BEFORE THE DEPARTMENT OF PUBLIC
HEALTH AND HUMAN SERVICES OF THE
STATE OF MONTANA
In the matter of the amendment of ARM 37.86.1006 pertaining to the establishment of an annual payment limit for dental services provided through Medicaid
NOTICE OF AMENDMENT
TO: All Concerned Persons
1. On October 29, 2015, the Department of Public Health and Human Services published MAR Notice No. 37-732 pertaining to the public hearing on the proposed amendment of the above-stated rule at page 1859 of the 2015 Montana Administrative Register, Issue Number 20.
2. The department has amended the following rule as proposed, but with the following changes from the original proposal, new matter underlined, deleted matter interlined:
37.86.1006 DENTAL SERVICES, COVERED PROCEDURES (1) through (5) remain as proposed.
(6) Medically necessary dental services outlined in (5)(c) through (e), excluding anesthesia services, are subject to an annual limit of $1,125 per benefit year. A benefit year begins on July 1st
, and ends the following June 30th. Members determined categorically eligible for Aged, Blind, and Disabled (ABD) Medicaid, in accordance with ARM 37.82.204, are not subject to the annual limit.
(7) through (18) remain as proposed.
AUTH: 53-2-201, 53-6-113, MCA
IMP: 53-6-101, 53-6-113, MCA
3. The department has thoroughly considered the comments and testimony received. A summary of the comments received and the department's responses are as follows:
COMMENT #1: Eight commenters offered examples of patients with disabilities or individuals who are senior citizens who require treatment in a hospital environment under anesthesia, describing the severity of their condition, and the cost to return them to a healthy state. These are complex interventions. Others who may go over the annual limit are pregnant woman or individuals with complex medical conditions such as organ transplant, cancer treatment, or a referred patient from a cardiologist. All these examples would take the member over the limit. They are requesting the department to allow exceptions to the limit that is listed in the proposed rule.
RESPONSE #1: The department appreciates the comments and thanks the commenters for the thoughtful examples and recommended solution. The department has decided to exclude the aged, blind, and disabled population from the monetary limit. Diagnostic, preventive, denture, and anesthesia services were previously excluded from the annual limit.
COMMENT #2: A commenter stated multiple concerns regarding: (1) the dental cap, because dentists may choose not to participate because they might be in the midst of a treatment plan and the money runs out, (2) this new policy is false hope to members that they have insurance and they might not be able to find a dentist to provide care, (3) a Federally Qualified Health Center (FQHC) will not be equipped to handle the surge of patients, and finally, (4) if the cap is placed, how will dentists request increased funding (an extension).
RESPONSE #2: The department appreciates the comments and thanks the commenter for his/her concern regarding this issue. The department has updated the proposed rule to exclude the aged, blind, and disabled population from the monetary limit. Dentists and other adult members will need to be aware of the status of expenditures prior to services. If they are near reaching their cap, a private pay agreement will need to be established. The department will continue to monitor access issues related to member demand, private practice, and FQHC appointment availability.
COMMENT #3: A commenter questioned if there will be preapproved exceptions to the cap. These exceptions should be outlined within the rule and not subject to a determination after the service is performed.
RESPONSE #3: The department appreciates the comment and thanks the commenter for a recommendation to resolve this issue. The department will not have a preapproved exception to the $1,125 cap, but has excluded the aged, blind, and disabled population from the monetary limit. Diagnostic, preventive, denture, and anesthesia services are also excluded from the annual monetary cap.
COMMENT #4: A commenter expressed concern regarding: (1) the Prospective Payment System at a FQHC being applied to the limit, even if some of those services are exempt under the rule; and (2) the cap for those adults who are aged and disabled.
RESPONSE #4: The department appreciates the comment and thanks the commenter for a recommendation to resolve this issue. The department has excluded the aged, blind, and disabled population from the monetary limit. Payment methodology for services rendered at a FQHC will be the ongoing prospective payment system per visit for all other adults. This amount will be deducted from the annual dollar limit/cap.
COMMENT #5: A commenter recommends that the department not include, in the annual dollar limit, the periodontal treatment codes D4341, D4342, and D4910.
RESPONSE #5: The department's analysis of past dental service utilization and projections of the new expansion group, paired with national utilization trends, tells us the $1,125 annual limit will meet a high level of sufficiency. The department's partners at the Montana Dental Association stated that dentists have the ability to "stage" or "prioritize" treatment plans to work through health conditions. Since the original analysis, additional procedure codes have been eliminated from the annual limit. The department is confident the $1,125 dental treatment limit is sufficient to meet the members' dental needs.
4. This rule amendment is effective January 1, 2016.
/s/ Geralyn Driscoll /s/ Robert Runkel for Richard H. Opper
Geralyn Driscoll, Attorney Richard H. Opper, Director
Rule Reviewer Public Health and Human Services
Certified to the Secretary of State December 14, 2015