Utah Admin. Code R414-49-5 - Blind or Disabled Members

Current through Bulletin 2022-07, April 1, 2022

This section defines the scope of dental services available to blind or disabled members eligible for Traditional Medicaid who are 18 years of age or older, as defined in Subsection 1614(a) of the Social Security Act. Services are authorized by a federal waiver of Medicaid requirements approved by the Centers for Medicare and Medicaid Services, and allowed under Section 1115 of the Social Security Act.

(1) The following program access requirements apply:
(a) dental services are available only through an enrolled dental provider that complies with all relevant laws and policy; and
(b) dental services provided to this population shall only be performed through the University of Utah School of Dentistry and their associated in-state provider network.
(2) The following coverage and limitation provisions apply:
(a) dental services are provided only within the parameters of generally accepted standards of dental practice and are subject to limitations and exclusions established by Medicaid;
(b) dental services are subject to limitations and exclusions of medical necessity and utilization control considerations or conditions;
(c) additional service limitations and exclusions are maintained in the Coverage and Reimbursement Code Look-up Tool and the Dental, Oral Maxillofacial, and Orthodontia Services Utah Medicaid Provider Manual, and are updated in the Medicaid Information Bulletin;
(d) Medicaid will reimburse one evaluation per member per day, even if more than one provider is involved from the same office or clinic, not multiple exams for the same date of service;
(e) Medicaid includes in the global payment, and does not reimburse separately, denture adjustments performed by the original provider within six months of a member receiving a denture;
(f) Medicaid may cover third -molar extractions when at least one of the third molars has documented pathology that requires extraction, and by discretion, a provider may remove the remaining third molars during the same procedure;
(g) Medicaid covers the treatment of temporomandibular joint fractures, but does not cover other temporomandibular joint treatments; and
(h) a laboratory or pathologist must submit claims directly to Medicaid for payment of laboratory services.
(3) Medicaid does not cover the following types of dental services:
(a) composite resin fillings on posterior teeth;
(b) pulpotomies or pulpectomies on permanent teeth, except in the case of an open apex;
(c) fixed bridges or pontics;
(d) all types of dental implants;
(e) tooth transplantation;
(f) ridge augmentation;
(g) osteotomies;
(h) vestibuloplasty;
(i) alveoloplasty;
(j) occlusal appliances, habit control appliances, or interceptive orthodontic treatment;
(k) treatment for temporomandibular joint syndrome, sequela, subluxation, or other therapies;
(l) procedures such as arthrostomy, meniscectomy, or condylectomy;
(m) nitrous oxide analgesia;
(n) house calls;
(o) consultation or second opinions not requested by Medicaid;
(p) services provided without prior authorization;
(q) general anesthesia for removal of an erupted tooth;
(r) oral sedation for behavior management;
(s) temporary dentures or temporary stayplate partial dentures;
(t) limited orthodontic treatment, including removable appliance therapies;
(u) removable appliances in conjunction with fixed banded treatment; and
(v) extraction of primary teeth at or near the time of exfoliation, as evidenced by mobility or loosening of the teeth.
(4) The following dental spend-ups apply:
(a) a Medicaid member may choose to upgrade a covered service to a non-covered service if the member assumes the responsibility for the difference in fees for the following dental procedures:
(i) covered amalgam fillings to non-covered composite resin fillings; and
(ii) covered stainless-steel, porcelain, and cast crowns to cast gold crowns, which means porcelain fused to metal.


Utah Admin. Code R414-49-5
Adopted by Utah State Bulletin Number 2019-10, effective 4/22/2019 Amended by Utah State Bulletin Number 2021-02, effective 1/1/2021

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