Dental Changes Effective September 28, 2022

Sep 28, 2022

On September 23, 2022, the Department adopted Section 25, Dental Services and Reimbursement Methodology, which is effective beginning today, September 28, 2022. This rule makes the following changes to covered service limits, prior authorization (PA) requirements, and rate changes that differ from the emergency Section 25 rule that has been in effect since July 1, 2022. 

Covered Service Changes 

1. The Department added coverage for sealants on premolars (bicuspids) for members under age 21 in Section 25.03-2(C). The Department also clarified that sealants are covered for permanent and primary first and second molars. 

2. The Department re-added coverage for diagnostic casts (CDT code D0470) in Section 25.03-1(F) for orthodontic treatment planning. 

3. In Section 25.03-2(H), the Department added coverage for preventive resin restorations (PRRs) (CDT code D1352) 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. 

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 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. 

Prior Authorization Changes 

1. The Department added a PA requirement for the second unit and any additional units of SRP delivered to each quadrant. A PA is not required for the first unit of SRP delivered to each quadrant. For example, SRP delivered for the first time to the first quadrant will not require a PA, but a PA is required to deliver SRP again to the first quadrant. 

2. 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 a PA if the member meets the criteria added to Section 25.03-2(A). 

3. The Department removed the PA requirement for replacement of lost or broken retainers in Section 25.03-8(G). 

4. The Department added a PA requirement for crowns for members age 21 and over in Section 25.03-3(B).

Rate Changes 

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). This increases the rates for limited orthodontic treatment from $921.09 to $1,228.12. The updated fee schedule can be found here. 

For the complete list of changes between the emergency and adopted rules, please see the Department’s Notice of Agency Rulemaking document here.