26 Tex. Admin. Code § 260.339 - Dental Treatment

(a) Dental treatment consists of the following:

(1) emergency dental treatments, which are procedures necessary to control bleeding, relieve pain, and eliminate acute infection; operative procedures that are required to prevent the imminent loss of teeth; and treatment of injuries to the teeth or supporting structures;

(2) routine preventative dental treatments, which are examinations, x-rays, cleanings, sealants, oral prophylaxes, and topical fluoride applications;

(3) therapeutic dental treatments, which include fillings, scaling, extractions, crowns, and pulp therapy for permanent and primary teeth; restoration of carious permanent and primary teeth; maintenance of space; and limited provision of removable prostheses when masticatory function is impaired, when an existing prosthesis is unserviceable, or when aesthetic considerations interfere with employment or social development;

(4) orthodontic dental treatments, which are procedures that include treatment of retained deciduous teeth; cross-bite therapy; facial accidents involving severe traumatic deviations; cleft palates with gross malocclusion that will benefit from early treatment; and severe, handicapping malocclusions affecting permanent dentition with a minimum score of 26 as measured on the Handicapping Labio-lingual Deviation Index; and

(5) dental sedation, which is sedation necessary to perform dental treatment including non-routine anesthesia, (for example, intravenous sedation, general anesthesia, or sedative therapy prior to routine procedures) but does not include the administration of routine local anesthesia only.

(b) Dental treatment does not include cosmetic orthodontia.

(c) HHSC approves the following amounts as the maximum for an individual's dental treatment:

(1) $2,500 per IPC period for services described in subsection (a)(1) - (4) of this section; and

(2) $2,000 per IPC period for sedation, other than the administration of routine local anesthesia, as described in subsection (a)(5) of this section.

(d) For an initial dental exam, a program provider may include up to $200 on the IPC without submitting a completed HHSC Prior Authorization for Dental Services form signed by the individual's dentist to HHSC for approval. For all other dental treatments, a program provider must submit a completed HHSC Prior Authorization for Dental Services form that has been signed by the individual's dentist to HHSC with the IPC for authorization.

(e) If a program provider determines emergency dental treatment is necessary to ensure an individual's health and welfare and the necessary service is not included on the individual's IPC and IPP or exceeds the amount included in the IPC for dental treatment, a program provider must submit a revised IPC and revised IPP to HHSC in accordance with § 260.77(c) of this chapter (relating to Renewal and Revision of an IPP and IPC).

(f) For an individual under 21 years of age, a program provider must first access dental treatment benefits through the Texas Health Steps--Comprehensive Care Program before dental treatment may be provided under the DBMD Program.

(g) A program provider must maintain, in the individual's record, a copy of the dentist's invoice for dental treatment.

(h) HHSC does not reimburse a program provider for cosmetic orthodontia.

Notes

26 Tex. Admin. Code § 260.339

Adopted by Texas Register, Volume 48, Number 07, February 17, 2023, TexReg 0915, eff. 2/26/2023