20070912-IR-405060005FRA Amends 405 IAC 5-14-1 and 405 IAC 5-14-3 to place limitations on dental services for adults that are in accordance with HEA 1001-2005, SECTION 239, and amends rules regarding coverage for diagnostic ...

TITLE 405 OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES

Final Rule

LSA Document #06-5(F)

DIGEST

Amends 405 IAC 5-14-1 and 405 IAC 5-14-3 to place limitations on dental services for adults that are in accordance with HEA 1001-2005, SECTION 239, and amends rules regarding coverage for diagnostic services. Effective 30 days after filing with the Publisher.

405 IAC 5-14-1; 405 IAC 5-14-3

SECTION 1. 405 IAC 5-14-1 IS AMENDED TO READ AS FOLLOWS:

405 IAC 5-14-1 Policy

Authority: IC 12-8-6-5; IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2; IC 12-15-21-3

Affected: IC 12-13-7-3; IC 12-15-13-6

Sec. 1. (a) Medicaid reimbursement is available only for those dental services listed in section 2 of this rule subject to the limitations set out in this rule.

(b) For those recipients twenty-one (21) years of age and over, covered services routinely provided in a dental office will be limited to six hundred dollars ($600) per recipient, per twelve (12) month period. This limit precedes all other limits within this rule. The procedure codes that will be included within the limitation:

(1) will be listed and published in a provider bulletin; and

(2) may be updated by the office as needed.

A provider bulletin issued under this subsection shall be effective no earlier than permitted under IC 12-15-13-6.

(c) For those recipients twenty-one (21) years of age and over, all covered services will require prior authorization except the following:

(1) Diagnostic and preventative services.

(2) Direct restorations.

(3) Treatment of lesions.

(4) Periodontal services for the following immuno-compromised individuals:

(A) Transplant patients.

(B) Pregnant women.

(C) Diabetic patients.

(5) Extractions.

(6) Emergency and trauma care.

(Office of the Secretary of Family and Social Services; 405 IAC 5-14-1; filed Jul 25, 1997, 4:00 p.m.: 20 IR 3319; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; filed Dec 13, 2002, 4:00 p.m.: 26 IR 1546; filed Aug 17, 2007, 3:23 p.m.: 20070912-IR-405060005FRA)

SECTION 2. 405 IAC 5-14-3 IS AMENDED TO READ AS FOLLOWS:

405 IAC 5-14-3 Diagnostic services

Authority: IC 12-8-6-5; IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2; IC 12-15-21-3

Affected: IC 12-13-7-3; IC 12-15

Sec. 3. Medicaid reimbursement is available for diagnostic services, including initial and periodic evaluations, prophylaxis, radiographs, and emergency treatments, with the following limitations:

(1) Either a full mouth series radiographs or panorex is limited to one (1) set per recipient every three (3) years.

(2) Bitewing and intraoral radiographs are limited to one (1) set per recipient every twelve (12) months. One (1) set of bitewings is defined as a total of either:

(A) four (4) single horizontal films; or

(B) seven (7) to eight (8) vertical films.

(3) Intraoral radiographs are limited to one (1) first film and seven (7) additional films, per recipient every twelve (12) months.

(4) Temporomandibular joint arthograms, arthrograms, other temporomandibular films, tomographic surveys, and cephalometric films are no longer covered in a dental office.

(3) (5) A comprehensive or detailed oral evaluation is limited to one (1) per lifetime, per recipient, per provider, with an annual limit of two (2) per recipient.

(4) (6) A periodic or limited oral evaluation is limited to one (1) every six (6) months, per recipient, any provider.

(5) (7) Mouth gum cultures and sensitivity tests are not covered.

(6) (8) Oral hygiene instructions:

(A) are reimbursed in the Medicaid payment allowance for diagnostic services; and

(B) may not be billed separately to Medicaid.

(7) (9) Payment for the writing of prescriptions:

(A) is included in the reimbursement for diagnostic services; and

(B) may not be billed separately to Medicaid.

(Office of the Secretary of Family and Social Services; 405 IAC 5-14-3; filed Jul 25, 1997, 4:00 p.m.: 20 IR 3320; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; filed Apr 16, 2003, 10:50 a.m.: 26 IR 2863; filed Aug 17, 2007, 3:23 p.m.: 20070912-IR-405060005FRA)

LSA Document #06-5(F)

Notice of Intent: February 1, 2006; 29 IR 1584

Proposed Rule: June 1, 2006; 29 IR 3095

Hearing Held: November 2, 2006

Approved by Attorney General: August 13, 2007

Approved by Governor: August 17, 2007

Filed with Publisher: August 17, 2007, 3:23 p.m.

Documents Incorporated by Reference: None Received by Publisher

Small Business Regulatory Coordinator: Scott Linneweber, Office of the Secretary of Family and Social Services, Indiana Government Center-South, 402 West Washington Street, Room W451, Indianapolis, IN 46204, [phone], [e-mail]

Posted: 09/12/2007 by Legislative Services Agency

DIN: 20070912-IR-405060005FRA

Composed: Oct 31,2016 11:46:44PM EDT

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