25 TAC §§33.301, 33.306, 33.308, 33.314, 33.316, 33.317
The Texas Department of Health (department) proposes amendments
to §§33.301, 33.306, 33.308, 33.314, 33.316, and 33.317, concerning
the administration of the Texas Health Steps (THSteps) dental services program.
The dental program is a component of the Medicaid Early and Periodic Screening,
Diagnosis and Treatment (EPSDT) program. The EPSDT program is known in Texas
as THSteps. Specifically, the proposed amendments clarify EPSDT dental screening
providers' standards of care and documentation requirements.
An amendment to §33.301, Definitions, corrects the subchapter reference
to which the rules are applicable.
An additional amendment to §33.301, and the proposed amendments to §§33.306,
Allowable Services and Limitations; 33.314, Claims; 33.316, Standards of Care;
and 33.317, Management of Complaints, implement House Bill 3507, 77th Legislative
Session (2001) which amended Chapter 32, concerning the Texas medical assistance
program (Medicaid), of the Human Resources Code. These amendments add a definition
for dental necessity in the THSteps dental services program and mandate dental
necessity as a condition for provider reimbursement, standards of care and
complaint management. These amendments also replace the term "medical necessity"
with "dental necessity" throughout the program rules.
The amendment to §33.308 requires providers to document the dental
necessity of a stainless steel crown as a condition for a provider's continuing
participation in Texas Health Steps and to comply with documentation and record
keeping requirements established by the State Board of Dental Examiners.
Gerald Cannaday, Bureau Chief of Support Services, Associateship for Family
Health, has determined that for the first five years the sections are in effect,
there will be no fiscal implications to state or local governments as a result
of enforcing the proposed amendments.
Mr. Cannaday has determined that for each of the first five years the sections
are in effect, the public benefit anticipated as a result of enforcing and
administering the sections will be to ensure only necessary dental services
are provided and reimbursed. There will be no adverse economic effects on
small businesses or microbusinesses because dentists are currently required
to ensure and document the dental necessity of their services. These rules
provide a definition for dental necessity, as opposed to medical necessity,
and reinforce documentation requirements, tying them to specific State Board
of Dental Examiner rules on documentation and record keeping. There will be
no anticipated economic costs to individuals required to comply with the amendments
as proposed. There is no anticipated impact on local employment.
Comments on the proposal may be submitted to YuFang Chang, Program Specialist
IV, Bureau of Children's Health, Texas Department of Health, 1100 West 49th
Street, Austin, Texas 78756, (512) 458-7323, yufang.chang@tdh.state.tx.us.
Comments will be accepted for 30 days following publication in the
Texas Register
. A public hearing on these proposed rules will be held
on June 13, 2002 at the Texas Department of Health, 1100 West 49th Street,
Austin, Texas 78756, Room G107, from 2:00-4:00 P.M., Central Daylight Saving
Time.
The amendments are proposed under the Human Resources Code, §32.021(c),
which allows the department to establish rules governing the Medicaid program;
the Human Resources Code, §32.053, which requires certain rules on dental
services; the Health and Safety Code, §12.001, which provides the Texas
Board of Health with the authority to adopt rules for its procedures and the
performance of each duty imposed by law on the board, the department, and
the Commissioner of Health; and the Government Code, §531.021, which
provides the Health and Human Services Commission with the authority to administer
the state's medical assistance program.
The proposed amendments affect the Human Resources Code, Chapter 32, and
the Government Code, Chapter 531.
§33.301.Definitions.
The following words and terms when used in Subchapters [
F,
]
G and H of this chapter, shall have the following meanings, unless the context
clearly indicates otherwise.
(1) - (2)
(No change.)
(3)
Dental necessity -- for dental services
or products provided, whether a prudent dentist would provide the service
or product to a patient to diagnose, prevent, or treat orofacial pain, infection,
disease, dysfunction, or disfiguration in accordance with generally accepted
practices:
(A)
of the professional dental community;
(B)
within the American Dental Association's Dental Practice
Parameters, published by the American Dental Association, Revised 1997; and/or
(C)
within the Quality Assurance Criteria of the American Academy
of Pediatric Dentistry, as applicable, published in Pediatric Dentistry, Journal
of the American Academy of Pediatric Dentistry, Reference Manual, 2000-2001,
Volume 22, Number 7.
(4)
[
(3)
] Department--The Texas Department
of Health.
(5)
[
(4)
] Early and Periodic Screening,
Diagnosis, and Treatment (EPSDT)--A component of the Medicaid program, also
known as Texas Health Steps (THSteps), which provides medical check-up and
dental services to Medicaid and Texas Health Steps clients under age 21 years.
(6)
[
(5)
] HHSC--Health and Human Services
Commission.
(7)
[
(6)
] Manual--The Texas Medicaid
Provider Procedures Manual, including all updates published in the Texas Medicaid
Bulletin.
(8)
[
(7)
] Medicaid--A medical and dental
program provided under Title XIX of the federal Social Security Act and the
Human Resources Code, Chapter 32.
(9)
[
(8)
] OIE--The Office of Investigations
and Enforcement at the Health and Human Services Commission.
(10)
[
(9)
] Parental involvement--this
term applies only to school health clinics, Head Start programs, and child-care
facilities which are exempt from the parental accompaniment requirement under §33.316(c)
of this title (relating to Standards of Care). The term means exempt entities
shall encourage parental involvement in and management of the health care
of children receiving services from the clinic, program, or facility by notifying
the child's parent, guardian, or other authorized adult before each visit
for an EPSDT dental checkup of the time and place of the child's appointment
and encouraging the parent, guardian, or other authorized adult to attend.
The parent, guardian, or other authorized adult shall be notified in a timely
manner by the means of communication determined by the clinic, program, or
facility to be most effective. Such communication must be documented and may
include, but is not limited to, one or more of the following options: a home
visit from an outreach worker, written or printed correspondence or telephone
contact.
(11)
[
(10)
] Recipient--A Medicaid-enrolled
client.
(12)
[
(11)
] SBDE--State Board of Dental
Examiners.
§33.306.Allowable Services and Limitations.
(a)
(No change.)
(b)
Payment shall be made only for services
for which
dental necessity is established
[
that are medically necessary,
allowable,
] and delivered in accordance with the Medicaid program requirements
in effect on the date of service.
(c)
(No change.)
§33.308.Requirements for Provider Enrollment and Continuing Participation.
(a)
Dentists providing Texas Health Steps Dental Services must:
(1) - (2)
(No change.)
(3)
document the dental necessity of a stainless
steel crown before the crown is applied by radiographs or other documentation
methods established by the SBDE;
(4)
comply with a minimum standard of documentation
and record keeping for each of the dentist's patients, pursuant to 22 T.A.C. §§108.7
and 108.8, concerning SBDE minimum standards of care and documentation requirements,
whether the patient's costs are paid privately or through the Texas Medicaid
program;
(5)
[
(3)
] practice in the United States
of America; and
(6)
[
(4)
] be enrolled as Texas Health
Steps dental providers.
(b) - (d)
(No change.)
§33.314.Claims--Time Limits, Submission, and Denial.
(a) - (c)
(No change.)
(d)
Claims for services shall be denied for any of the following
reasons:
(1) - (2)
(No change.)
(3)
the dental necessity of
the service
was
not established
[
was either not medically necessary
] or
the service was
not delivered according to
the Medicaid
program
rules and policy in effect on the date of service, or both;
(4) - (8)
(No change.)
§33.316.Standards of Care.
(a)
(No change.)
(b)
Texas Health Steps recipients shall:
(1) - (2)
(No change.)
(3)
receive only that treatment required to address documented
dental
[
medical
] necessity and which meets professionally
recognized standards of health care as recognized by the SBDE.
(c)
(No change.)
§33.317.Management of Complaints.
(a)
(No change.)
(b)
Referrals to other state agencies.
(1)
The department shall refer to OIE based on OIE criteria.
OIE criteria for referral by the department include, but are not limited to,
complaints or allegations of provider fraud or abuse, including program abuse;
abuse or harm to a recipient; lack of
dental
[
medical
]
necessity; overbilling; soliciting or collecting unauthorized payments from
recipients; or failure to refund payments to recipients. Such complaints or
allegations shall be made in writing and forwarded to the OIE. The OIE may
utilize staff from the department or its claims processing contractor to assist
in determining the validity of any complaints or allegations received. A departmental
employee acting as an agent of OIE is governed by the parameters of authority
and investigation for OIE.
(2) -(3)
(No change.)
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed with the Office of
the Secretary of State on May 23, 2002.
TRD-200203203
Susan Steeg
General Counsel
Texas Department of Health
Earliest possible date of adoption: July 7, 2002
For further information, please call: (512) 458-7236