Dental Benefits and Limitations, MO HealthNet Program

PURPOSE: This rule describes the dental services for which the MO HealthNet Division shall pay when the service is provided to an eligible assistance participant; the service is provided by a licensed dentist, licensed dental hygienist, or licensed and certified dental specialist who has entered into an agreement for that purpose with the division; and the service is listed as a covered item in the MO HealthNet Dental Manual sponsored by the division. The MO HealthNet Dental Manual describes the dental services which shall be paid under limitations and those which shall not be paid under present conditions. PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here. (1) Administration. The MO HealthNet dental program shall be administered by the MO HealthNet Division, Department of Social Services. The dental services covered and not covered, the limitations under which services are covered, and the maximum allowable fees for all covered services shall be determined by the MO HealthNet Division and shall be included in the MO HealthNet Dental Provider Manual, which is incorporated by reference and made part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at www.dss.mo.gov/mhd, May 2, 2016. This rule does not incorporate any subsequent amendments or additions. Dental services covered by the MO HealthNet program shall include only those which are clearly shown to be medically necessary. The division reserves the right to effect changes in services, limitations, and fees with proper notification to MO HealthNet dental providers. (2) Provider Participation. A dentist shall be licensed by the dental board of the state in which s/he is practicing and shall have signed a participation agreement to provide dental services under the MO HealthNet program. An oral surgeon or other dentist specialist shall be licensed in his/her specialty area by the dental board of the state in which s/he is practicing. In those states not having a specialty licensure requirement, the dentist specialist shall be a graduate of and hold a certificate from a graduate training program in that specialty in an accredited dental school. In either case, the dental specialist shall have signed a participation agreement to provide dental services under the MO HealthNet program. A dental hygienist shall be licensed by the dental board of the state for at least three (3) consecutive years and practicing in a public health setting to provide fluoride treatments, teeth cleaning, and sealants to MO HealthNet/MO HealthNet for Kids eligible children ages zero (0) to twenty (20). (3) Participant Eligibility. The MO HealthNet dental provider shall ascertain the patient’s MO HealthNet status before any service is performed. The participant’s MO HealthNet/MO HealthNet for Kids eligibility is determined by the Family Support Division. The participant’s eligibility shall be verified from a current MO HealthNet/MO HealthNet for Kids identification card or a letter of new approval in the participant’s possession. The patient must be a MO HealthNet eligible participant under the MO HealthNet/MO HealthNet for Kids program on the date the service is performed. The MO HealthNet Division is not allowed to pay for any service to a patient who is not eligible under the MO HealthNet/MO HealthNet for Kids program. (A) Coverage of dental services for adults is limited to certain categories of service and may require prior authorization: trauma of the mouth, jaw, teeth, or other contiguous sites as a result of injury; treatment of a disease/medical condition without which the health of the individual would be adversely affected; preventive services; restorative services; periodontal treatment; oral surgery; extractions; radiographs; pain evaluation and relief; infection control; and general anesthesia. Further detail on covered adult dental services may be referenced at www.dss.mo.gov/mhd. (4) Prior Authorization. When prior authorization is required, the form provided by the MO HealthNet Division or its contracted agent shall be used. The dental service shall not be started until written approval has been received. Telephone approval shall not be given. Prior authorization shall be effective for a period of one hundred twenty (120) days from the date of written approval. Prior authorization approves the medical necessity of the requested dental service. It shall not guarantee payment for that service as the patient must be a MO HealthNet eligible participant on the date the service is performed. The division reserves the right to request documentation regarding any specific request for prior authorization. (5) Orthodontia Services. When an eligible participant is believed to have a condition that may require orthodontic treatment, the attending dentist should refer the participant to a qualified dentist or orthodontist for preliminary examination to determine if the treatment will be approved. The fact that the participant has moderate or even severe orthodontic problems, or has been advised by a dentist or orthodontist to have treatment is not, by itself, a guarantee that the patient will qualify for orthodontia services through MO HealthNet. Coverage is determined solely by meeting the criteria listed below in subsections (5)(A) and (5)(B) or (5)(C). (A) To be eligible for orthodontia services, the participant must meet all of the following general requirements: 1. Be under twenty-one (21) years of age; and 2. Have good oral hygiene documented in the child’s treatment plan; and 3. Have permanent dentition. Exceptions to having permanent dentition are as follows: A. Participant has a primary tooth retained due to ectopic or missing permanent tooth; or B. Participant may have primary teeth present if they have cleft palate, severe traumatic deviations, or an impacted maxillary central incisor; or C. Participant may have primary teeth if they are thirteen (13) years of age or older. (B) The determination whether or not a participant will be approved for orthodontic services shall be initially screened using the Handicapping Labio-Lingual Deviation (HLD) Index. The HLD Index must be fully completed in accordance with the instructions. The division will approve orthodontic services when the individual meets all of the criteria in subsection (5)(A) above and one (1) of the criteria listed in paragraphs 1. to 7. below— 1. Has a cleft palate; 2. Has a deep impinging overbite when the lower incisors are damaging the soft tissue of the palate (lower incisor contact only on the palate is not sufficient); 3. Has a cross-bite of individual anterior teeth when damage of soft tissue is present; 4. Has severe traumatic deviations; 5. Has an over-jet greater than nine millimeters (9 mm) or reverse over-jet of greater than three and one-half millimeters (3.5 mm); 6. Has an impacted maxillary central incisor; or 7. Scores twenty-eight (28) points or greater on the HLD Index. (C) If the participant meets the criteria in subsection (5)(A) above but does not meet any of the criteria in subsection (5)(B), the division will consider whether orthodontic services should be provided based upon other evidence that orthodontic services are medically necessary— 1. The division shall consider additional information of a substantial nature about the presence of severe deviations affecting craniofacial health. Other deviations shall be considered to be severe if, left untreated, they would cause irreversible damage to the teeth and underlying structures, result in disease related bone and tooth loss, or craniofacial deformities associated with developmental disabilities in chewing or speaking. 2. Other evidence shall include information of a substantial nature about the presence of a medical condition which is directly affected by the condition of the mouth or underlying structures. Orthodontic treatment shall be considered to be medically necessary if, without the orthodontic treatment, the medical condition would be adversely affected and would result in pain, infection, illness, or significant and immediate impact on the normal function of the body and the individual’s ability to function. In addition, such orthodontic treatment must be demonstrated to be 1) of clear clinical benefit to the eligible participant; 2) Appropriate for the injury or illness in question; and 3) Conform to the standards of generally accepted orthodontic practice as supported by applicable medical and scientific literature. In addition to documentation from an orthodontist or dentist, a recommendation for orthodontic treatment in relation to a medical condition must also be supported by documented evidence of the medical condition from a licensed medical doctor, board certified to diagnose the medical condition. 3. In addition, the division may consider information of a substantial nature about the presence of mental, emotional, and/or behavioral problems, disturbances, or dysfunctions, as defined in the most current edition of the Diagnostic Statistical Manual of the American Psychiatric Association, and which may be caused by the participant’s daily functioning as it relates to a dentofacial deformity. The MO HealthNet Division will only consider cases where a diagnostic evaluation has been performed by a licensed psychiatrist or a licensed psychologist who has accordingly limited his or her practice to child psychiatry or child psychology. The evaluation must clearly and substantially document how the dentofacial deformity is related to the child’s mental, emotional, and/or behavioral problems and must clearly and substantially document that orthodontic treatment is medically necessary and will significantly ameliorate the problems. 4. Orthodontic treatment shall not be considered to be medically necessary when— A. The orthodontic treatment is for aesthetic or cosmetic reasons only; or B. The orthodontic treatment is to correct crowded teeth only, if the child can adequately protect the periodontium with reasonable oral hygiene measures; or C. The child has demonstrated a lack of motivation to maintain reasonable standards of oral hygiene and oral hygiene is deficient. (D) Transfer Participants. 1. A participant who becomes MO HealthNet eligible and is already receiving orthodontic treatment through an entity other than a State Medicaid Agency must demonstrate that the need for service requirements specified in subsection (5)(A) and subsection (5)(B) or (5)(C) of these regulations were met before orthodontic treatment commenced, meaning that prior to the onset of treatment the participant would have met the need for service requirements. 2. A participant who becomes MO HealthNet eligible and is already receiving orthodontic treatment through the Medicaid Agency in another state may continue to receive covered orthodontic treatment services through MO HealthNet Division. (6) Services, Covered and Noncovered. The MO HealthNet Dental Provider Manual shall provide the detailed listing of procedure codes for services covered by the MO HealthNet Dental Program. Pricing information can be obtained from the fee schedule posted at www.dss.mo.gov/mhd/providers/pages/cptagree.htm. (7) General Regulations. General regulations of the MO HealthNet program apply to the dental program. (8) Records Retention. Sanctions may be imposed by the MO HealthNet agency against a provider for failing to make available, and disclosing to the MO HealthNet agency or its authorized agents, all records relating to services provided to MO HealthNet participants or records related to MO HealthNet payments, whether or not the records are comingled with non-MO HealthNet records in compliance with 13 CSR 70-3.030. These records must be retained for five (5) years from the date of service. Fiscal and medical records coincide with and fully document services billed to the MO HealthNet agency. Providers must furnish or make the records available for inspection or audit by the Department of Social Services or its representative upon request. Failure to furnish, reveal, or retain adequate documentation for services billed to the MO HealthNet program, as specified above, is a violation of this regulation. AUTHORITY: section 208.152, RSMo Supp. 2015, and sections 208.153 and 208.201, RSMo Supp. 2013.* This rule was previously filed as 13 CSR 40-81.040. Original rule filed Jan. 21, 1964, effective Jan. 31, 1964. Amended: Filed March 30, 1964, effective April 9, 1964. Amended: Filed April 27, 1965, effective May 7, 1965. Amended: Filed Dec. 7, 1966, effective Dec. 17, 1966. Amended: Filed Oct. 13, 1967, effective Oct. 23, 1967. Amended: Filed Jan. 22, 1968, effective Feb. 1, 1968. Amended: Filed Aug. 24, 1968, effective Sept. 3, 1968. Amended: Filed April 16, 1970, effective April 26, 1970. Amended: Filed Feb. 16, 1971, effective Feb. 26, 1971. Amended: Filed Jan. 3, 1973, effective Jan. 13, 1973. Amended: Filed Feb. 6, 1975, effective Feb. 16, 1975. Amended: Filed July 9, 1976, effective Oct. 11, 1976. Amended: Filed Feb. 7, 1977, effective May 11, 1977. Amended: Filed Nov. 14, 1977, effective Feb. 11, 1978. Emergency rescission filed June 14, 1979, effective July 31, 1979, expired Sept. 13, 1979. Emergency rule filed June 14, 1979, effective Aug. 1, 1979, expired Sept. 13, 1979. Rescinded and readopted: Filed June 14, 1979, effective Sept. 14, 1979. Emergency amendment filed April 10, 1981, effective April 20, 1981, expired July 10, 1981. Amended: Filed April 10, 1981, effective July 11, 1981. Emergency amendment filed Sept. 18, 1981, effective Oct. 1, 1981, expired Jan. 13, 1982. Amended: Filed Sept. 18, 1981, effective Jan. 14, 1982. Amended: Filed July 15, 1991, effective Nov. 30, 1991. Amended: Filed Aug. 14, 1992, effective Feb. 26, 1993. Emergency amendment filed June 27, 2002, effective July 7, 2002, terminated Dec. 17, 2002. Emergency amendment filed Aug. 19, 2005, effective Sept. 1, 2005, expired Feb. 27, 2006. Amended: Filed June 15, 2005, effective Jan. 30, 2006. Amended: Filed Aug. 17, 2009, effective Feb. 28, 2010. Amended: Filed Sept. 28, 2011, effective May 30, 2012. Amended: Filed April 1, 2016, effective Nov. 30, 2016. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015; 208.153, RSMo 1967, amended 1973, 1989, 1990, 1991, 2007, 2012; and 208.201, RSMo 1987, amended 2007.