Purpose: The rule updates and clarifies existing policy regarding orthodontic services, including program definitions, provider requirements, expedited prior authorization, and reimbursement. In addition, the rules incorporate into permanent rule the federal requirements of Public Law 104-101 (Health Insurance Portability and Accountability Act of 1996).

     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 74.08.090 and 74.09.520.

     Other Authority: RCW 74.09.035, 74.09.500.

      Adopted under notice filed as WSR 04-19-110 on September 21, 2004.

     Changes Other than Editing from Proposed to Adopted Version: The following changes have been made to the proposed rules (additions indicated by underlined text, and deletions indicated by strikethrough text), as a result of comments received:

WAC 388-535A-0020 Eligibility for orthodontic services.

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

     (1)(d) Clients who are eligible for services under the EPSDT program may receive orthodontic services under the provisions of WAC 388-534-0100. See WAC 388-535A-0040(7) for how MAA evaluates a request under the EPSDT program for a noncovered orthodontic service or an orthodontic service that exceeds limitations.

WAC 388-535A-0030 Providers of orthodontic services.

     (1) Orthodontics Orthodontists;

WAC 388-535A-0040 Covered and noncovered orthodontic services and limitations to coverage.

     (4)(a) Panoramic radiographs (x-rays), allowed once per client in a three-year period.

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

     (4)(c) Limited transitional orthodontic treatment, allowed up to one year from the date of...

     (4)(d) Comprehensive full orthodontic treatment, allowed up to two years from the date of...

     (5) ...under the provisions of WAC 388-501-0165. See subsection (7) of this section for a request for an LE for a client eligible under the EPSDT program.

     (6) ...under the provisions of WAC 388-501-0165. See subsection (7) of this section for a request for a noncovered service for a client eligible under the EPSDT program.

     (7) If a noncovered orthodontic service, or a covered orthodontic service that exceeds limitations, is requested or prescribed under the EPSDT program, MAA evaluates it as a covered service under EPSDT's standard of coverage that requires the service to be: (a) Medically necessary; (b) Safe and effective; and (c) Not experimental. MAA reviews requests for orthodontic treatment for clients who are eligible for services under the EPSDT program according to the provisions of WAC 388-534-0100.

     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 davisjs@dshs.wa.gov. No changes were made. The preliminary cost benefit analysis will be final.

     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: December 3, 2004.

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

     "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 ((patient's)) 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, ((to)) 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. ((It is an extension of preventive orthodontics that may include localized tooth movement.)) 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 ((the abnormal contact between the)) improper alignment of biting or chewing surfaces of upper and lower teeth ((that interferes with the highest efficiency during the movements of the jaw that are essential to chewing)).

     "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, 74.09.035, 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) receive orthodontic services through age twenty((;)).

     (b) Clients in the ((children's health)) medically needy program (MNP) receive orthodontic services through age ((eighteen; and)) twenty.

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

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

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

     (3) Eligible clients ((in department-designated border areas)) may receive the same orthodontic services in designated border cities as if provided in-state. See WAC 388-501-0175.

[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) ((Dentists who specialize in orthodontics)) Orthodontists;

     (2) Pediatric dentists ((who provide MAA-approved orthodontic services));

     (3) General dentists ((who provide MAA-approved orthodontic services)); and

     (4) ((Oral surgeons who provide MAA-approved)) Department recognized craniofacial teams or other orthodontic ((services)) specialists approved by MAA's orthodontic consultant.

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

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

     (ii) 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 Washington Modified Handicapping Labiolingual Deviation (HLD) Index Score that result in a score of twenty-five or higher. On a case-by-case basis, MAA reviews all requests for treatment for conditions that result in a score of less ((then)) than twenty-five, based on medical necessity ((on a case-by-case basis)).

     (2) MAA may cover requests for orthodontic treatment for dental malocclusions((,)) other than those listed in subsection (1) of this section when MAA determines that the treatment is medically necessary.

     (3) ((MAA reviews requests for orthodontic treatment for children who are eligible for services under the EPSDT program according to the provisions of WAC 388-534-0100.

     (4) MAA covers orthodontic appliance removal for a client whose appliance was placed by a provider not participating with MAA, or whose payment MAA did not cover.

     (5) MAA does not cover lost or broken orthodontic appliances.

     (6) MAA covers panoramic radiographs (x-rays) once in a three-year period)) MAA does not cover:

     (a) Lost or 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; or

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

     (4) MAA 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), once per client in a three-year period.

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

     (c) Limited transitional orthodontic treatment, up to one year from date of original appliance placement (see subsection (5) of this section for information on limitation extensions).

     (d) Comprehensive full orthodontic treatment, up to two years from the date of original appliance placement (see subsection (5) 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; and

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

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

     (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. MAA evaluates and approves requests for LE for orthodontic services when medically necessary, under the provisions of WAC 388-501-0165.

     (6) MAA evaluates a request for any orthodontic service not listed as covered in this section under the provisions of WAC 388-501-0165.

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

[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.]

     (2) ((MAA does not require prior authorization)) For orthodontic treatment of a client with cleft lip, cleft palate, or other craniofacial anomaly ((when the client is)), prior authorization:

     (a) ((Eligible under WAC 388-535A-0020)) 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 to treat cleft lip, cleft palate, or other craniofacial anomalies; and

     (b) ((Being treated by a department-recognized cleft palate or craniofacial team)) 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 requires prior authorization for orthodontic treatment ((of:

     (a) Severe handicapping malocclusions;

     (b) Dental malocclusions that result in severe dental functional impairment;

     (c) Those cases that result in a score less than thirty on the Washington Modified HLD Index Scale; and

     (d) Services provided per WAC 388-535A-0030.

     (4) MAA allows orthodontists to use expedited prior authorization (EPA) for those cases that score thirty or more on the Washington Modified HLD Index Scale. The EPA process is designed to eliminate the need for telephone prior authorization for selected procedures. The orthodontist must create an authorization number using the process explained in MAA's orthodontic billing instructions. When MAA finds that a provider is using EPA inappropriately, MAA may:

     (a) Require the provider to obtain prior authorization from MAA before providing services to any client; or

     (b) Take one or more of the actions in WAC 388-502-0230(3))) for other dental malocculusions that are not listed in WAC 388-535A-0040(1).

[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 considers that a provider who furnishes covered orthodontic services to an eligible client has accepted MAA's rates and fees.

     (((2))) (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:

     (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 bill MAA 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. Treatment provided after one year from the date the appliance is placed requires a limitation extension. See WAC 388-535A-0040(5).

     (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:

     (a) The first six months of treatment starts the date the initial appliance is placed and includes active treatment within the six months. The provider should bill MAA 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. Treatment provided after two years from the date the appliance is placed requires a limitation extension. See WAC 388-535A-0040(5).

     (5) Payment for orthodontic services is based on MAA's schedule of maximum allowances; fees listed in the fee schedule are the maximum allowable fees.

     (((3) MAA uses state-assigned procedure codes to identify covered orthodontic services.

     (4) MAA does not cover out-of-state orthodontic treatment.

     (5))) (6) Orthodontic providers who are in department-designated ((border areas)) 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.

     (((6) MAA reimburses for interceptive orthodontic treatment for cleft palate or craniofacial anomaly per WAC 388-535A-0050.))

     (7) ((With the exception of the conditions listed in subsection (6) of this section, MAA reimburses for interceptive orthodontic treatment once per client's lifetime for clients with severe handicapping malocclusions.

     (8) MAA reimburses for limited transitional orthodontic treatment for a maximum of one year from original appliance placement. Follow up treatment is allowed in three-month increments, beginning three months after the initial placement.

     (9) MAA reimburses for comprehensive full orthodontic treatment up to a maximum of two years from original appliance placement. Six follow up treatments are allowed in three-month increments, beginning six months after the initial placement.

     (10))) 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 does not reimburse for these services.

     (((11))) (8) 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 does not reimburse for these services.

     (((12) The client is responsible for paying for services when the client has not disclosed coverage to the provider, per))

     (9) See WAC 388-502-0160 and 388-501-0200((; MAA does not reimburse in these situations)) for when a provider or a client is responsible to pay for a covered service.

[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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