NOTICES
Medical Assistance Dental Benefit Package Changes
[41 Pa.B. 5133]
[Saturday, September 24, 2011]The Department of Public Welfare (Department), under the authority of section 443.6(g) of the Public Welfare Code (code) (62 P.S § 443.6(g)), as amended by the act of June 30, 2011 (P. L. 89, No. 22), announces benefit package changes for certain dental services for adult Medical Assistance (MA) recipients 21 years of age and older, effective September 30, 2011.
Background
The MA Program provides a continuum of physical and behavioral health services, including long-term care, inpatient hospital, pharmacy and outpatient services to approximately 2.2 million people in this Commonwealth.
States across the country, including Pennsylvania, are struggling to maintain their Medicaid programs as state revenues continue to lag, failing to keep pace with ever increasing caseloads and health care costs. While the caseload of persons eligible for the MA program in this Commonwealth continues to grow in State Fiscal Year (SFY) 2011-2012, the General Fund Budget is 4.1% less than SFY 2010-2011 amounts, to near SFY 2008-2009 levels.
The Department has taken steps to identify cost containment initiatives that will have the least detrimental impact on the health care needs of the MA population.
Rather than eliminating all dental services for the MA adult population, for example, the Department closely evaluated the utilization of, and payments for, particular dental services to determine which services could be limited with minimal impact. Based on MA utilization and claims data from SFY 2009-2010, the most recent year for which complete data is available, the changes to the dental benefit package would have had no impact on over 96% of the total MA eligible adult population eligible for dental benefits who received services in that fiscal year. The Department will therefore realize significant cost savings while maintaining core preventive dental services as well as some other dental services for recipients.
Dental Benefit Changes
Effective September 30, 2011, adult MA recipients 21 years of age and older will be eligible for the following:
• One partial upper denture or one full upper denture and one partial lower denture or one full lower denture per lifetime. Additional dentures will require a benefit limit exception.
• One dental exam and prophylaxis per 180 days, per adult recipient. Additional dental exams and prophylaxis will require a benefit limit exception.
• Crowns and adjunctive services, periodontal and endodontic services if the recipient receives a benefit limit exception.
The Department will grant benefit limit exceptions to the dental benefit package when one of the following criteria is met:
1. The Department determines the recipient has a serious chronic systemic illness or other serious health condition and denial of the exception will jeopardize the life of the recipient.
2. The Department determines the recipient has a serious chronic systemic illness or other serious health condition and denial of the exception will result in the rapid, serious deterioration of the health of the recipient.
3. The Department determines that granting a specific exception is a cost effective alternative for the MA Program.
4. The Department determines that granting an exception is necessary to comply with Federal law.
The specified dental benefit package changes do not apply to MA recipients under 21 years of age or to MA recipients who reside in a nursing facility, in an intermediate care facility for persons with mental retardation or in an intermediate care facility for persons with other related conditions.
Dental services previously approved through the Department's prior authorization process will be covered if the services are initiated prior to the close of the authorization period.
The Department will provide detailed instructions to providers regarding the dental benefit package changes by means of an MA Bulletin and updated Dental Handbook pages that include instructions for submitting a benefit limit exception
MA physical health managed care organizations (MCO) have the option to impose the same or lesser limits for the aforementioned dental services. If an MA physical health MCO imposes the same or lesser limits, the MA physical health MCO will issue individual notice to its members at least 30 days in advance of the changes and will notify network providers, according to the MCO individual provider agreements, in advance of the changes.
Fiscal Impact
The Fiscal Year 2011-2012 fiscal impact as a result of the changes to the dental benefit package is a savings of $42.201 million ($18.901 million in State funds and $23.300 million in Federal funds).
Public Comment
Interested persons are invited to submit written comments regarding this notice to the Department of Public Welfare, Office of Medical Assistance Programs, c/o Regulations Coordinator, Room 515, Health and Welfare Building, Harrisburg, PA 17120. Comments received within 30 days will be reviewed and considered for any subsequent revision of the dental benefit package.
Persons with a disability who require an auxiliary aid or service may submit comments using the Pennsylvania AT&T Relay Service at (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).
GARY D. ALEXANDER,
SecretaryFiscal Note: 14-NOT-718. No fiscal impact; (8) recommends adoption. The cost containment change is expected to save $18,901,000 in State funds in Fiscal Year 2011-2012.
[Pa.B. Doc. No. 11-1672. Filed for public inspection September 23, 2011, 9:00 a.m.]
No part of the information on this site may be reproduced for profit or sold for profit.This material has been drawn directly from the official Pennsylvania Bulletin full text database. Due to the limitations of HTML or differences in display capabilities of different browsers, this version may differ slightly from the official printed version.
