PROPOSAL
Maryland Register
Issue Date: January 4, 2019
Volume 46 • Issue 1 • Page 22-25
Title 10
DEPARTMENT OF HEALTH AND MENTAL HYGIENE
Subtitle 09 MEDICAL CARE PROGRAMS
10.09.05 Dental Services
Authority: Health-General Article, §§2-104(b), 15-103, and 15-105, Annotated Code of Maryland
Notice of Proposed Action
[18-350-P]
The Secretary of Health proposes to amend Regulations .01—.05 and .07 under COMAR 10.09.05 Dental Services.
Statement of Purpose
The purpose of this action is to outline parameters for coverage of certain medically necessary dental services for dual eligible participants ages 21 through 64 years old, pursuant to S.B. 284 of 2018, Maryland Medical Assistance Program — Dental Coverage for Adults. Additionally, this proposal adds physician assistants as providers who can be EPSDT-certified, clarifies documentation required in order to be a Medicaid provider of dental services, clarifies language regarding patient record sharing for children who receive services at mobile dental units, and clarifies that the Program does not cover implants.
Comparison to Federal Standards
There is no corresponding federal standard to this proposed action.
Estimate of Economic Impact
I. Summary of Economic Impact. Based on preliminary analysis, the total estimated cost of the program is $5 million total funds (50 percent federal funds, 50 percent general funds) annually. Given a start date of January 1, 2019, the estimated cost for FY19 is $2.5 million total funds (50 percent federal funds, 50 percent general funds).
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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+) |
$5,012,922.50 |
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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: |
(+) |
$4,819,911.60 |
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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. This amount assumes the Centers for Medicare and Medicaid Services (CMS) will approve the waiver the Department applied for to implement the adult dental pilot. Subject to the approval of CMS, the pilot will go into effect January 1, 2019.
The Statewide pilot program will serve individuals between the ages of 21 and 64 who are dually eligible for both Medicare and Medicaid. The Department estimates approximately 38,510 participants will gain dental coverage under the pilot. Average per member per month (PMPM) cost, inclusive of both service costs and administrative fees for the Medicaid Program’s dental benefit manager, is estimated to be $10.82.
Expenditures will be subject to a 50 percent federal match. |
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D. This amount assumes $0.39 of the PMPM cost covers administrative fees, leaving the remaining $10.43 to cover service costs paid to dental providers. |
Economic Impact on Small Businesses
The proposed action has a meaningful economic impact on small business. An analysis of this economic impact follows.
Small business dental practices that serve Medicaid dual-eligible participants may benefit from the influx of newly eligible patients.
Impact on Individuals with Disabilities
The proposed action has no impact on individuals with disabilities.
Opportunity for Public Comment
Comments may be sent to Jake Whitaker, Acting Director, Office of Regulation and Policy Coordination, 201 West Preston Street, Room 512, Baltimore, MD 21201, or call 410-767-6499 (TTY 800-735-2258), or email to mdh.regs@maryland.gov, or fax to 410-767-6483. Comments will be accepted through February 4, 2019. A public hearing has not been scheduled.
.01 Definitions.
A. (text unchanged)
B. Terms Defined.
(1)—(8) (text unchanged)
(9) 'Covered services' means:
(a) (text unchanged)
(b) Certain medically necessary dental services for pregnant women and REM 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[.]; and
(d) Effective January 1, 2019, certain medically necessary services for dual-eligible participants 21 through 64 years old.
(10)—(12) (text unchanged)
(13) Dual Eligible.
(a) “Dual eligible” means an individual who is enrolled in both the Maryland Medical Assistance Program and Medicare.
(b) “Dual eligible” does not include Medicaid participants who only receive assistance with their Medicare premiums, deductibles, or copayments.
[(13)] (14)—[(18)] (19) (text unchanged)
[(19)] (20) “Maryland Healthy Smiles Dental Program” means the Maryland Medicaid dental program that provides coverage for:
(a)—(b) (text unchanged)
(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[.]; and
(e) Eligible participants who are:
(i) Dual eligible; and
(ii) 21 through 64 years old.
[(20)] (21)—[(32)] (33) (text unchanged)
.02 License Requirements.
A.—D. (text unchanged)
E. An EPSDT certified provider shall be:
(1) (text unchanged)
(2) A nurse practitioner who is licensed and certified to practice in the state in which services are provided; [or]
(3) A physician assistant who is licensed to practice in the state in which services are provided; or
[(3)] (4) A local health department, or a federally qualified health center, which has on its staff, and under whose supervision EPSDT services are delivered:
(a) A doctor of medicine licensed in the state in which the service is provided; [or]
(b) A nurse practitioner licensed and certified in the state in which services are provided[.]; or
(c) A physician assistant licensed in the state in which services are provided.
F.—G. (text unchanged)
.03 Provider Qualifications and Conditions for Participation.
A.—B. (text unchanged)
C. To participate in the Program as an EPSDT certified provider of fluoride varnish services, the provider shall:
(1) (text unchanged)
(2) Meet the following requirements:
(a) (text unchanged)
(b) Be a licensed physician, physician assistant, or licensed and certified nurse practitioner, delivering primary health care to children and adolescents; or
(c) (text unchanged)
D. The provider shall:
(1) Complete the Dental Provider Application; and
(2) Submit verification of the National Provider Identifier (NPI) Number[;].
[(3) Complete a W-9 Tax Identification Form; and
(4) Submit a copy of the current professional liability insurance certificate or declaration page (face sheet) of the insurance policy.]
[E. The face sheet referenced in §D(4) of this regulation, shall include:
(1) The name of the insurance company;
(2) The name of the policy holder;
(3) The policy number;
(4) Dates of coverage;
(5) The amounts of coverage; and
(6) The state in which the coverage is effective.]
[F.] E. Mobile Dental Unit.
(1)—(3) (text unchanged)
(4) The mobile dental unit shall have and utilize the electronic technology that enables the same day exchange of patient records with [the]:
(a) The primary dental office[.]; and
(b) If requested, the dental office of the parent or legal guardian’s choice.
(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], which shall:
(i) Be renewed each school year before treating a minor; and
(ii) Allow the parent or legal guardian to request that the dental records be sent to a provider of their choice;
(d)—(u) (text unchanged)
(7)—(8) (text unchanged)
F. For services provided pursuant to Regulation .04C of this chapter, the dental provider shall:
(1) Inform the participant in writing of the $800 annual cap on Medicaid coverage; and
(2) Obtain the participant’s written approval prior to beginning any services that cannot be completed within the cap amount.
.04 Covered Services.
A. The Program covers the following medically necessary dental services for 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)—(6) (text unchanged)
(7) Oral Health assessment by an EPSDT certified provider, and if determined medically necessary, the application of fluoride varnish for children 9 months old through [3] 5 years old;
(8)—(9) (text unchanged)
B. The Program covers the following medically necessary dental services for pregnant participants and REM participants 21 years old or older:
(1) Periodic, limited, and comprehensive oral [examination] examinations;
(2) X-rays, including [single]:
(a) Single first and each additional intraoral periapical film[, and single film and two film bitewings];
(b) Single, two, three, or four film bitewings, which are limited to:
(i) Two per patient per year for REM participants 21 years old or older; or
(ii) One per patient per year for pregnant participants 21 years old or older; and
(c) One panoramic radiographic image every 36 months;
(3) Prophylaxis for adults, which is limited to [two per patient per year;]:
(i) One per patient per 3 months for REM participants 21 years old or older; or
(ii) One per patient per 6 months for pregnant participants 21 years old or older;
(4) Topical application of fluoride, which is limited to [two applications per patient per year;]:
(a) One application per patient per 6 months for REM participants 21 years old or older; or
(b) One application per patient per year for pregnant participants 21 years old or older;
(5) Amalgam restorations for permanent teeth for one, two, three, four, or more surfaces, which are limited to one identical restoration per tooth per [year] 36 months;
(6) Resin restorations for anterior permanent teeth for one, two, three, four, or more surfaces or involving incisal angle, which are limited to one identical restoration per tooth per [year] 36 months;
(7)—(20) (text unchanged)
C. As provided for in the budget, the Program covers the following medically necessary dental services, up to $800 per calendar year, for dual eligible participants who are 21 through 64 years old:
(1) Periodic, limited, and comprehensive oral examinations;
(2) X-rays, including:
(a) Single first and each additional intraoral periapical film limited to six per patient per 12 months;
(b) Single, two, three, or four film bitewings which is limited to one per patient per 12 months; and
(c) One panoramic radiographic image every 36 months;
(3) Prophylaxis for adults, which is limited to one per patient per 6 months;
(4) Amalgam restorations for permanent teeth for one, two, three, four, or more surfaces, which is limited to one identical restoration per tooth per 36 months;
(5) Resin restorations for anterior permanent teeth for one, two, three, four, or more surfaces or involving incisal angle, which are limited to one identical restoration per tooth per 36 months; and
(6) Simple or surgical extractions of an erupted tooth or roots.
[C.] D. The Program shall reimburse for covered services in [§§A and B] §§A—C of this regulation if:
(1)—(4) (text unchanged)
.05 Limitations.
A. (text unchanged)
B. The Program does not cover:
(1)—(15) (text unchanged)
(16) Services when reimbursement is included under another segment of the Program; [and]
(17) Unilateral partial dentures replacing less than three teeth, excluding third molars[.]; and
(18) Implants.
C. On an annual basis, the Department may evaluate coverage of dental services for dual eligible participants who are 21 through 64 years old on the standards of cost and quality.
.07 Payment Procedures.
A.—F. (text unchanged)
G. Pursuant to Regulation .03F of this chapter, to obtain compensation from the Department for rendering services outlined in Regulation .04C of this chapter, the provider shall:
(1) Inform the participant in writing of the $800 annual cap on Medicaid coverage; and
(2) Obtain the participant’s written approval before beginning any services that cannot be completed within the cap amount.
[G.] H.—[N.] O. (text unchanged)
ROBERT R. NEALL
Secretary of Health
