Washington State

House of Representatives

Office of Program Research

BILL

ANALYSIS

Health Care & Wellness Committee

HB 2498

This analysis was prepared by non-partisan legislative staff for the use of legislative members in their deliberations. This analysis is not a part of the legislation nor does it constitute a statement of legislative intent.

Brief Summary of Bill

Eliminates prior authorization requirements for dental services and supplies provided through medical assistance programs if the payment rate for the service or supplies is less than half of the usual and customary fee for the service or supplies.

Background:

Medical assistance is available to eligible low-income state residents and their families from the Health Care Authority (Authority), primarily through the Medicaid program. The majority of medical assistance clients are served under a managed care arrangement which provides a prepaid, comprehensive system of medical and health care delivery, including primary, specialty, and ancillary health services. Dental services for medical assistance clients, however, are provided through a fee-for-service arrangement in which the dentist directly bills the Authority. Certain dental services require that the dental provider obtain authorization prior to the service being performed. Prior authorization generally requires that the dental provider establish medical necessity for the service through sufficient, objective, clinical information.

Summary of Bill:

Medical assistance programs may not apply prior authorization requirements to dental services and supplies if the payment for the service or supplies is less than half of the usual and customary fee. The term "usual and customary fee" means the amount charged for a dental service based on the fee usually charged for the same or similar dental service by providers in the area.