Current through Register Vol. 50, No. 9, September 20, 2024
A. Services covered
in the EPSDT Dental Program shall be reimbursed at the lower of either:
1. the dentist's billed charges minus any
third party coverage; or
2. the
state's established schedule of fees, which is developed in consultation with
the Louisiana Dental Association and the Medicaid dental consultants, minus any
third party coverage.
B.
Effective for dates of service on and after December 24, 2008, the
reimbursement fees for EPSDT dental services are increased to the following
percentages of the 2008 National Dental Advisory Service comprehensive fee
report 70th percentile rate, unless otherwise stated in this Chapter. The
reimbursement fees are increased to:
1. 80
percent for all oral examinations;
2. 75 percent for the following services:
a. radiograph - periapical and panoramic
film;
b. prophylaxis;
c. topical application of fluoride or
fluoride varnish; and
d. removal of
impacted tooth;
3. 70
percent for the following services:
a.
radiograph - complete series, occlusal film and bitewings;
b. sealant, per tooth;
c. space maintainer, fixed (unilateral or
bilateral;
d. amalgam, primary or
permanent;
e. resin-based composite
and resin-based composite crown, anterior;
f. prefabricated stainless steel or resin
crown;
g. core buildup, including
pins;
h. pin retention;
i. prefabricated post and core, in addition
to crown;
j. extraction or surgical
removal of erupted tooth;
k.
removal of impacted tooth (soft tissue or partially bony); and
l. palliative (emergency) treatment of dental
pain; and
m. surgical removal of
residual tooth roots; and
4. 65 percent for the following dental
services:
a. oral/facial images;
b. diagnostic casts;
c. re-cementation of space maintainer or
crown;
d. removal of fixed space
maintainer;
e. all endodontic
procedures except:
i. unspecified endodontic
procedure, by report;
f.
all periodontic procedures except:
i.
unspecified periodontal procedure, by report;
g. fluoride gel carrier;
h. all fixed prosthodontic procedures
except:
i. unspecified fixed
prosthodontic procedure, by report;
i. tooth re-implantation and/or stabilization
of accidentally evulsed or displaced tooth;
j. surgical access of an unerupted
tooth;
k. biopsy of oral
tissue;
l. transseptal
fiberotomy/supra crestal fiberotomy;
m. alveoloplasty in conjunction with
extractions;
n. incision and
drainage of abscess;
o. occlusal
orthotic device;
p. suture of
recent small wounds;
q.
frenulectomy;
r. fixed appliance
therapy; and
s. all adjunctive
general services except:
i. palliative
(emergency) treatment of dental pain, and
ii. unspecified adjunctive procedure, by
report.
C. The reimbursement fees for all other
covered dental procedures shall remain at the rate on file as of December 23,
2008.
D. Effective for dates of
service on or after January 22, 2010, the reimbursement fees for EPSDT dental
services shall be reduced to the following percentages of the 2008 National
Dental Advisory Service comprehensive fee report 70th percentile, unless
otherwise stated in this Chapter:
1. 73
percent for diagnostic oral evaluation services;
2. 70 percent for the following periodic
diagnostic and preventive services:
a.
radiographs-periapical, first film;
b. radiograph-periapical, each additional
film;
c. radiograph-panoramic
film;
d. prophylaxis-adult and
child;
e. topical application of
fluoride, 0-15 years of age (prophylaxis not included); and
f. topical fluoride varnish, therapeutic
application for moderate to high caries risk patients (under 6 years of age);
and
3. 65 percent for
the remainder of the dental services.
E. Effective for dates of service on or after
August 1, 2010, the reimbursement fees for EPSDT dental services shall be
reduced to the following percentages of the 2009 National Dental Advisory
Service comprehensive fee report 70th percentile, unless otherwise stated in
this Chapter:
1. 69 percent for the following
oral evaluation services:
a. periodic oral
examination;
b. oral
examination-patients under three years of age; and
c. comprehensive oral examination-new
patient;
2. 65 percent
for the following annual and periodic diagnostic and preventive services:
a. radiographs-periapical, first
film;
b. radiograph-periapical,
each additional film;
c.
radiograph-panoramic film;
d.
prophylaxis-adult and child;
e.
topical application of fluoride-adult and child (prophylaxis not included);
and
f. topical fluoride varnish,
therapeutic application for moderate to high caries risk patients (under 6
years of age);
3. 50
percent for the following diagnostic and adjunctive general services:
a. oral/facial images;
b. non-intravenous conscious sedation;
and
c. hospital call; and
4. 58 percent for the remainder of
the dental services.
F.
Removable prosthodontics and orthodontic services are excluded from the August
1, 2010 rate reduction.
G.
Effective for dates of service on and after January 1, 2011, the reimbursement
fees for EPSDT dental services shall be reduced to the following percentages of
the 2009 National Dental Advisory Service comprehensive fee report 70th
percentile, unless otherwise stated in this Chapter:
1. 67.5 percent for the following oral
evaluation services:
a. periodic oral
examination;
b. oral
Examination-patients under 3 years of age; and
c. comprehensive oral examination-new
patients;
2. 63.5
percent for the following annual and periodic diagnostic and preventive
services:
a. radiographs-periapical, first
film;
b. radiographs-periapical,
each additional film;
c.
radiographs-panoramic film;
d.
diagnostic casts;
e.
prophylaxis-adult and child;
f.
topical application of fluoride, adult and child (prophylaxis not included);
and
g. topical fluoride varnish,
therapeutic application for moderate to high caries risk patients (under 6
years of age);
3. 73.5
percent for accession of tissue, gross and microscopic examination, preparation
and transmission of written report;
4. 70.9 percent for accession of tissue,
gross and microscopic examination, including assessment of surgical margins for
presence of disease, preparation and transmission of written report;
5. 50 percent for the following diagnostic
and adjunctive general services:
a.
oral/facial image;
b.
non-intravenous conscious sedation; and
c. hospital call; and
6. 57 percent for the remainder of the dental
services.
H. Removable
prosthodontics and orthodontic services are excluded from the January 1, 2011
rate reduction.
I. Effective for
dates of service on or after July 1, 2012, the reimbursement fees for EPSDT
dental services shall be reduced to the following percentages of the 2009
National Dental Advisory Service comprehensive fee report 70th percentile,
unless otherwise stated in this Chapter:
1.
65 percent for the following oral evaluation services:
a. periodic oral examination;
b. oral examination-patients under three
years of age; and
c. comprehensive
oral examination-new patients;
2. 62 percent for the following annual and
periodic diagnostic and preventive services:
a. radiographs-periapical, first
film;
b. radiographs-periapical,
each additional film;
c.
radiographs-panoramic film;
d.
diagnostic casts;
e.
prophylaxis-adult and child;
f.
topical application of fluoride, adult and child (prophylaxis not included);
and
g. topical fluoride varnish,
therapeutic application for moderate to high caries risk patients (under six
years of age);
3. 45
percent for the following diagnostic and adjunctive general services:
a. oral/facial image;
b. non-intravenous conscious sedation;
and
c. hospital call; and
4. 56 percent for the remainder of
the dental services.
J.
Removable prosthodontics and orthodontic services are excluded from the July 1,
2012 rate reduction.
K. Effective
for dates of service on or after August 1, 2013, the reimbursement fees for
EPSDT dental services shall be reduced by 1.5 percent of the rate on file July
31, 2013, unless otherwise stated in this Chapter.
1. The following services shall be excluded
from the August 1, 2013 rate reduction:
a.
removable prosthodontics; and
b.
orthodontic services.
L. Effective for dates of service on or after
July 1, 2023, the reimbursement rates for EPSDT dental services shall be
reimbursed based on the Louisiana Medicaid fee schedule. All rates in the fee
schedule are published on the Medicaid provider website at
www.lamedicaid.com.
1. Implementation of these rates is subject
to approval by the U.S. Department of Health and Human Services, Centers for
Medicare and Medicaid Services.
Implementation of the provisions of this Rule may be
contingent upon the approval of the U.S. Department of Health and Human
Services, Centers for Medicare and Medicaid Services (CMS), if it is determined
that submission to CMS for review and approval is required.
AUTHORITY
NOTE: Promulgated in accordance with
R.S.
36:254 and Title XIX of the Social Security
Act.
