5160-5-09 Dental program: covered oral surgery services and limitations.

 

 

 

FEDERAL MEDICAID NOTICE AND PUBLIC HEARING NOTICE OHIO DEPARTMENT OF MEDICAID

 

DATE:   November 16, 2015

TIME:  11:00 a.m.

LOCATION:   Room A501, Lazarus Government Center

50 West Town Street, Columbus, OH  43215

 

Pursuant to section 5164.02 and Chapter 119. of the Ohio Revised Code and 42 CFR 447.205, the director of the Ohio Department of Medicaid gives notice of the Department's intent to consider the amendment, rescission, or adoption of the rules identified below and to hold a public hearing on these rules.  The public hearing will be held at the date, time, and location listed at the top of this notice.  Both written and oral testimony will be accepted at the public hearing, and written comments submitted or postmarked no later than the date of the public hearing will be treated as testimony.

The following rules in Chapter 5160-5 of the Ohio Administrative Code set forth Medicaid coverage and payment policies for dental services and related oral health services:

                                                          , "Dental program: general and co-payment provisions"

                                  , "Dental program: covered diagnostic services and limitations"

                                                          , "Dental program: covered tests and laboratory examinations and limitations" 5160-5-04, "Dental program: covered preventive services and limitations"

5160-5-05, "Dental program: covered restorative services and limitations" 5160-5-06, "Dental program: covered endodontic services and limitations" 5160-5-07, "Dental program: covered periodontic services and limitations"

5160-5-08, "Dental program: covered removable prosthodontic services and limitations" 5160-5-09, "Dental program: covered oral surgery services and limitations"

5160-5-10, "Dental program: covered orthodontic services and limitations" 5160-5-11, "Dental program: other covered services and limitations"

These existing rules are being proposed for rescission, and their provisions are being consolidated into a single new rule.

New rule 5160-5-01, "Dental services," sets forth Medicaid coverage and payment policies for dental services. It includes two appendices, one that lays out coverage of services by category and one that lists maximum payment amounts by procedure.

Several changes incorporated into the new rule are noteworthy:

·         Procedure terminology is updated.  The descriptors for a number of preventive and diagnostic services are revised.  In Appendix B to the new rule, new procedure codes are listed, coverage changes are noted, and one outdated local-level procedure code (Y7255) for surgical removal of a supernumerary tooth is discontinued and replaced with the current industry standard.

·         Certain longstanding program policies are codified and clarified.  The first date of service, for example, may be reported on claims for items (such as dentures) that require multiple fittings, so long as the claim is not submitted until after the individual has received the item.  And in instances when it is clinically appropriate for separate restorations to be performed on the same surface of the same tooth, the rule now specifies

 

 

 

 

that payment may be made for such restorations performed on mandibular teeth as well as on maxillary teeth.

·         Prior authorization requirements have been removed for certain services or procedures.

·         Set payment amounts have been established for certain services or procedures that previously required manual pricing.

·         A payment increase and a rural payment fee differential have been established, based on funds appropriated in House Bill 64 of the 131st General Assembly, for dental services rendered in a rural area.

·         Coverage is established for periodontal scaling and root planing services and for intravenous conscious sedation/analgesia.

·         Coverage is extended to equivalent services or procedures.

·         The add-on incentive payment for general anesthesia provided in an office setting is eliminated, and the maximum payment for general anesthesia as a dental service is increased by the incentive amount.

·         Form ODM 03630, "Referral evaluation criteria for comprehensive orthodontic treatment," is updated and retitled "Referral evaluation for comprehensive orthodontic treatment." It will be available on the ODM web site as a standalone document rather than as a rule appendix.

It is estimated that the rescission and adoption of these rules will have on annual aggregate increase of Medicaid expenditures of $9,000,000.

Any person affected by these rules may examine them and obtain a copy, without charge, at the following locations:

Ohio Department of Medicaid, 50 West Town Street, Suite 400, Columbus, Ohio 43215; Any county department of job and family services; or

On the internet at http://www.registerofohio.state.oh.us/.

Testimony on the proposed rules may also be reviewed at the Ohio Department of Medicaid, 50 West Town Street, Suite 400, Columbus, Ohio 43215.

Requests for a copy of the proposed rules or a copy of testimony on the rules should be submitted in any of the following ways:

By mail to the Rule Administrator, Office of Chief Legal Counsel, Ohio Department of Medicaid, 50 West Town Street, Suite 400, Columbus, OH 43215;

By fax to [phone]; or

By e-mail to [e-mail].