La. Admin. Code tit. 50 § XV-6905

Current through Register Vol. 50, No. 11, November 20, 2024

Section XV-6905 - Reimbursement

A. Services covered in the EPSDT Dental Program shall be reimbursed at the lower of either:

1. the dentist's billed charges minus any third party coverage; or

2. the state's established schedule of fees, which is developed in consultation with the Louisiana Dental Association and the Medicaid dental consultants, minus any third party coverage.

B. Effective for dates of service on and after December 24, 2008, the reimbursement fees for EPSDT dental services are increased to the following percentages of the 2008 National Dental Advisory Service comprehensive fee report 70th percentile rate, unless otherwise stated in this Chapter. The reimbursement fees are increased to:

1. 80 percent for all oral examinations;

2. 75 percent for the following services:

a. radiograph - periapical and panoramic film;

b. prophylaxis;

c. topical application of fluoride or fluoride varnish; and

d. removal of impacted tooth;

3. 70 percent for the following services:

a. radiograph - complete series, occlusal film and bitewings;

b. sealant, per tooth;

c. space maintainer, fixed (unilateral or bilateral;

d. amalgam, primary or permanent;

e. resin-based composite and resin-based composite crown, anterior;

f. prefabricated stainless steel or resin crown;

g. core buildup, including pins;

h. pin retention;

i. prefabricated post and core, in addition to crown;

j. extraction or surgical removal of erupted tooth;

k. removal of impacted tooth (soft tissue or partially bony); and

l. palliative (emergency) treatment of dental pain; and

m. surgical removal of residual tooth roots; and

4. 65 percent for the following dental services:

a. oral/facial images;

b. diagnostic casts;

c. re-cementation of space maintainer or crown;

d. removal of fixed space maintainer;

e. all endodontic procedures except:

i. unspecified endodontic procedure, by report;

f. all periodontic procedures except:

i. unspecified periodontal procedure, by report;

g. fluoride gel carrier;

h. all fixed prosthodontic procedures except:

i. unspecified fixed prosthodontic procedure, by report;

i. tooth re-implantation and/or stabilization of accidentally evulsed or displaced tooth;

j. surgical access of an unerupted tooth;

k. biopsy of oral tissue;

l. transseptal fiberotomy/supra crestal fiberotomy;

m. alveoloplasty in conjunction with extractions;

n. incision and drainage of abscess;

o. occlusal orthotic device;

p. suture of recent small wounds;

q. frenulectomy;

r. fixed appliance therapy; and

s. all adjunctive general services except:

i. palliative (emergency) treatment of dental pain, and

ii. unspecified adjunctive procedure, by report.

C. The reimbursement fees for all other covered dental procedures shall remain at the rate on file as of December 23, 2008.

D. Effective for dates of service on or after January 22, 2010, the reimbursement fees for EPSDT dental services shall be reduced to the following percentages of the 2008 National Dental Advisory Service comprehensive fee report 70th percentile, unless otherwise stated in this Chapter:

1. 73 percent for diagnostic oral evaluation services;

2. 70 percent for the following periodic diagnostic and preventive services:

a. radiographs-periapical, first film;

b. radiograph-periapical, each additional film;

c. radiograph-panoramic film;

d. prophylaxis-adult and child;

e. topical application of fluoride, 0-15 years of age (prophylaxis not included); and

f. topical fluoride varnish, therapeutic application for moderate to high caries risk patients (under 6 years of age); and

3. 65 percent for the remainder of the dental services.

E. Effective for dates of service on or after August 1, 2010, the reimbursement fees for EPSDT dental services shall be reduced to the following percentages of the 2009 National Dental Advisory Service comprehensive fee report 70th percentile, unless otherwise stated in this Chapter:

1. 69 percent for the following oral evaluation services:

a. periodic oral examination;

b. oral examination-patients under three years of age; and

c. comprehensive oral examination-new patient;

2. 65 percent for the following annual and periodic diagnostic and preventive services:

a. radiographs-periapical, first film;

b. radiograph-periapical, each additional film;

c. radiograph-panoramic film;

d. prophylaxis-adult and child;

e. topical application of fluoride-adult and child (prophylaxis not included); and

f. topical fluoride varnish, therapeutic application for moderate to high caries risk patients (under 6 years of age);

3. 50 percent for the following diagnostic and adjunctive general services:

a. oral/facial images;

b. non-intravenous conscious sedation; and

c. hospital call; and

4. 58 percent for the remainder of the dental services.

F. Removable prosthodontics and orthodontic services are excluded from the August 1, 2010 rate reduction.

G. Effective for dates of service on and after January 1, 2011, the reimbursement fees for EPSDT dental services shall be reduced to the following percentages of the 2009 National Dental Advisory Service comprehensive fee report 70th percentile, unless otherwise stated in this Chapter:

1. 67.5 percent for the following oral evaluation services:

a. periodic oral examination;

b. oral Examination-patients under 3 years of age; and

c. comprehensive oral examination-new patients;

2. 63.5 percent for the following annual and periodic diagnostic and preventive services:

a. radiographs-periapical, first film;

b. radiographs-periapical, each additional film;

c. radiographs-panoramic film;

d. diagnostic casts;

e. prophylaxis-adult and child;

f. topical application of fluoride, adult and child (prophylaxis not included); and

g. topical fluoride varnish, therapeutic application for moderate to high caries risk patients (under 6 years of age);

3. 73.5 percent for accession of tissue, gross and microscopic examination, preparation and transmission of written report;

4. 70.9 percent for accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report;

5. 50 percent for the following diagnostic and adjunctive general services:

a. oral/facial image;

b. non-intravenous conscious sedation; and

c. hospital call; and

6. 57 percent for the remainder of the dental services.

H. Removable prosthodontics and orthodontic services are excluded from the January 1, 2011 rate reduction.

I. Effective for dates of service on or after July 1, 2012, the reimbursement fees for EPSDT dental services shall be reduced to the following percentages of the 2009 National Dental Advisory Service comprehensive fee report 70th percentile, unless otherwise stated in this Chapter:

1. 65 percent for the following oral evaluation services:

a. periodic oral examination;

b. oral examination-patients under three years of age; and

c. comprehensive oral examination-new patients;

2. 62 percent for the following annual and periodic diagnostic and preventive services:

a. radiographs-periapical, first film;

b. radiographs-periapical, each additional film;

c. radiographs-panoramic film;

d. diagnostic casts;

e. prophylaxis-adult and child;

f. topical application of fluoride, adult and child (prophylaxis not included); and

g. topical fluoride varnish, therapeutic application for moderate to high caries risk patients (under six years of age);

3. 45 percent for the following diagnostic and adjunctive general services:

a. oral/facial image;

b. non-intravenous conscious sedation; and

c. hospital call; and

4. 56 percent for the remainder of the dental services.

J. Removable prosthodontics and orthodontic services are excluded from the July 1, 2012 rate reduction.

K. Effective for dates of service on or after August 1, 2013, the reimbursement fees for EPSDT dental services shall be reduced by 1.5 percent of the rate on file July 31, 2013, unless otherwise stated in this Chapter.

1. The following services shall be excluded from the August 1, 2013 rate reduction:

a. removable prosthodontics; and

b. orthodontic services.

L. Effective for dates of service on or after July 1, 2023, the reimbursement rates for EPSDT dental services shall be reimbursed based on the Louisiana Medicaid fee schedule. All rates in the fee schedule are published on the Medicaid provider website at www.lamedicaid.com.

1. Implementation of these rates is subject to approval by the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services.

Implementation of the provisions of this Rule may be contingent upon the approval of the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS), if it is determined that submission to CMS for review and approval is required.

La. Admin. Code tit. 50, § XV-6905

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 33:1138 (June 2007), amended LR 34:1032 (June 2008), amended by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 35:1890 (September 2009), LR 36:2040 (September 2010), LR 37:1598 (June 2011), LR 39:1048 (April 2013), LR 40:1007 (May 2014), Amended by the Department of Health, Bureau of Health Services Financing, LR 49, Amended LR 491214 (7/1/2023).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.