MaineCare Benefits Manual, Chapter II, Section 25, Dental Services (repeal); Chapter III, Section 25, Allowances for Dental Services (repeal); Chapter II, Section 25, Dental Services and Reimbursement Methodology (this rule replaces the two repealed rules

Sep 28, 2022

The Division of Policy posts all proposed and recently adopted rules on MaineCare’s Policy and Rules webpage.  This website keeps the proposed rules on file until they are finalized and until the Secretary of State website is updated to reflect the changes.  The MaineCare Benefits Manual is available on-line at the Secretary of State’s website. 

Below, please find a Notice of Agency Rule-making Adoption. You can access the complete rule at http://www.maine.gov/dhhs/oms/rules/index.shtml.

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Notice of Agency Rule-making Adoption

AGENCY:  Department of Health and Human Services, MaineCare Services

CHAPTER NUMBER AND TITLE: 10-144 C.M.R. Chapter 101, MaineCare Benefits Manual, Chapter II, Section 25, Dental Services (repeal); Chapter III, Section 25, Allowances for Dental Services (repeal); Chapter II, Section 25, Dental Services and Reimbursement Methodology (this rule replaces the two repealed rules)

ADOPTED RULE NUMBER:

CONCISE SUMMARY:

The Department adopts this rule, which repeals Ch. II and Ch. III, Section 25, and replaces them with a new Ch. II rule, “Dental Services and Reimbursement Methodology.”

On July 1, 2022, the Department implemented the vast majority of changes in this adopted rule via emergency rulemaking, pursuant to P.L. 2021, Ch. 398 (eff. July 1, 2021), Sec. A-17 (the “Budget”), Part CCC, Sec. CCC-1, Part GGGG, and Section GGGG-1.

Between August 2021 and May 2022, the Department met with the dental subcommittee of the MaineCare Advisory Committee (“MAC”) ten times and with the full MAC once. The Department also held two stakeholder forums to receive input on the benefit design and reimbursement methodology. Stakeholders included MaineCare dental providers and various oral health advocates, including representatives from Maine Equal Justice, Maine Primary Care Association, and Children’s Oral Health Network of Maine. This rule incorporates recommendations from this stakeholder engagement, invests $45 million to increase rates and expand the adult dental benefit, as well as fully integrates the children and adult benefits and rates into a single rule. The adopted rule adds a comprehensive array of dental services for adult members, per 22 MRS 3174-F(1). 

Additionally, this adopted rule implements the recommendations from the Department’s Comprehensive Rate System Evaluation, conducted by the firm Myers and Stauffer. The new Section 25 dental reimbursement rates will be posted on a website, and those rates will be set based on either the “Commercial Median Benchmark” or the “All-States Medicaid Average Benchmark,” as defined by the adopted rule. The dental code benchmarks shall undergo updates every two years, per the methodology included in the adopted rule. Since April 11, 2022, the Department has conferred multiple times with providers and the MAC regarding this new reimbursement methodology. 

The differences between the adopted rule and the former, now repealed Chapters II and III, Section 25, rules include the following:

1. Section 25.06 (Reimbursement Methodology). The rule replaces specified rates with a reimbursement methodology. Whereas the former Chapter II, Section 25, rule stated rates would be the amounts listed in Chapter III, Section 25, the adopted rule implements a reimbursement methodology that increases overall reimbursement consistent with recommendations from the comprehensive rate setting evaluation. 

The reimbursement methodology sets rates for diagnostic, endodontic, periodontic, preventive, and limited orthodontic treatment services based on 67% of the Commercial Median Benchmark or 133% of the Medicaid State Average Benchmark, if the Commercial Median Benchmark rate is unavailable or unreliable.

The reimbursement methodology sets rates for adjunctive, oral and maxillofacial surgery, orthodontics (except for limited orthodontic treatment), prosthodontics, and restorative services based on 50% of the Commercial Median Benchmark or 100% of the Medicaid State Average Benchmark if the Commercial Median Benchmark rate is unavailable or unreliable. 

2. In addition, the rule eliminates inconsistent payment for services billed as medical versus dental services. To ensure that there is not a rate disparity between CDT and CPT codes that represent the same service and to leverage the ‘percent of Medicare methodology’ in Section 90, the adopted rule removes coverage of some oral and maxillofacial surgery and maxillofacial prosthetic services so that they are solely covered under Section 90, Physician Services. The Department removed services from the adopted rule that have a CPT code equivalent, that are medical in nature, and are primarily delivered by oral surgeons who already bill the services under Section 90, Physician Services.

3. Replaces emergency-only adult dental coverage with comprehensive adult dental coverage. To implement the new comprehensive adult dental benefit, the adopted rule adds coverage for adults for diagnostic, preventive, restorative, endodontic, periodontic, prosthodontic, oral and maxillofacial surgery, and adjunctive services. To enable this comprehensive adult coverage, the adopted rule removes the Section 25.04 requirement that adult dental care be limited to acute surgical care directly related to an accident; oral medical procedures not involving the dentition and gingiva; extraction of teeth that are severely decayed and pose a serious threat of infection during cardiovascular surgery; or treatment necessary to relive pain, eliminate infection, or prevent imminent tooth loss.

4. Replaces separate adult and child coverage provisions with a single covered services description generally applicable to all members. As a result of removing the restrictions on adult dental coverage, the adopted rule contains one “Covered Services” provision, which includes the services, limits, and other requirements for all members, regardless of age, unless otherwise specified. Some services will continue to be age-limited, and they are noted as such in the rule.
5. In addition to adding broad coverage for adult dental services, the adopted rule adds or increases coverage for many existing services for members under 21, including the following::

• Comprehensive periodontal evaluations
• Counseling for the control and prevention of adverse oral, behavioral, and systemic health effects associated with high-risk substance use
• Removable unilateral space maintainers
• Multiple types of crowns
• Prefabricated crowns
• Apicoectomies
• Immediate partial dentures
• Complete denture repairs
• Partial denture relines
• Multiple types of pontics and prosthodontic retainers
• Re-cement or re-bond and repairs of fixed partial dentures
• Dental case management
• Single bitewings
• Panoramic radiographs
• Topical fluoride
• Denture adjustments
• Nutritional counseling
• Preventive resin restorations

     6.  Aligns limits and prior authorization (PA) requirements with other state Medicaid agencies, commercial payers, and stakeholder recommendations. Because of the limited scope of the adult dental benefit in the previous rule, the adopted rule makes changes to align the new covered services and limits with typical comprehensive dental coverage. Specifically:

• The adopted rule removes the requirement that adults have a qualifying medical condition to receive removable prosthodontics (dentures).
• The adopted rule establishes medically appropriate limits where none previously existed, based on recommendations from clinical consultation and alignment with other comprehensive dental coverage (commercial payers and other Medicaid agencies).
• The adopted rule adds and removes PAs to align with other payers and based on recommendations from clinical consultation and rule commenters. The emergency rule did not contain PAs for scaling and root planing (SRP), crowns, and sedation, but the proposed rule included PAs for all three to allow for further public comment and Department deliberation. As a result of comments, the Department removed the PA for crowns for members under age 21, removed the PA for the first unit of SRP delivered to each quadrant, and removed the PA for sedation, which only applied to members 21 and over. Also as a result of comments, the Department removed the PAs in the proposed rule for replacement of a lost or broken retainer and for a third prophylaxis treatment.
• The adopted rule removes the “more than once every 150 days” requirement for detailed and extensive and periodic oral evaluations and prophylaxis treatments.

     7.  Removes unnecessary and overly detailed provisions. The adopted rule removes the following from the rule:

• Unnecessary and unused definitions.
• Reference to coverage for members residing in an “Intermediate Care Facility for Persons with Mental Retardation (ICF-IID)” because these members will now receive the services covered for members 21 and over (adults).
• Requirements that address the covered services certain provider types can provide under their scope of practices because providers’ scope of practices are already defined in 32 M.R.S. Ch. 147.
• Prescriptive descriptions of services that are overly detailed for the rule.
• Section 25.03-9, Temporomandibular Joint Services, because these services are covered under Section 90, Physician Services, and they are billed for using Common Procedural Terminology (CPT) codes.
• Section 25.06-1, Member’s Records, because Chapter I, Section 1.03-8(M) and Board rule 02-313 CMR Chapter 12 both contain member/patient record requirements.
• Section 25.06-2, The Division of Program Integrity, because it only refers providers to Chapter I, which already applies to all providers.
• Requirements and instructions in Section 25.06-3, Prior Authorization of Dental Services, because they either exist in Chapter I of the MBM or in MaineCare’s Prior Authorization Manual on the HealthPAS Portal.
• Section 25.06-5, Case Management, because it describes standard health care provider practices and because the adopted rule adds coverage for a dental case management service.
• Sections 25.07-4, Denturist Services, and 25.07-5, Dental Hygienist Services, because it is unnecessary to include the services that these providers can deliver under their scopes of practice, which are defined in 32 MRS Ch. 147. Section 25.07-5 also includes outdated guidance.
• Section 25.07-6, Independent Practice Dental Hygienist (IPDH) Services, because IPDHs must comply with their scope of practice, as defined in 32 M.R.S. Ch. 143 § 18375, and practice requirements outlined in Board rule 02-313 C.M.R. Ch. 12, and it would be redundant to list either in this rule. In addition, the requirement for IPDHs delivering temporary fillings to have a dentist who can treat the member within 60 calendar days is not required in statute or Board rules.
• The appendix because the forms either exist on the HealthPAS Portal, will no longer be required, or the documents are required by the Board, not the Department.

The Department shall seek approval from the Centers for Medicare and Medicaid Services (CMS) of state plan amendments (SPAs) for the changes in this rulemaking. In addition, on June 29, 2022, the Department published a notice of change in reimbursement methodology pursuant to 42 C.F.R. § 447.205.

As described in detail in the List of Changes to the Final Rule at the end of the Summary of Comments and Responses document, the Department made the following changes in the adopted rule (compared to the changes that were included in the proposed rule):

1. The Department added coverage for sealants on premolars (bicuspids) for members under age 21 in Section 25.03-2(C).

2. In Section 25.03-2(H), the Department added coverage for preventive resin restorations (PRRs) once per eligible tooth per three years for members with a moderate to high caries risk when an active cavitated lesion in a pit or fissure does not extend into the dentin.

3. The Department clarified in Section 25.03-2(C) that sealants are covered for permanent and primary first and second molars.

4. The Department added coverage for CDT code D1310, nutritional counseling for control of dental disease, in Section 25.03-2(I) with a limit of once per member per year when delivered in addition to another covered service. The Department also added a description of the service.

5. The Department changed the reimbursement methodology used to set rates for limited orthodontic treatment from the 50% of commercial median benchmark methodology described in Section 25.06(B)(2) to the 67% of commercial median benchmark methodology described in Section 25.06(B)(1), to reflect evidence indicating that limited orthodontic treatment is an effective preventive approach to avoid severe malocclusion.

6. The Department updated Section 25.03-5(E) to not require a PA for the first unit of SRP delivered to each quadrant but will require PA for the second unit and any additional units of SRP delivered to each quadrant. For example, SRP delivered for the first time to the first quadrant will not require PA, but a PA is required to deliver SRP again to the first quadrant.

7. The Department will no longer require risk assessment results and a PA that includes those results to authorize a third prophylaxis treatment. Instead, a third prophylaxis treatment per year will be permissible without PA if the member meets the criteria added to Section 25.03-2(A).

8. The Department clarified in Section 25.03-9(F) that behavior management is covered when behavior delays, as well as prevents, a covered service from being delivered, meaning providers may bill behavior management whether a covered service is delivered or not. The Department also increased the limit from three times per member per lifetime per service location to three times per member per year per service location.
9. The Department clarified the limit for bitewings in Section 25.03-1(B).
10. The Department re-added coverage for diagnostic casts (CDT code D0470) in Section 25.03-1(F) because they enable orthodontic treatment planning.
11. The Department removed the PA requirement for replacement of lost or broken retainers in Section 25.03-8(G).
12. As a result of comments, in Section 25.05-3, the Department clarified that “year” in the context of service limits defined on a “per year” basis means calendar year. For any limit that is defined on a multi-year basis, each “year” means a rolling 365-day period or the 365 days following the date of the delivery of the first covered service subject to the limit. For example, a “two per three years” limit means a member cannot receive more than two of the specified services in any given 1,095-day period.
13. The Department removed the PA requirement for sedation in Section 25.03-9(A).
14. The Department removed the PA requirement for crowns for members under the age of 21 in Section 25.03-3(B).
15. The Department revised the definition for dental extern because the Board no longer issues permits to dental externs.
16. The Department redefined “dental resident” to mean “any person with a resident dental license, as defined in 32 M.R.S. § 18302.”
17. The Department clarified in Section 25.03-6(A) that replacement dentures are covered when they are no longer sufficiently functional and there is not a cost-efficient way to repair them, not when they are “medically necessary,” because dentures are not technically medically necessary.

See http://www.maine.gov/dhhs/oms/rules/index.shtml for rules and related rulemaking documents.

EFFECTIVE DATE:                            September 28, 2022

STATUTORY AUTHORITY:             22 M.R.S. §§ 42, 3173; P.L. 2021, Ch. 398, Sec. A-17, Part CCC

AGENCY CONTACT PERSON:        Henry Eckerson, Comprehensive Health Planner II

AGENCY NAME:                               MaineCare Services

ADDRESS:                                         109 Capitol Street, 11 State House Station

                                                            Augusta, Maine 04333-0011

EMAIL:                                               henry.eckerson@maine.gov

TELEPHONE:                                    207-624-4085 FAX: (207) 287-6106

                                                            TTY: 711 (Deaf or Hard of Hearing)