10 Colo. Code Regs. § 2505-10-8.7519

Current through Register Vol. 47, No. 24, December 25, 2024

Section 10 CCR 2505-10-8.7519 - Dental

8.7519ADental Eligibility

1. Dental is available to Members enrolled in one of the following HCBS waivers:

a. Developmental Disabilities Waiver

b. Supported Living Services Waiver

8.7519.BDental Definition

1. Dental care means services administered for diagnostic and preventative care to abate tooth decay, and medically appropriate treatments to restore dental health.

8.7519.CDental Inclusions

1. Preventative services include:

a. Dental insurance premiums, copayments/and coinsurance;

b. Periodic examination and diagnosis;

c. Radiographs when indicated;

d. Non-intravenous sedation;

e. Basic and deep cleanings;

f. Mouth guards;

g. Topical fluoride treatment; and

h. Retention or recovery of space between teeth when indicated

2. Basic services include:

a. Fillings;

b. Root canals;

c. Denture realigning or repairs;

d. Repairs/re-cementing crowns and bridges;

e. Non-emergency extractions including simple, surgical, full and partial;

f. Treatment of injuries; or

g. Restoration or recovery of decayed or fractured teeth.

3. Major services include:

a. Implants when necessary to support a dental bridge for the replacement of multiple missing teeth or are necessary to increase the stability of crowns of, crowns, bridges, and dentures. The cost of implants is only reimbursable with prior approval in accordance with The Department procedures.

b. Crowns.

c. Bridges.

d. Dentures.

8.7519.DDental Exclusions and Limitations

1. Dental services are provided only when the services are not available through the Medicaid State Plan due to not meeting the need for medical necessity as defined at Section 8.076.1.8, or available through a third party. General limitations to dental services including frequency will follow the Department's guidelines using industry standards and are limited to the most cost effective and efficient means to alleviate or rectify the dental issue associated with the Member.

2. Implants are a benefit only when the procedure is necessary to support a dental bridge for the replacement of multiple missing teeth or is necessary to increase the stability of dentures. The cost of implants is reimbursable only with prior authorization by the Administrative Service Organization.

3. Implants shall not be a benefit for Members who use tobacco daily due to the substantiated increased rate of implant failures for chronic tobacco users.

4. Subsequent implants are not a covered service. Exceptions would be exclusive to situations involving failure of the implant. In these instances, a formal grievance must be filed in order to determine if a full review is necessary to assess the cause of the implant failure.

5. Full mouth implants or crowns are not covered.

6. Dental services do not include cosmetic dentistry, procedures predominated by specialized prosthodontic, maxillo-facial surgery, craniofacial surgery or orthodontia, which includes, but is not limited to:

a. Elimination of fractures of the jaw or face,

b. Elimination or treatment of major handicapping malocclusion, or

c. Congenital disfiguring oral deformities.

7. Cosmetic dentistry is defined as aesthetic treatment designed to improve the appearance of the teeth or smile, including teeth whitening, veneers, contouring and implants or crowns solely for the purpose of enhancing appearance.

8. Preventative and basic services are limited to $2,000 per support plan year. Major services are limited to $10,000 for the five year renewal period of the waiver.

10 CCR 2505-10-8.7519

47 CR 03, February 10, 2024, effective 3/16/2024

47 CR 21, November 10, 2024, effective 11/30/2024