Current through Reg. 50, No. 13; March 28, 2025
(a) The facility
must assist a resident in obtaining routine and 24-hour emergency dental care.
(1) At the time of admission, the facility
must obtain the name of the resident's preferred dentist and record the name in
the clinical record.
(2) At least
annually, the facility must ask each resident and resident representative if
the resident desires a dental examination at the resident's expense.
(3) The facility must make all reasonable
efforts to arrange for a dental examination for each resident who desires
one.
(4) The facility is not liable
for the cost of the resident's dental care.
(5) Licensed-only facilities must maintain a
list of local dentists for a resident who requires a dentist.
(b) Medicaid-certified facilities
also must provide or obtain from an outside resource, in accordance with §
554.1906 of this chapter (relating
to Use of Outside Resources), the following dental services to meet the needs
of each resident:
(1) Emergency dental
services, which are limited to procedures necessary to control bleeding,
relieve pain, and eliminate acute infection; operative procedures which are
required to prevent the imminent loss of teeth; treatment of injuries to the
teeth or supporting structures.
(A) Covered
emergency dental procedures include:
(i)
alleviation of extreme pain in oral cavity associated with serious infection or
swelling;
(ii) repair of damage
from loss of tooth due to trauma (acute care only, no restoration);
(iii) open or closed reduction of fracture of
the maxilla or mandible;
(iv)
repair of laceration in or around oral cavity;
(v) excision of neoplasms, including benign,
malignant and premalignant lesions, tumors and cysts;
(vi) incision and drainage of
cellulitis;
(vii) root canal
therapy, for which payment is subject to dental necessity review and pre- and
post-operative x-rays are required; and
(viii) extractions: single tooth, permanent;
single tooth, primary; supernumerary teeth; soft tissue impaction; partial bony
impaction; complete bony impaction; surgical extraction of erupted tooth or
residual root tip.
(B)
Routine restorative procedures are not considered emergency procedures. Dental
services not covered include:
(ii) filling teeth with
amalgam composite, glass ionomer, or any other restorative material;
(iii) cast or preformed crowns
(capping);
(iv) restoration of
carious or noncarious permanent or primary teeth, including those requiring
root canal therapy;
(v) replacement
or repositioning of teeth;
(vi)
services to the alveolar ridges or periodontium of the maxilla and the
mandible, except for procedures covered under subparagraph (A) of this
paragraph; and
(vii) complete or
partial dentures.
(2) Assistance to the resident, if necessary:
(A) in making appointments; and
(B) by arranging for transportation to and
from the dentist's office.
(3) Prompt referral, within three days, of a
resident with lost or damaged dentures for dental services. If a referral does
not occur within three days, the facility must provide documentation of what
they did to ensure the resident could still eat and drink adequately while
awaiting dental services and the extenuating circumstances that led to the
delay.
(4) Coordination of dental
services for pediatric residents age 12 months to 21 years, in accordance with
Texas Health Steps (THSteps) guidelines.
(c) The facility must have a written policy
identifying those circumstances when the loss or damage of dentures is the
facility's responsibility and may not charge a resident for the loss or damage
of dentures determined in accordance with facility policy to be the facility's
responsibility.
(d)
Medicaid-certified facilities are not required to provide routine dental
services.
(e) Payment for services
provided on the teeth, gums, alveolar ridges, and supporting structures are not
a benefit of the Texas Medicaid Program; however, recipients with applied
income may use incurred medical expenses to pay for routine dental services and
appliances.
