PROPOSED RULES
SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)
Original Notice.
Preproposal statement of inquiry was filed as WSR 00-22-083.
Title of Rule: Chapter 388-535 WAC, Dental-related services.
Purpose: The Medical Assistance Administration (MAA) is proposing to amend chapter 388-535 WAC, Dental-related services, to clarify and update existing policy. This includes updating (and deleting where necessary) definitions; clarifying provider requirements and adding cross-references to other provider information; clarifying the services that are covered and not covered; clarifying policy regarding dentures (including replacements for lost dentures to be included in the limitation of one set of dentures allowed in a ten-year period), partials, and laboratory fees; and reorganizing and rewriting sections within the chapter to improve readability and understanding to meet the requirements of Executive Order 97-02.
Statutory Authority for Adoption: RCW 74.08.090, 74.09.035, 74.09.500, 74.09.520, 42 U.S.C. 1396d(a), 42 C.F.R. 440.100 and 440.225.
Statute Being Implemented: RCW 74.09.035, 74.09.500, 74.09.520, 42 U.S.C. 1396d(a), 42 C.F.R. 440.100 and 440.225.
Summary: The proposed rules update program definitions; clarify and add cross-references to provider information; clarify covered and noncovered services; clarify policy regarding dentures (including replacements for lost dentures to be included in the limitation of one set of dentures allowed in a ten-year period), partials, and laboratory fees; and reorganize and rewrite sections within the chapter to improve readability and understanding to meet the requirements of Executive Order 97-02.
Reasons Supporting Proposal: To ensure department policy is accurately reflected in rule, and meet the requirements of EO 97-03.
Name of Agency Personnel Responsible for Drafting: Ann Myers, 925 Plum Street S.E., Olympia, WA 98501, (360) 725-1345; Implementation: Carree Moore, 649 Woodland Square Loop Road, Lacey, WA 98503, (360) 725-1653; and Enforcement: Sharon Morrison, 623 8th Avenue S.E., Olympia, WA 98501, (360) 725-1671.
Name of Proponent: Department of Social and Health Services, governmental.
Rule is not necessitated by federal law, federal or state court decision.
Explanation of Rule, its Purpose, and Anticipated Effects: The proposed rule clarifies policy regarding dental-related services, including program definitions; provider requirements; covered and noncovered services; and dentures, partials, and laboratory fees.
The purpose is to ensure department policy is accurately reflected in rule, and to meet the regulatory improvement goals of EO 97-02.
The anticipated effects are that department policy will reflect current policy and be more easily understood.
Proposal Changes the Following Existing Rules: The rules described above add and delete program definitions, add cross-references for provider requirements, clarify those services that are covered and noncovered, make replacements for lost dentures subject to the same one-set-in-ten-years requirement that original dentures are subject to, clarify that MAA does not pay laboratory fees directly to a laboratory, and reorganizes and rewrites sections within the section for clarity and readability.
A small business economic impact statement has been prepared under chapter 19.85 RCW.
• Update program-related definitions;
• Clarify provider requirements and add cross-references for other provider information;
• Clarify the services that are covered and are not covered under this program;
• Clarify department policy regarding dentures, partials, and laboratory fees; and
• Reorganize and rewrite sections within the chapter to improve readability and understanding to meet the requirements of Executive Order 97-02.
SMALL BUSINESS ECONOMIC IMPACT STATEMENT: Chapter 19.85 RCW, the
Regulatory Fairness Act, requires that the economic impact of
proposed regulations be analyzed in relation to small businesses
and outlines the information that must be included in a small
business economic impact statement (SBEIS). Preparation of an
SBEIS is required when a proposed rule has the potential of
placing a more than minor economic impact on business.
The Medical Assistance Administration (MAA) has analyzed the proposed rule, and concluded that although there would likely be an economic impact on the small businesses affected by it, MAA is unable to calculate an exact dollar amount based on specific information. This is because the proposed rule could require dental office staff to contact MAA regarding client eligibility for replacement dentures, and MAA does not know how often this may occur or how much time it may take. In addition, MAA does not currently have the means to track how many dentures have been provided as replacements for lost ones. The proposed rule limits replacement dentures to one set in a ten-year period when the reason for the replacement is that the existing dentures were lost - the same limitation placed on original dentures. Providers may not replace lost dentures without prior authorization when the replacement dentures exceed this limit.
Even though MAA is unable to determine an economic impact which is based on specific information for staff costs and replacement of lost dentures, the following is an estimate based on the information that is available to MAA:
From 1997 through 2001, MAA reimbursed providers for approximately 22,000 "units" (a "unit" is either a partial or a denture) each year. In fiscal year 2000, MAA's reimbursement to providers was approximately $8,200,000.00 for the entire prosthodontic program, including relines, rebases, repairs to bridges, etc. In order to arrive at a working figure for the calculations below, MAA disregarded the fact that expenses for services other than dentures were included in the total cost, and calculated an average reimbursement per unit of $375.00 ($8,200,000 ÷ 22,000 units = $372.73).
Since MAA is currently unable to determine how many dentures are replacements for lost ones, some reasonable assumptions must be made for the purpose of this calculation. MAA assumes that one-third of the 22,000 units provided are dentures, and that one-third of those are replacements for lost dentures (this is based on the current policy of non-limited replacement of dentures that are: a) lost; b) damaged beyond repair; or c) unserviceable). MAA contracts with approximately 2,000 dental providers, and assumes that one-quarter, or 500, of them provide dentures to Medicaid clients. Based on these figures, the following calculation shows a possible annual economic impact (not including staff time for client eligibility verification) on MAA providers:
&lhlsqbul; 22,000 total units ÷ 3 = 7,333 denture units.
&lhlsqbul; 7,333 denture units ÷ 3 reasons for replacements = 2,444 replacements for lost dentures
&lhlsqbul; 2,444 replacements x $375 reimbursement per unit = $916,500.00 reimbursement for lost dentures
&lhlsqbul; $916,500 reimbursement ÷ 500 providers = $1,833.00 reimbursement per provider per year
EVALUATION OF PROBABLE COSTS AND PROBABLE BENEFITS: The proposed amendments do "make significant amendments to a policy or regulatory program" (see RCW 34.05.328 (5)(c)(iii)). MAA is proposing to amend the policy regarding replacement dentures for those dentures that are lost, applying the same limitation as applies to original dentures. Therefore, MAA has determined the proposed rules do meet the definition of "significant" as defined by the legislature.
As required by RCW 34.05.328 (1)(c), the administration has analyzed the probable costs and probable benefits of the proposed amendments, taking into account both the qualitative and quantitative benefits and costs.
Probable Costs: MAA's analysis above reveals that while the proposed amendments impose no actual "new" costs, providers may receive approximately $1,833.00 less per year in Medicaid reimbursement for replacement dentures that do not meet the one-set-in-ten-years limitation. Since dental office staff may need to contact MAA to verify a client's eligibility for replacement dentures, there could be some additional administrative costs associated with the proposed amendment, but MAA is unable to calculate these at this time.
Probable Benefits: It is generally recognized that Medicaid reimbursement does not cover the full cost of providing dentures. The proposed amendments require the provider to get prior approval from MAA for replacing lost dentures, if those dentures exceed the one-set-in-ten-years limitation. This allows the provider to verify client eligibility; if eligible, the provider can choose to provide the dentures and accept the Medicaid reimbursement. If the client is not eligible, the provider can choose not to provide the dentures, or make arrangements with the client to pay for the full cost of the dentures. Therefore, the provider has greater control over his/her costs.
Please contact me if you have any questions.
A copy of the statement may be obtained by writing to Ann Myers, DSHS Medical Assistance Administration, P.O. Box 45533, 925 Plum Street S.E., Olympia, WA 98501, phone (360) 725-1345, fax (360) 586-9727.
RCW 34.05.328 applies to this rule adoption. MAA analyzed the proposed rule and concluded that it meets the definition of a "significant legislative rule" as defined by the legislature. An analysis of the probable costs and probable benefits may be obtained by contacting the person listed above.
Hearing Location: Office Building - 2 Auditorium (DSHS Headquarters) (parking off 12th and Jefferson), 1115 Washington, Olympia, WA 98504, on May 21, 2002, at 10:00 a.m.
Assistance for Persons with Disabilities: Contact Andy Fernando, DSHS Rules Coordinator, by May 17, 2002, phone (360) 664-6094, TTY (360) 664-6178, e-mail fernaAX@dshs.wa.gov.
Submit Written Comments to: Identify WAC Numbers, DSHS Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 664-6185, e-mail fernaax@dshs.wa.gov, by 5:00 p.m., May 21, 2002.
Date of Intended Adoption: No sooner than May 22, 2002.
March 28, 2002
Margaret J. Partlow
for Brian H. Lindgren, Manager
Rules and Policies Assistance Unit
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 02-09 issue of the Register.