Ohio Department of Medicaid Proposes Changes to Dental Reimbursement and Coverage Rule
Client AlertJuly 29, 2024
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".
- Clarifies that periodic dental evaluations and dental prophylaxis are covered once per 180 days for several special groups, including but not limited to:
There will be a hearing on these proposed rule changes August 12, 2024. Please contact BMD Healthcare Member Daphne Kackloudis at dlkackloudis@bmdllc.com for questions or to help you prepare comments on the rules.