PROPOSAL
Maryland Register
Issue Date: May 12, 2017
Volume 44 • Issue 10 • Pages 489—491
Title 10
DEPARTMENT OF HEALTH AND MENTAL HYGIENE
Subtitle 09 MEDICAL CARE PROGRAMS
Authority: Health-General Article, §§2-104(b), 15-103, and 15-105, Annotated Code of Maryland
Notice of Proposed Action
[17-137-P-I]
The Secretary of Health and Mental Hygiene proposes to amend Regulations .01—.09, and .11 under COMAR 10.09.05 Dental Services.
Statement of Purpose
The purpose of this action is to change the regulations to allow former foster care participants younger than 26 years old to access medically necessary dental benefits effective January 1, 2017. This proposal clarifies that mobile dental units shall renew written, informed consent from parents each school year. Finally, this proposal updates the dental fee schedule that is incorporated by reference in this chapter.
Comparison to Federal Standards
There is no corresponding federal standard to this proposed action.
Estimate of Economic Impact
I. Summary of Economic Impact. The Program will provide medically necessary dental services to former foster care children who are younger than 26 years old during FY2017 resulting in a net expenditure of $308,085. This amount is included in the FY2017 budget.
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Revenue (R+/R-) |
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II. Types of Economic Impact. |
Expenditure (E+/E-) |
Magnitude |
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A. On issuing agency: |
(E+) |
$308,085 |
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B. On other State agencies: |
NONE |
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C. On local governments: |
NONE |
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Benefit (+)
Cost (-) |
Magnitude |
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D. On regulated industries or trade groups: |
(+) |
$308,085 |
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E. On other industries or trade groups: |
NONE |
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F. Direct and indirect effects on public: |
NONE |
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III. Assumptions. (Identified by Impact Letter and Number from Section II.) |
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A. and D. The State’s budget allocation for Fiscal Year 2017 provides for $308,085 to pay for medically necessary dental services for former foster care children who are younger than 26 years old. The projected number of former foster care children that will be eligible to receive dental services is estimated to be around 2,375 cases for the third and fourth quarter of Fiscal Year 2017. |
Economic Impact on Small Businesses
The proposed action has a meaningful economic impact on small business. An analysis of this economic impact follows.
The proposed action will generate $308,085 in revenue to regulated industries (dental). It is expected that many of the practices providing dental services to former foster care children will be small businesses.
Impact on Individuals with Disabilities
The proposed action has no impact on individuals with disabilities.
Opportunity for Public Comment
Comments may be sent to Michele Phinney, Director, Office of Regulation and Policy Coordination, Department of Health and Mental Hygiene, 201 West Preston Street, Room 512, Baltimore, MD 21201, or call 410-767-6499 (TTY 800-735-2258), or email to dhmh.regs@maryland.gov, or fax to 410-767-6483. Comments will be accepted through June 12, 2017. A public hearing has not been scheduled.
Editor’s Note on Incorporation by Reference
Pursuant to State Government Article, §7-207, Annotated Code of Maryland, the Maryland Medicaid Dental Fee Schedule and Procedures Codes CDT 2017 (Maryland Medical Assistance Program — Effective January 1, 2017) has been declared a document generally available to the public and appropriate for incorporation by reference. For this reason, it will not be printed in the Maryland Register or the Code of Maryland Regulations (COMAR). Copies of this document are filed in special public depositories located throughout the State. A list of these depositories was published in 44:1 Md. R. 9 (January 6, 2017), and is available online at www.dsd.state.md.us. The document may also be inspected at the office of the Division of State Documents, 16 Francis Street, Annapolis, Maryland 21401.
.01 Definitions.
A. (text unchanged)
B. Terms Defined.
(1)—(3) (text unchanged)
(4) 'Appeal' means the process:
(a) To resolve a [recipient's] participant’s dispute with any adverse action taken by the ASO to deny, reduce, terminate, delay, or suspend a covered service; and
(b) (text unchanged)
(5) (text unchanged)
(6) 'Benefits' means a schedule of dental services to be administered by the ASO to Medical Assistance [recipients] participants pursuant to this chapter.
(7)—(8) (text unchanged)
(9) 'Covered services' means:
(a) All medically necessary dental services for Medical Assistance or State Children's Health Insurance Program (SCHIP) eligible children younger than 21 years old; [and]
(b) Certain medically necessary dental services for pregnant women and REM [recipients] participants 21 years old or older[.]; and
(c) Effective January 1, 2017, all medically necessary dental services for eligible former foster care participants younger than 26 years old.
(10)—(18) (text unchanged)
(19) “Maryland Healthy Smiles Dental Program” means the Maryland Medicaid dental program that provides coverage for:
(a) (text unchanged)
(b) Eligible pregnant women 21 years old or older; [and]
(c) Eligible adults 21 years old or older enrolled in the Rare and Expensive Case Management (REM) program; and
(d) Eligible former foster care participants younger than 26 years old.
(20)—(23) (text unchanged)
(24) 'Network provider' means a health care entity or health care professional that is either employed by, or has executed a provider agreement with, the dental benefits administrator, or its subcontractor to render covered services to the [recipient] participant.
(25) 'Participant' means an individual who is certified as eligible for, and is receiving, Medical Assistance benefits.
[(25)] (26)—[(27)] (28) (text unchanged)
[(28)] (29) 'Provider' means:
(a) An individual dentist, duly licensed to provide services for [recipients] participants, or an association, partnership, or an incorporated or unincorporated group of dentists so licensed, that, through appropriate agreement with the Department, has been identified as a Program provider by the issuance of an individual account number; or
(b) (text unchanged)
[(29) 'Recipient' means a person who is certified as eligible for, and is receiving, Medical Assistance benefits.]
(30)—(32) (text unchanged)
.02 License Requirements.
A.—E. (text unchanged)
F. The provider shall [insure] ensure that all X-ray or other radiological equipment is inspected and meets the standards established in COMAR 26.12.01 or other applicable standards established by the state in which the service is provided.
G. (text unchanged)
.03 Provider Qualifications and Conditions for Participation.
A.—E. (text unchanged)
F. Mobile Dental Unit.
(1)—(5) (text unchanged)
(6) A mobile dental unit shall:
(a)—(b) (text unchanged)
(c) Obtain written, informed consent, which shall be renewed each school year, from a parent or legal guardian before treating a minor;
(d)—(u) (text unchanged)
(7)—(8) (text unchanged)
.04 Covered Services.
A. The Program covers the following medically necessary dental services for [individuals] participants younger than 21 years old, and effective January 1, 2017, eligible former foster care participants younger than 26 years old, including but not limited to the following:
(1)—(3) (text unchanged)
(4) Orthodontic care for conditions which:
(a) (text unchanged)
(b) Cause dysfunction due to a handicapping malocclusion that is supported by comprehensive pretreatment orthodontic records, which include at a minimum:
[(i) Upper and lower study models;]
[(ii)] (i)—[(vii)] (vi) (text unchanged)
(5) Consultations for [recipients] participants who meet the requirements of §A(1), (2), (3), or (4) of this regulation;
(6)—(9) (text unchanged)
B. The Program covers the following medically necessary dental services for pregnant [recipients] participants and REM [recipients] participants 21 years old or older:
(1)—(20) (text unchanged)
C. The Program shall reimburse for covered services in §§A and B of this regulation if:
(1) The services are rendered in:
(a) (text unchanged)
(b) The [recipient’s] participant’s home;
(c)—(h) (text unchanged)
(2) (text unchanged)
(3) The services are clearly related to the [recipient's] participant’s individual dental care needs as ameliorative, diagnostic, curative, palliative, preventive, or rehabilitative services; and
(4) The services are adequately described on the [recipient's] participant’s dental care record.
.05 Limitations.
A. The Program places the following limitations upon covered services:
(1)—(5) (text unchanged)
(6) Replacement dentures for [recipients] participants who meet the requirements of Regulation .04A(3) of this chapter will be covered only when:
(a)—(b) (text unchanged)
(7)—(9) (text unchanged)
(10) Separate reimbursement will not be made for cavity liners and office visits, as these procedures are considered to be components of the necessary treatment. These services may not be billed to the [recipient] participant.
(11)—(14) (text unchanged)
B. (text unchanged)
.06 Preauthorization Requirements.
A.—C. (text unchanged)
D. Preauthorization is valid for dental services when the services are approved and completed within 6 months after the date of the receipt of the preauthorization number from the Program and is contingent on the [recipient's] participant’s continued eligibility.
E.—F. (text unchanged)
.07 Payment Procedures.
A.—D. (text unchanged)
E. The current Maryland Medicaid Dental Services Fee Schedule and Procedure Codes CDT is incorporated by reference, effective January 1, [2015] 2017.
F.—H. (text unchanged)
I. Reimbursement for Self-Ligating Braces.
(1) (text unchanged)
(2) When a claim is submitted to the Program for the banding of self-ligating braces, the following documentation shall be submitted with the claim:
(a) (text unchanged)
(b) A statement signed by the parent or guardian of the child receiving treatment, acknowledging that:
(i) (text unchanged)
(ii) The [recipient] participant will not be able to pursue additional orthodontic services from the Medicaid Program at a later date.
J. (text unchanged)
K. The Department may not make direct payment to the [recipient] participant.
L.—N. (text unchanged)
.08 Recovery and Reimbursement.
A. If the [recipient] participant has insurance or other coverage, or if any other person is obligated, either legally or contractually, to pay for or to reimburse the [recipient] participant for services covered by this chapter, the provider shall seek payment from that source first. If an insurance carrier rejects the claim or pays less than the amount allowed by the Medical Assistance Program, the provider may submit a claim to the Program. The provider shall submit a copy of the insurance carrier's notice or remittance advice with his invoice. If payment is made by both the Program and the insurance or other source for the same service, the provider shall refund to the Department, within 60 days of receipt, the amount paid by the Program, or the insurance or other source, whichever is less.
B. (text unchanged)
.09 Cause for Suspension or Removal and Imposition of Sanctions.
A.—C. (text unchanged)
D. Any provider who voluntarily withdraws from the Program or is removed or suspended from the Program according to this regulation shall notify [recipients] participants that [he] the provider no longer honors Medical Assistance cards before rendering additional services.
.11 Interpretive Regulation.
Except when the language of a specific regulation indicates an attempt by the Department to provide reimbursement for covered services to Program [recipients] participants without regard to the availability of federal financial participation, State regulations shall be interpreted in conformity with applicable federal statutes and regulations.
DENNIS R. SCHRADER
Secretary of Health and Mental Hygiene
