MaineCare Notice of Agency Rule-making Proposal, MaineCare Benefits Manual, Chapter II, Section 25 (repeal); Chapter III, Section 25 (repeal) and Chapter II, Section 25, Dental Services and Reimbursement Methodology (replaces the two repealed rules)

Jul 20, 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 Proposal. You can access the complete rule at http://www.maine.gov/dhhs/oms/rules/index.shtml.

Notice of Agency Rule-making Proposal

AGENCY:  Department of Health and Human Services, MaineCare Services, Division of Policy

CHAPTER NUMBER AND TITLE: 10-144 C.M.R. Chapter 101, Chapter II, Section 25, Dental Services (repeal)

10-144 C.M.R. Chapter 101, Chapter III, Section 25, Allowances for Dental Services (repeal)

10-144 C.M.R. Chapter 101, Chapter II, Section 25, Dental Services and Reimbursement Methodology (this rule replaces the two repealed rules)

PROPOSED RULE NUMBER:

CONCISE SUMMARY: This rulemaking proposes to repeal Ch. II and Ch. III, Section 25, and replace them with a new Ch. II, Section 25 rule. On July 1, 2022, the Department implemented these changes 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. Following notice and comment on the proposed routine technical rule, the Department shall permanently adopt the new Ch. II, Section 25.

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 proposed rule adds a comprehensive array of dental services for adult members, per 22 MRS 3174-F(1).

Additionally, this proposed 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 proposed rule. The dental code benchmarks shall undergo updates every two years, per the methodology included in the proposed 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 proposed rule and the former 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 amount listed in Chapter III, Section 25, the proposed 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, and preventive 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, 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, the proposed 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 removes services from the proposed 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 proposed 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 proposed 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 proposed 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 proposed rule adds or increases coverage for many existing services, 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

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

• The proposed rule removes the requirement that adults have a qualifying medical condition to receive removable prosthodontics (dentures).
• The proposed rule establishes medically appropriate limitations where none previously existed, based on recommendations from clinical consultation and alignment with other comprehensive dental coverage (commercial payers and other Medicaid agencies).
• The proposed rule adds and removes prior authorizations to align with other payors and based on recommendations from clinical consultation. Additionally, the proposed rule adds certain prior authorization requirements that were not in the emergency Section 25 rule: Sec. 25.03-3(B) (Crowns); 25.03-5(E) (periodontal scaling and root planning); and 25.03-9(A) (sedation for members 21 and over). There was not clear consensus from pre-rulemaking consultation with stakeholders and Department clinical resources on whether these services should require PA and including the PA requirements in the proposed rule allows for further public comment and Department deliberation to determine whether to adopt the requirements in the final rule.
• The proposed 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 proposed 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 MRS Ch. 147.
• Prescriptive descriptions of services that are overly detailed for the rule.
• Section 25.03-9, Temporomandibular Joint Services, because it is not clear what specific services this provision encompasses and because services that are related to the temporomandibular joint are listed in the new covered services Section.
• 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 proposed 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 MRS Ch. 143 § 18375, and it is redundant to list services that IPDHs can deliver in rule. In addition, the requirements for IPDHs delivering temporary fillings no longer have a basis in Board rules and have been a roadblock to delivering this service. The requirements for processing and exposing radiographs are also no longer in effect.
• The appendix because the forms either exist on the HealthPAS Portal or will no longer be required.

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.

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

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

PUBLIC HEARING: 1:00pm; Monday, August 8, 2022

Due to the ongoing threat posed by COVID-19, DHHS has determined that its public hearing will be conducted solely remotely, via Zoom. This is in accordance with the DHHS Remote Rulemaking Hearings Policy issued September 10th, 2021.

(link to Remote Hearings Policy: https://www.maine.gov/dhhs/sites/maine.gov.dhhs/files/inline-files/9%209%2021%20Remote%20Rulemaking%20Hearings%20Policy.pdf)

Zoom Meeting link: https://mainestate.zoom.us/j/88309744257

Meeting ID: 883 0974 4257

Some devices may require downloading a free app from Zoom prior to joining the public hearing event. The Department requests that any individual requiring special arrangements to participate in the hearing contact the person listed for this filing 5 days in advance of the hearing.

DEADLINE FOR COMMENTS:          Comments must be received by 11:59 PM on August 18, 2022.

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)

IMPACT ON MUNICIPALITIES OR COUNTIES (if any): The Department anticipates that this rulemaking will not have any impact on municipalities or counties.

CONTACT PERSON FOR SMALL BUSINESS INFORMATION (if different): N/A