New Medicaid rules effective Jan. 1, 2016

The state’s largest dental benefits program, Ohio Medicaid, is implementing new rules effective Jan. 1, 2016. The wide-ranging rules impact coverage and payment policies for dental services and related oral health services.

More than 2.6 million Ohioans are covered by Medicaid, the state and federally funded health insurance program that covers low-income adults, children, pregnant women, senior citizens and individuals with disabilities.

New fees and payment policies

On June 30, Gov. John Kasich signed into law the state budget bill (House Bill 64) for fiscal years 2016-17.  It increased the dental Medicaid budget by roughly $15 million over the biennium and was the first net funding increase since 2000.

Since the state budget was adopted, representatives of Ohio Medicaid and the Ohio Dental Association Medicaid Working Group have quietly worked together to figure out the best way to allocate the approved funding and to address other issues related to Medicaid’s dental program rules.

The proposed new rules for the dental Medicaid program include a statewide fee increase of nearly 10 percent for extractions (D7140) and between a 5 percent and 94 percent fee increase for various denture repair services.

Additionally, the new rules provide for a 5 percent across the board fee increase for all dental services provided in 52 rural Ohio counties (Adams, Ashland, Ashtabula, Athens, Auglaize, Champaign, Clinton, Columbiana, Coshocton, Crawford, Darke, Defiance, Erie, Fayette, Gallia, Guernsey, Hancock, Hardin, Harrison, Henry, Highland, Hocking, Holmes, Huron, Jackson, Knox, Logan, Marion, Meigs, Mercer, Monroe, Morgan, Muskingum, Noble, Ottawa, Paulding, Perry, Pike, Preble, Putnam, Ross, Sandusky, Scioto, Seneca, Shelby, Tuscarawas, Van Wert, Vinton, Washington, Wayne, Williams and Wyandot).

Medicaid has codified and clarified certain longstanding program policies. For example, the first date of service may be reported on claims for items such as dentures that require multiple fittings, as long as the claim is not submitted until after the patient has received the item. Also, in instances when it is clinically appropriate for separate restorations to be performed on the same surface of the same tooth, Medicaid now explicitly specifies that payment may be made for such restorations performed on mandibular teeth as well as on maxillary teeth.

The add-on incentive payment for general anesthesia provided in an office setting has been eliminated. In its place the maximum payment for general anesthesia as a dental service has been increased by the amount of the incentive amount.

Reimbursement levels for certain services or procedures that have previously been manually priced are now listed with set payment amounts.

Procedure code terminology and descriptors have been updated to be consistent with the American Dental Association’s “Current Dental Terminology 2016.” In doing so Medicaid has discontinued the outdated local-level procedure code for surgical removal of a supernumerary tooth (Y7255).

Prior authorization requirements have been relaxed.

Medicaid’s form ODM 03630, “Referral evaluation criteria for comprehensive orthodontic treatment,” has been updated and retitled “Referral evaluation for comprehensive orthodontic treatment” and will be available on Medicaid’s website as a standalone document.

New covered services

Medicaid now includes coverage for comprehensive periodontal evaluations (D0180), gingivectomies or gingivoplasties, one to three contiguous teeth or tooth bounded spaces per quadrant (D4211), periodontal scaling and root planning (both D4341 and D4342) and periodontal maintenance (D4910).

New coverage also includes intravenous conscious sedation/analgesia (D9243).

The new rules now enable Ohio Medicaid to cover a host of new services that are “equivalent” to other currently covered restorative services. These include anterior resin-based composite crowns (D2390), porcelain/ceramic substrate crowns (D2740), porcelain fused to predominately base metal crowns (D2751), prefabricated esthetic coated stainless steel crowns on primary teeth (D2934) and prefabricated post and cores in addition to the crown (D2954).

Medicaid will now provide reimbursement for the application of fluoride varnish by physician assistants and advanced practice registered nurses, in addition to physicians, and this benefit is expanded to cover children up to 6 years old.

All of the Medicaid rule changes take effect on Jan. 1, 2016.

“Medicaid’s new rules are wide-ranging and well-conceived,” said Dr. Roderick Adams Jr., chairman of both the ODA Council on Access to Dental Care and the ODA Medicaid Working Group. “They were developed with input from the ODA, dentists who actively provide care to patients covered by Medicaid and other stakeholders. The rules make sense from our perspective as dentists, both as health care practitioners and as small businesspeople.”

Dr. Manny Chopra, chairman of ODA Council on Dental Care Programs and Dental Practice, said that “while there is still much work for the governor and legislature to do relative to fees, we are very pleased with all of the work the representatives of Ohio Medicaid have done to move the dental program forward on a number of initiatives. Medicaid has done very well with the limited resources available to it.”

Dr. Adams noted “it is expected that the state’s Medicaid HMOs and their dental subcontractors will appropriately revise and update their fee schedules and benefits plans to reflect the changes that Ohio Medicaid has adopted and the ODA Medicaid Working Group will be closely monitoring their activities in this regard.”

ODA members who would like to submit a dental insurance related question, problem or concern may do so by sending the appropriate information to the ODA Dental Insurance Working Group, 1370 Dublin Road, Columbus, OH 43215, or 614-486-0381 FAX, or