WSR 23-17-080
PROPOSED RULES
HEALTH CARE AUTHORITY
[Filed August 15, 2023, 9:55 a.m.]
Original Notice.
Preproposal statement of inquiry was filed as WSR 23-13-022.
Title of Rule and Other Identifying Information: WAC 182-535-1088 Dental-related services—Covered—Periodontic services.
Hearing Location(s): On September 26, 2023, at 10:00 a.m. The health care authority (HCA) holds public hearings virtually without a physical meeting place. To attend the virtual public hearing, you must register in advance https://us02web.zoom.us/webinar/register/WN_E7tAxNWnSVCG-SIhvxxsWg. If the link above opens with an error message, please try using a different browser. After registering, you will receive a confirmation email containing information about joining the public hearing.
Date of Intended Adoption: September 27, 2023.
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 September 26, 2023, by 11:59 p.m.
Assistance for Persons with Disabilities: Contact Johanna Larson, phone 360-725-1349, fax 360-586-9727, telecommunication[s] relay service 711, email Johanna.larson@hca.wa.gov, by September 8, 2023.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: HCA is amending this rule to increase the allowable number of periodontal treatments to up to four per 12-month period for apple health eligible clients, age 21 and over, with a current diagnosis of diabetes. Effective January 1, 2024, periodontal maintenance is allowed once every three months when criteria are met. In subsection (2)(a)(i), the agency removed "subgingival calculus" as it is unnecessary language.
Reasons Supporting Proposal: See purpose.
Statute Being Implemented: ESSB 5187 Conference Budget, section 211(60); RCW
41.05.021,
41.05.160.
Rule is not necessitated by federal law, federal or state court decision.
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: Jayson Diaz, P.O. Box 55076, Olympia, WA 98504-5076, 360-725-1822.
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.
Scope of exemption for rule proposal from Regulatory Fairness Act requirements:
Is not exempt.
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. HCA is amending this rule to increase the allowable number of periodontal treatments. This change does not impose a more-than-minor cost.
August 15, 2023
Wendy Barcus
Rules Coordinator
OTS-4724.2
AMENDATORY SECTION(Amending WSR 17-20-097, filed 10/3/17, effective 11/3/17)
WAC 182-535-1088Dental-related services—Covered—Periodontic services.
Clients described in WAC 182-535-1060 are eligible to receive the dental-related periodontic services listed in this section, subject to coverage limitations, restrictions, and client-age requirements identified for a specified service.
(1) Surgical periodontal services. The medicaid agency covers the following surgical periodontal services, including all postoperative care:
(a) Gingivectomy/gingivoplasty (does not include distal wedge procedures on erupting molars) only on a case-by-case basis and when prior authorized and only for clients age ((twenty))20 and younger; and
(b) Gingivectomy/gingivoplasty (does not include distal wedge procedures on erupting molars) for clients of the developmental disabilities administration of the department of social and health services (DSHS) according to WAC 182-535-1099.
(2) Nonsurgical periodontal services. The agency:
(a) Covers periodontal scaling and root planing for clients age ((thirteen through eighteen))13 through 18, once per quadrant per client, in a two-year period on a case-by-case basis, when prior authorized, and only when:
(i) The client has radiographic evidence of periodontal disease ((and subgingival calculus));
(ii) The client's record includes supporting documentation for the medical necessity, including complete periodontal charting done within the past ((twelve))12 months from the date of the prior authorization request and a definitive diagnosis of periodontal disease;
(iii) The client's clinical condition meets current published periodontal guidelines; and
(iv) Performed at least two years from the date of completion of periodontal scaling and root planing or surgical periodontal treatment, or at least ((twelve))12 calendar months from the completion of periodontal maintenance.
(b) Covers periodontal scaling and root planing once per quadrant per client in a two-year period for clients age ((nineteen))19 and older. Criteria in (a)(i) through (iv) of this subsection must be met.
(c) Considers ultrasonic scaling, gross scaling, or gross debridement to be included in the procedure and not a substitution for periodontal scaling and root planing.
(d) Covers periodontal scaling and root planing only when the services are not performed on the same date of service as prophylaxis, periodontal maintenance, gingivectomy, or gingivoplasty.
(e) Covers periodontal scaling and root planing for clients of the developmental disabilities administration of DSHS according to WAC 182-535-1099.
(f) Covers periodontal scaling and root planing, one time per quadrant in a ((twelve))12-month period for clients residing in an alternate living facility or nursing facility.
(3) Other periodontal services. The agency:
(a) Covers periodontal maintenance for clients age ((thirteen through eighteen))13 through 18 once per client in a ((twelve))12-month period on a case-by-case basis, when prior authorized, and only when:
(i) The client has radiographic evidence of periodontal disease;
(ii) The client's record includes supporting documentation for the medical necessity, including complete periodontal charting done within the past ((twelve))12 months with location of the gingival margin and clinical attachment loss and a definitive diagnosis of periodontal disease;
(iii) The client's clinical condition meets current published periodontal guidelines; and
(iv) The client has had periodontal scaling and root planing but not within ((twelve))12 months of the date of completion of periodontal scaling and root planing, or surgical periodontal treatment.
(b) Covers periodontal maintenance once per client in a twelve month period for clients age ((nineteen))19 and older. Criteria in (a)(i) through (iv) of this subsection must be met.
(c) Covers periodontal maintenance only if performed at least ((twelve))12 calendar months after receiving prophylaxis, periodontal scaling and root planing, gingivectomy, or gingivoplasty.
(d) Covers periodontal maintenance for clients of the developmental disabilities administration of DSHS according to WAC 182-535-1099.
(e) Covers periodontal maintenance for clients residing in an alternate living facility or nursing facility:
(i) Periodontal maintenance (four quadrants) substitutes for an eligible periodontal scaling or root planing once every six months.
(ii) Periodontal maintenance allowed six months after scaling or root planing.
(f) Covers periodontal maintenance for clients 21 and older with a diagnosis of diabetes:
(i) Periodontal maintenance allowed once every three months. Criteria in (a)(i) through (iii) of this subsection must be met.
(ii) Periodontal maintenance allowed three months after scaling or root planing.
(g) Covers full-mouth scaling in the presence of generalized moderate or severe gingival inflammation and only:
(i) For clients age ((nineteen))19 and older once in a ((twelve))12-month period after an oral evaluation; and
(ii) For clients age ((thirteen through eighteen))13 through 18 once in a ((twelve))12-month period after an oral evaluation and when prior authorized.