This section defines dental necessity and limits Medicaid dental services and reimbursement to medically necessary care, with added documentation, audit, and preventive-care requirements.
Sec. 32.054. DENTAL SERVICES. (a) For purposes of this section, the "dental necessity" for a dental service or product is based on whether a prudent dentist, acting in accordance with generally accepted practices of the professional dental community and within the American Dental Association's Parameters of Care for Dentistry and within the quality assurance criteria of the American Academy of Pediatric Dentistry, as applicable, would provide the service or product to a patient to diagnose, prevent, or treat orofacial pain, infection, disease, dysfunction, or disfiguration. (b) A dental service or product may not be provided under the medical assistance program unless there is a dental necessity for the service or product. (c) In providing dental services under the medical assistance program, the commission shall: (1) ensure that a stainless steel crown is not used as a preventive measure; (2) require a dentist participating in the medical assistance program to document, through x-rays or other methods established by commission rule, the dental necessity for a stainless steel crown before the crown is applied; (3) require a dentist participating in the medical assistance program to comply with a minimum standard of documentation and recordkeeping for each of the dentist's patients, regardless of whether the patient's costs are paid privately or through the medical assistance program; (4) replace the 15-point system used for determining the dental necessity for hospitalization and general anesthesia with a more objective and comprehensive system developed by the commission; and (5) take all necessary action to eliminate unlawful acts described by Section 36.002 in the provision of dental services under the medical assistance program, including: (A) aggressively investigating and prosecuting any dentist who abuses the system for reimbursement under the medical assistance program; and (B) conducting targeted audits of dentists whose billing activities under the medical assistance program are excessive or otherwise inconsistent with the billing activities of other similarly situated dentists. (d) In setting reimbursement rates for dental services under the medical assistance program, the executive commissioner shall: (1) provide for reimbursement of a behavior management fee only if: (A) the patient receiving dental treatment has been previously diagnosed with an intellectual or developmental disability or a mental disability or disorder, and extraordinary behavior management techniques are necessary for therapeutic dental treatment because of the patient's uncooperative behavior; and (B) the dentist includes in the patient's records and on the claim form for reimbursement a narrative description of: (i) the specific behavior problem demonstrated by the patient that required the use of behavior management techniques; (ii) the dentist's initial efforts to manage the patient's behavior through routine behavior management techniques; and (iii) the dentist's extraordinary behavior management techniques subsequently required to manage the patient's behavior; and (2) redistribute amounts made available through limitation of the behavior management fee under Subdivision (1) to other commonly billed dental services for which adequate accountability measures exist. (e) The commission shall develop the minimum standard described by Subsection (c)(3) in cooperation with the State Board of Dental Examiners. (f) To prevent serious medical conditions and reduce emergency room visits necessitated by complications resulting from a lack of access to dental care, the commission shall provide medical assistance reimbursement for preventive dental services, including reimbursement for one preventive dental care visit per year, for an adult recipient with a disability who is enrolled in the STAR+PLUS Medicaid managed care program. This subsection does not apply to an adult recipient who is enrolled in the STAR+PLUS home and community-based services (HCBS) waiver program. This subsection may not be construed to reduce dental services available to persons with disabilities that are otherwise reimbursable under the medical assistance program. Added by Acts 2001, 77th Leg., ch. 1470, Sec. 1.01, eff. Sept. 1, 2001. Renumbered from Human Resources Code Sec. 32.053 by Acts 2003, 78th Leg., ch. 1275, Sec. 2(98), eff. Sept. 1, 2003. Amended by: Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 4.129, eff. April 2, 2015. Acts 2021, 87th Leg., R.S., Ch. 820 (H.B. 2658), Sec. 6, eff. September 1, 2021. Acts 2021, 87th Leg., R.S., Ch. 954 (S.B. 1648), Sec. 6, eff. September 1, 2021.