Conn. Agencies Regs. § 17-134d-35

Current through October 16, 2024

Section 17-134d-35 - Orthodontic services provided under the early and periodic screening, diagnosis and treatment (EPSDT) program

(a)Orthodontic services will be paid for when

(1) provided by a qualified dentist; and

(2) deemed medically necessary as described in these regulations.

(b)Definition

(1) Qualified Dentist

"Qualified Dentist" means a dentist who:

(A) Holds himself out to be an orthodontist in accordance with section 20-106a of the Connecticut State Statutes, or

(B) Documents completion of an American Dental Association accredited post graduate continuing education course consisting of a minimum of two (2) years of orthodontic seminars, and/or submitting three (3) completed case histories with a comparable degree of difficulty as those cases meeting the department's requirements in section (e) of the department's orthodontic policy if requested by the orthodontic consultant.

(2) The Department

"The Department" means the State Department of Income Maintenance.

(3) Preliminary Handicapping Malocclusion Assessment Record

"Preliminary Handicapping Malocclusion Assessment Record" means the method of determining the degree of malocclusion and eligibility for orthodontic services. Such assessment is completed prior to performing the comprehensive diagnostic assessment.

(4) Comprehensive Diagnostic Assessment

"Comprehensive Diagnostic Assessment" means a minimum evaluative tool for an orthodontic case which determines the plan for treatment necessary to correct the malocclusion. The assessment includes, but is not limited to, the following diagnostic measures: Radiographs; full face and profile photographs or color slides.

(c)Services Covered and Limitations

The Department may reimburse a qualified dentist for the following orthodontic services (including permanent and/or deciduous dentition);

(1) Orthodontic screening-one (1) per provider of the same recipient;

(2) Orthodontic consultation-one (1) per provider for the same recipient;

(3) Preliminary assessment study models-one (1) per provider for the same recipient;

(4) Comprehensive diagnostic assessment-one (1) per provider for the same recipient;

(5) Initial appliance-one (1) per provider for the same recipient;

(6) Active Treatment-up to a maximum of thirty (30) months;

(7) Retainer appliances-retainers may be replaced only once, per dental arch, for the same recipient.

(d)Other Limitations

Orthodontic services are limited to recipients under twenty-one (21) years of age.

(e)Need for Services

When an eligible recipient is determined to have a malocclusion, the attending dentist should refer the recipient to a qualified dentist for preliminary examination of the degree of malocclusion.

(1) The need for orthodontic services shall be determined on the basis of the magnitude of the malocclusion. Accordingly, the "Preliminary Handicapping Malocclusion Assessment Record," available from the Department, must be fully completed in accordance with the instructions sections of the form. The Department deems orthodontic services to be medically necessary when a correctly scored total of twenty-four (24) points or greater is calculated from the preliminary assessment. However, if the total score is less than twenty-four (24) points the Department shall consider additional information of a substantial nature about the presence of other severe deviations affecting the mouth and underlying structures. Other deviations shall be considered to be severe if, left untreated, they would cause irreversible damage to the teeth and underlying structures.

(2) If the total score is less than twenty-four (24) points the Department shall consider additional information of a substantial nature about the presence of severe mental, emotional, and/or behavior problems, disturbances or dysfunctions, as defined in the most current edition of the Diagnostic Statistical Manual of the American Psychiatric Association, and which may be caused by the recipient's daily functioning. The department will only consider cases where a diagnostic evaluation has been performed by a licensed psychiatrist or a licensed psychologist who has accordingly limited his or her practice to child psychiatry or child psychology. The evaluation must clearly and substantially document how the dentofacial deformity is related to the child's mental, emotional, and/or behavior problems. And that orthodontic treatment is necessary and, in this case, will significantly ameliorate the problems.

(3) A recipient who becomes Medicaid eligible and is already receiving orthodontic treatment must demonstrate that the need for service requirements specified in subsections (e) (1) and (2) of these regulations were met before orthodontic treatment commenced, meaning that prior to the onset of treatment the recipient would have met the need for services requirements.

(f)Prior Authorization

(1) Prior authorization is required for the comprehensive diagnostic assessment.

The qualified dentist shall submit:

(A) the authorization request form;

(B) the completed Preliminary Handicapping Malocclusion Assessment Record;

(C) Preliminary assessment study models of the patient's dentition; and,

(D) additional supportive information about the presence of other severe deviations described in Section (e) (if necessary).

The study models must clearly show the occlusal deviations and support the total point score of the preliminary assessment. If the qualified dentist receives authorization from the Department he may proceed with the diagnostic assessment.

(2) Prior authorization is required for orthodontic treatment for the initial appliance; first, second, and third year of active treatment; and for replacement of retainers. No authorization shall be given if there is evidence that little or no progress has been made at the end of each yearly period. In this case, the qualified dentist shall be required to resubmit the authorization request. The authorization shall be based on reasonable progress made in active treatment as deemed by the Department. There will be no monthly payment allowed during this period.

(A) For the initial appliance and the first year of active treatment (1st through 12th month) the qualified dentist shall submit, prior to initiating treatment:

(i) the authorization request form;

(ii) the diagnosis;

(iii) a written treatment plan;

(iv) a description of the appliance to be utilized;

(v) the length of time treatment is necessary;

(vi) the length of the retention period necessary after active treatment;

(vii) a list of all other medical or dental treatment which is necessary in preparation for, or completion of, the orthodontic treatment.

(B) For the second year of active treatment (13th through 24th month) the qualified dentist shall submit, prior to initiating continued treatment:

(i) the authorization request form covering the second (2nd) year of active treatment;

(ii) study models and/or photographs clearly showing the progress of treatment to date.

(C) For the third (3rd) year of active treatment (25th through 30th month) the qualified dentist shall submit prior to initiating continued treatment:

(i) the authorization request form covering the third (3rd) year of active treatment;

(ii) study models and/or photographs clearly showing the case is ready for retention.

(D) Replacement of retainers with documentation to justify.

(E) Any requests for modification of the treatment plan as authorized by the Department's orthodontic consultant must be submitted to the orthodontic consultant in writing providing evidence in support of such a request. However, no authorization shall be given beyond thirty (30) months of active treatment.

(g)Other Requirements

(1) The recipients, together with the parent or guardian, should have the desire and the ability to complete an extended treatment plan as determined by the qualified dentist performing the treatment or other professionals involved with the recipient or family.

(2) When an orthodontic case is authorized by the Department, local Early Periodic Screening, Diagnostic and Treatment (EPSDT) staff will contact the recipient and the qualified dentist to help facilitate the recipient's participation in and completion of the treatment plan.

(3) The course of orthodontic treatment must be completed prior to the recipient's twenty first (21st) birthday.

(4) The qualified dentist shall maintain a specific record for each recipient eligible for Medicaid reimbursement including, but not limited to: name, address, birth date, Medicaid identification number, pertinent diagnostic information and X-ray, a current treatment plan, pertinent treatment notes signed by the qualified dentist; and documentation of the dates of service. Records or documentation must be maintained for a minimum of five (5) years.

(5) For the retention period the qualified dentist shall submit, prior to initiating placement of retainers, study models and/or photographs clearly showing the case is ready for retention.

(h)Payment Limitation

(1) Payment for orthodontic services shall be made in accordance with the Department's dental fee schedule.

(2) An initial payment and monthly payments are made for active treatment of orthodontic services.

(3) The initial payment covers the placement of the initial appliances.

(4) No payment is made for monitoring growth and development.

(5) A dentist, other than a qualified dentist as defined in these regulations, may receive payment for an orthodontic screening. The screening includes an oral examination and/or examination of the patient's records for the purposes of completing Sections I, II and IIIA-D of the Preliminary Handicapping Malocclusion Assessment Record Form No. W-1428.

(6) The fee for the orthodontic consultation includes a dental screening and the completion of the preliminary assessment form. No separate payment shall be made to a qualified dentist for the orthodontic screening.

(7) The number of monthly payments is limited to the number of months of active treatment stipulated in the treatment plan as approved by the Department.

(8) The monthly installment rate for active treatment is based on an average of one (1) visit per month and will be payable once a month during the authorized active treatment period no matter how many times the orthodontist sees the patient during this period.

(9) Payment for the comprehensive diagnostic assessment includes all diagnostic measure, e.g., X-rays, photographs or slides, and the written treatment plan. No separate payment is made for individual diagnostic materials except the preliminary assessment study models.

(10) For a recipient who becomes ineligible for Medicaid during the authorized term of active treatment, the final payment from the Department shall be made for the month in which the recipient becomes ineligible for Medicaid or EPSDT services, whichever comes first.

(11) The cost of the initial retainer appliance, including: fitting, adjustments and all necessary visits, is included in the first twenty-four (24) monthly active treatment installments.

(12) The fee for the replacement of retainer appliances includes the fitting and all necessary visits.

Conn. Agencies Regs. § 17-134d-35

Effective January 27, 1988