Ohio Department Of Medicaid Proposes Changes To Dental Reimbursement And Coverage Rule

The Ohio Department of Medicaid is proposing amendments to Ohio Administrative Code rule 5160-5-01 to do all of the following:

• Procedure Code Updates
  • Update covered services based on new procedure codes added to the 2024 American Dental Association Code on Dental Procedures and Nomenclature.
• Frequency Limitations and Coverage Clarifications
  • Amend frequency limitations, coverage clarifications, and service descriptions for: Dental exams, Prophylaxis, Imaging, Pin retention, Re-cementing, Re-bonding, Orthodontic treatments, Biopsy, Application of fluoride varnish.
• Imaging Payments
  • Allow reimbursement for multiple bitewings taken in conjunction with a panoramic image.
• Vaccine Administration
  • Discontinue payment for the administration of COVID-19 and human papillomavirus vaccines.
• Pin Retention
  • Reimburse pin retention per tooth, with a maximum of three pins per tooth.
• Re-cementing and Re-bonding Crowns
  • Remove the frequency limit for re-cementing and re-bonding crowns.
• Orthodontic Treatment Payments
  • Ensure payment for comprehensive orthodontic treatment (D8080) covers the initial placement visit and the first quarter of treatment.
  • Allows seven calendar quarters of periodic orthodontic treatment visits (D8670) per course of treatment.
  • Prohibits reimbursement for D8670 in the same quarter as D8080.
• Partial Dentures
  • Removes the restriction stating "A partial denture with a resin base may be covered only for a patient younger than 19".
• Dental Evaluations and Prophylaxis
  • Clarifies that periodic dental evaluations and dental prophylaxis are covered once per 180 days for several special groups, including but not limited to:
    • Pregnant women
    • Foster children
    • Employed individuals with disabilities, regardless of age
  • Prior Authorization (PA) Requirements
    • The PA Required column will indicate when procedures are paid by report.
    • Prohibits reimbursement for excisional biopsies of salivary glands in conjunction with another biopsy on the same date of service.
  • Topical Fluoride Varnish Application
    • Adds the Current Procedural Terminology code for "Application of topical fluoride varnish by a physician or other qualified health care professional when performed in a nondental clinic or facility setting".

There will be a hearing on these proposed rule changes August 12, 2024.

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