DAR File No. 28619

Health, Health Care Financing, Coverage and Reimbursement Policy

R414-50

Dental, Oral and Maxillofacial Surgeons

NOTICE OF PROPOSED RULE

DAR File No.: 28619
Filed: 04/14/2006, 04:17
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

Funding was not provided for adult dentures by the 2006 Utah Legislature. This rulemaking is necessary to reflect that action.

Summary of the rule or change:

In Section R414-50-3, additional wording is added that defines who can receive treatment. In Subsection R414-50-5(1), the word "dental" is added in two different sentences. Subsection R414-50-5(3) is a new subsection that defines who is covered for work by an oral surgeon. The rest of the subsections are renumbered.

State statutory or constitutional authorization for this rule:

Section 26-18-3

Anticipated cost or savings to:

the state budget:

This rulemaking saves the general fund $638,668 and matching federal funds of $1,511,007 for a total of $2,149,675.

local governments:

Local governments do not provide dental services, therefore there is no impact to local governments.

other persons:

Providers may lose approximately $2,149,675 in Medicaid reimbursements for services that they may no longer provide as a result of this rulemaking. Medicaid clients, if they obtain the same services and pay for them out-of-pocket will experience an aggregate cost of about $4,300,000 because they will pay for the service at a higher, non-Medicaid rate.

Compliance costs for affected persons:

A single Medicaid denture provider may lose approximately $12,426 annually for services that the provider no longer provides. This is based on the total number of 173 Medicaid denture providers who provides dentures once per year for each Medicaid client. Full dentures under Medicaid cost $900 per client. A Medicaid client who obtains dentures and pays for them out-of-pocket will pay about $1,800 for the same full dentures.

Comments by the department head on the fiscal impact the rule may have on businesses:

This rule will reduce the number of Medicaid recipients eligible to receive dentures and is necessary to stay within appropriations. David N. Sundwall, MD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Direct questions regarding this rule to:

Ross Martin at the above address, by phone at 801-538-6592, by FAX at 801-538-6099, or by Internet E-mail at rmartin@utah.gov

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

05/31/2006

This rule may become effective on:

06/01/2006

Authorized by:

David N. Sundwall, Executive Director

RULE TEXT

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-50. Dental, Oral and Maxillofacial Surgeons.

R414-50-3. Client Eligibility Requirements.

Oral and maxillofacial surgery service is available to categorically and medically needy clients who are ages 20 and younger or who are pregnant.[ Dental services to non-pregnant adults ages 21 and older are limited to emergency services only.]

R414-50-5. Service Coverage.

(1) Emergency dental services are covered services. Emergency dental services provided by a dentist in areas where an oral and maxillofacial surgeon is unavailable are covered services.

(2) Appropriate general anesthesia necessary for optimal management of the emergency is a covered service.

(3) Physician services and medical and surgical services if performed by an oral surgeon are covered for all recipient age groups and not subject to section (4) above.

(4) Hospitalization of patients for dental surgery may be a covered service if a patient's physician, at the time of the proposed hospitalization, verifies that the patient's general health status dictates that hospitalization is necessary for the health and welfare of the patient.

([4]5) Treatment of temporomandibular joint fractures is a covered service. All other temporomandibular joint treatments are not covered services.

([5]6) For procedures requiring prior approval, Medicaid shall deny payment if the services are rendered before prior approval is obtained. Exceptions may be made for emergency services, or for recipients who obtain retroactive eligibility. The provider must apply for approval as soon as is practicable after the service is provided.

([6]7) Extraction of primary teeth at or near the time of exfoliation, as evidenced by mobility or loosening of the teeth, is not a covered service.

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [January 28, 2004]2006

Notice of Continuation: November 3, 2004

Authorizing and Implemented or Interpreted Law: 26-1-4.1; 26-1-5; 26-18-3

ADDITIONAL INFORMATION

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For questions regarding the content or application of this rule, please contact Ross Martin at the above address, by phone at 801-538-6592, by FAX at 801-538-6099, or by Internet E-mail at rmartin@utah.gov

For questions about the rulemaking process, please contact the Division of Administrative Rules (801-538-3764). Please Note: The Division of Administrative Rules is NOT able to answer questions about the content or application of these administrative rules.