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Ohio Department of Medicaid Proposes Changes to Dental Reimbursement and Coverage Rule

Client Alert

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. Please contact BMD Healthcare Member Daphne Kackloudis at dlkackloudis@bmdllc.com for questions or to help you prepare comments on the rules.


Recent Litigation Challenges the Affordable Care Act Preventive Services Requirement

The Affordable Care Act (ACA) has been met with numerous legal challenges. The most recent legal challenge, Braidwood Management Inc. v. Becerra, could affect millions of people covered by private health insurance.

340C – Prospective Legislation to Protect Federally Qualified Health Centers

Advocates for Community Health (ACH), an organization created to implement policy and advocacy initiatives for health care systems across the United States, has begun drafting legislation that is geared towards protecting Federally Qualified Health Centers (“FQHCs”) enrolled in the 340B Program, which is being dubbed “340C.”

Getting Paid to Vote

Can you get paid to vote? Election Day is upon us and employees across the country are asking whether they can get paid to vote. Essentially, can they take paid leave of a few hours to go to the polling location to cast their vote in a midterm election or presidential election. Well, it depends on the state where the employee works.

BMD Makes 2023 U.S. News & World Report "Best Law Firms" Edition

Best Law Firms 2023

EEOC’s New “Know Your Rights” Poster to Replace “EEO is the Law” Poster

Under federal law, covered employers are required to post a notice in the workplace describing federal antidiscrimination laws. The Equal Employment Opportunity Commission (EEOC) prepares the mandatory posters summarizing antidiscrimination laws and explaining how employees and applicants can file a complaint if they believe they have experienced job discrimination. On October 19, 2022, the EEOC released a new poster: “Know Your Rights: Workplace Discrimination is Illegal,” replacing the “EEO is the Law” poster. Employers must now use the poster captioned as “Know Your Rights: Workplace Discrimination is Illegal – Revised 10/20/22.” Employers may be reprimanded for failure to appropriately and compliantly post the updated poster.