TITLE 405 OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES
Final Rule
LSA Document #15-450(F)
DIGEST
Authority:
IC 12-15
Sec. 1. (a) Medicaid reimbursement is available only for those dental services listed in section 2 of this rule subject to the limitations set out in this rule.
(b) For those members twenty-one (21) years of age and over, covered services routinely provided in a dental office will be limited to one thousand dollars ($1,000) per member, per twelve (12) month period. This limit precedes all other limits within this rule. All procedure codes will be included within the limitation. A provider bulletin issued under this subsection shall be effective no earlier than permitted under IC 12-15-13-6.
(c) (b) For those members twenty-one (21) years of age and over, all covered services will require prior authorization except the following:
(1) Diagnostic and preventative services.
(2) Direct restorations.
(3) Treatment of lesions.
(4) Periodontal services for the following immuno-compromised individuals:
(A) Transplant patients.
(B) Pregnant women.
(C) Diabetic patients.
(5) Extractions.
(6) Emergency and trauma care.
(Office of the Secretary of Family and Social Services; 405 IAC 5-14-1; filed Jul 25, 1997, 4:00 p.m.: 20 IR 3319; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; filed Dec 13, 2002, 4:00 p.m.: 26 IR 1546; filed Aug 17, 2007, 3:23 p.m.: 20070912-IR-405060005FRA; readopted filed Sep 19, 2007, 12:16 p.m.: 20071010-IR-405070311RFA; filed May 9, 2011, 4:01 p.m.: 20110608-IR-405100795FRA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFA; filed Aug 1, 2016, 3:44 p.m.: 20160831-IR-405150418FRA; filed Sep 2, 2016, 12:26 p.m.: 20160928-IR-405150450FRA)
Authority:
IC 12-15-1-10;
IC 12-15-1-15;
IC 12-15-21-2;
IC 12-15-21-3
Sec. 2. The following are covered dental services under Medicaid:
(1) Evaluations.
(2) Radiographs.
(3) Prophylaxis.
(4) Topical fluoride for members twenty (20) years of age and younger.
(5) Sealant for permanent molars and premolars for members twenty (20) years of age and younger.
(6) Amalgam.
(7) Unilateral and bilateral space maintainers for members twenty (20) years of age and younger.
(8) Resin anteriors and posteriors.
(9) Recement crowns.
(10) Steel crown primary.
(11) Stainless steel crown permanent.
(12) Therapeutic pulpotomy.
(13) Extractions.
(14) Oral biopsies.
(15) Alveoplasty.
(16) Excision of lesions.
(17) Excision of benign tumor.
(18) Odontogenic cyst removal.
(19) Nonodontogenic cyst removal.
(20) Incise and drain abscess.
(21) Fracture simple stabilize.
(22) Compound fracture of the mandible.
(23) Compound fracture of the maxilla.
(24) Repair of wounds.
(25) Suturing.
(26) Emergency treatment dental pain.
(27) Analgesia for members twenty (20) years of age and younger.
(28) Drugs and medicaments.
(29) Periodontal surgery limited to drug-induced periodontal hyperplasia. Periodontic procedures.
(30) Other dental services as medically necessary to treat members eligible for the EPSDT program.
(31) Periodontal root planing and scaling.
(32) (31) General anesthesia.
(33) (32) Intravenous (IV) sedation covered only for oral surgical services.
(34) (33) Dentures and partials.
(35) (34) Orthodontic services for members twenty (20) years of age and under only.
(35) Physician fluoride varnish services for members younger than four (4) years of age.
Authority:
IC 12-15-1-10;
IC 12-15-1-15;
IC 12-15-21-2;
IC 12-15-21-3
Sec. 4. Reimbursement is available for one (1) topical application of fluoride every six (6) months per member only for patients who are twelve (12) months of age or older but who are younger than twenty-one (21) years of age. from the time of first tooth eruption. Topical applications of fluoride are not covered for members twenty-one (21) years of age or older. Brush-in fluoride (topical application of fluoride phosphate) is not a covered service.
(Office of the Secretary of Family and Social Services; 405 IAC 5-14-4; filed Jul 25, 1997, 4:00 p.m.: 20 IR 3320; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; filed Apr 16, 2003, 10:50 a.m.: 26 IR 2863; readopted filed Sep 19, 2007, 12:16 p.m.: 20071010-IR-405070311RFA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFA; filed Aug 1, 2016, 3:44 p.m.: 20160831-IR-405150418FRA; filed Sep 2, 2016, 12:26 p.m.: 20160928-IR-405150450FRA)
Hearing Held: July 20, 2016
Approved by Attorney General: August 17, 2016
Approved by Governor: September 1, 2016
Filed with Publisher: September 2, 2016, 12:26 p.m.
Documents Incorporated by Reference: None Received by Publisher
Small Business Regulatory Coordinator: Amanda Alvey, Indiana Family and Social Services Administration, Office of Medicaid Policy and Planning, Indiana Government Center South, 402 West Washington Street, Room W374, Indianapolis, IN 46204, (317) 234-5551, amanda.alvey@fssa.in.gov
Posted: 09/28/2016 by Legislative Services Agency
DIN: 20160928-IR-405150450FRA
Composed: May 18,2024 4:33:07PM EDT
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