)

WAC 182-535-1245Access to baby and child dentistry (ABCD) program.

The access to baby and child dentistry (ABCD) program ((is a program established to)) increases access to dental services for certain medicaid-eligible clients ((ages five and younger)).

(1) ((Client eligibility))A client is eligible for the ABCD program ((is as follows))if the client is:

(a) ((Clients must be age five and younger. Once enrolled in the ABCD program, eligible clients are covered until their sixth birthday.

(b) Clients))Eligible ((under))for one of the following medical assistance programs ((are eligible for the ABCD program)):

(i) Categorically needy program (CNP);

(ii) Limited casualty program-medically needy program (LCP-MNP);

(iii) Children's health program; or

(iv) State children's health insurance program (SCHIP); and

(b) Follow the age requirements:

(i) Under age six; or

(ii) Under age 13 and has one or more disabilities as defined by RCW 74.09.390.

(2) If the eligible client is enrolled in an agency-contracted managed care organization (MCO):

(a) Dental providers must bill the agency's fee-for-service payment system for ABCD program services.

(b) Medical providers must bill the MCO for ABCD program services.

(3) If the eligible client is not enrolled in an agency-contracted managed care organization (MCO):

(a) Dental providers must bill the agency's fee-for-service payment system for ABCD program services.

(b) Medical providers must bill the agency's fee-for-service payment system for ABCD program services.

(((c) ABCD program services provided by a dental provider for eligible clients who are enrolled in an agency-contracted managed care organization (MCO) are paid through the fee-for-service payment system.

(d) ABCD program services provided by a medical provider for eligible clients who are enrolled in an agency-contracted managed care organization (MCO) must be billed directly through the client's MCO.

(2)))(4) Health care providers and community service programs identify and refer eligible clients to the ABCD program. If ((enrolled,)) the eligible client is treated by an ABCD certified provider, the client and an adult family member may receive:

(a) Oral health education;

(b) "Anticipatory guidance" (expectations of the client and the client's family members, including the importance of keeping appointments); and

(((3)))(5) Only ABCD-certified ((dentists and other agency-approved certified))dental providers and primary care providers certified in ABCD are paid an enhanced fee for furnishing ABCD program services. ABCD program services include, when appropriate:

(a) Family oral health education. An oral health education visit:

(i) Is limited to one visit per day per family, up to two visits per ((child))client in a ((twelve-month))12-month period, per provider or clinic; and

(ii) Must include ((documentation of the following))all of the following services, provision of which must be documented in the client's record:

(A) "Lift the lip" training;

(B) Oral hygiene training;

(D) Dietary counseling; and

(E) ((Discussion))Benefits of fluoride ((supplements; and

(F) Documentation in the client's record to record the activities provided at the oral education visit)).

(b) Comprehensive oral evaluations as defined in WAC 182-535-1050, once per client, per provider or clinic, as an initial examination. The agency covers an additional comprehensive oral evaluation if the client has not been treated by the same provider or clinic within the past five years;

(c) Periodic oral evaluations as defined in WAC 182-535-1050, once every six months. Six months must elapse between the comprehensive oral evaluation and the first periodic oral evaluation;

(d) Topical application of fluoride varnish;

(e) Amalgam, resin, and glass ionomer restorations on primary teeth, as specified in the agency's current published documents;

(f) Interim therapeutic restorations (ITRs) for primary teeth((, only for clients age five and younger)). The agency pays an enhanced rate for these restorations to ABCD-certified, ITR-trained dentists as follows:

(i) A one-surface, resin-based composite, or glass ionomer restoration with a maximum of five teeth per visit; and

(ii) Restorations on a tooth can be done every ((twelve))12 months ((through age five,)) or until the client can be definitively treated for a restoration.

(g) Therapeutic pulpotomy;

(h) Prefabricated stainless steel crowns on primary teeth, as specified in the agency's current published documents;

(i) Resin-based composite crowns on anterior primary teeth; and

(j) Other dental-related services, as specified in the agency's current published documents.

(((4) The client's record must show documentation of the ABCD program services provided.))