HEALTH CARE AUTHORITY

[Filed November 30, 2018, 1:49 p.m., effective January 1, 2019]

Effective Date of Rule: January 1, 2019.

Purpose: This rule making is necessary to implement SSB 5883 which directs the agency to develop and implement a three-year pilot program to test the effect that enhanced dental benefits for adult medicaid clients with diabetes and pregnant medicaid clients have on access to dental care, health outcomes, and medical care costs. The pilot program must include enhanced reimbursement rates for specific current dental terminology codes for participating providers and an increase in the allowable number of periodontal treatments to up to four per calendar year.

Citation of Rules Affected by this Order: New WAC 182-535-1270.

Statutory Authority for Adoption: RCW 41.05.021, 41.05.160, SSB 5883.

Adopted under notice filed as WSR 18-20-118 on October 3, 2018.

Changes Other than Editing from Proposed to Adopted Version:

Proposed/Adopted	WAC Subsection	Reason
WAC 182-535-1270 Oral health connection pilot project.
Proposed	(3)(a) Age twenty-one or older;	Medicare clients are excluded from participation. The agency clarified age-range to align with age limits for medicare eligibility.
Adopted	(3)(a) Age twenty-one to sixty-four;
Proposed	(3)(c) Receiving services under this oral health connections pilot project in Cowlitz, Spokane, or Thurston counties; and	Clarified what services the agency is referencing in (3)(c).
Adopted	(3)(c) Receiving services in subsection (6) of this section in Cowlitz, Spokane, or Thurston counties; and
Proposed	(3)(d) Referred by a nondental primary health care provider or a designated community organization to a qualified oral health connections pilot project dental provider.	Added "managed care organizations" to clarify that managed care organizations can refer enrollees to the pilot program.
Adopted	(3)(d) Referred by a nondental primary health care provider, managed care organization, or a designated community organization to a qualified oral health connections pilot project dental provider.
Proposed	(6)(a) One comprehensive oral exam, per client, per provider;	Added frequency as frequency is listed for other services in this WAC.
Adopted	(6)(a) One comprehensive oral exam, per client, per provider in a five-year period;

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 1, Amended 0, Repealed 0.

Number of Sections Adopted at the 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 1, 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 0, Repealed 0.

Date Adopted: November 30, 2018.

WAC 182-535-1270Oral health connections pilot project.

(1) The oral health connections pilot project is effective for dates of service from January 1, 2019, through December 31, 2021.

(2) The purpose of the oral health connections pilot project is to test the effect that enhanced oral health services have on the overall health of diabetic or pregnant medicaid clients receiving services in Cowlitz, Spokane, and Thurston counties.

(3) To be eligible for the oral health connections pilot project, a client must be:

(a) Age twenty-one to sixty-four;

(b) Pregnant, diabetic, or both;

(d) Referred by a nondental primary health care provider, managed care organization, or a designated community organization to a qualified oral health connections pilot project dental provider. For the purposes of this section, a designated community organization is defined as an auxiliary group or groups that partner with the agency and Arcora foundation to implement the oral health connections pilot project.

(4) A client who qualifies for the oral health connections pilot project due to pregnancy may continue receiving services through the duration of the maternity cycle as defined in WAC 182-533-0315, but must actually be pregnant at the start of services.

(5) The following are excluded from the oral health connections pilot project:

(a) Family planning only and TAKE CHARGE programs under chapter 182-532 WAC;

(b) Medical care services (MCS) program under WAC 182-508-0005; and

(6) Under the oral health connections pilot project, the medicaid agency pays an enhanced rate for the following services:

(a) One comprehensive oral exam, per client, per provider in a five-year period;

(b) One complete series of intraoral radiographic images per client in a three-year period;

(d) Periodontal scaling and root planing – Four or more teeth per quadrant, once per quadrant per client in a two-year period;

(e) Periodontal scaling and root planing - Three or more teeth per quadrant, once per quadrant per client in a two-year period; and

(f) Up to three additional periodontal maintenance visits in a twelve-month period. At least ninety days must elapse following periodontal scaling and root planing or at least ninety days must elapse following initial periodontal maintenance, and then every ninety days afterwards for a total of three additional periodontal maintenance visits per eligible client in a twelve-month period.

(7) The services listed in subsection (6) of this section are the only services the agency pays at the enhanced rate. The agency pays for all other covered dental services at the standard rate.

(8) To receive the enhanced rate, dental providers must:

(a) Be enrolled to participate in the oral health connections pilot project;

(b) Meet the qualifications in WAC 182-535-1070;

(d) Complete training designed specifically for the oral health connections pilot project.

(9) The agency assigns a special identifier to providers who complete the training in subsection (8)(d) of this section which allows them to receive the enhanced rate.