la-202609-afcab1b075: Adult Denture Program

Department of Health Bureau of Health Services Financing Adult Denture Program(LAC 50:XXV.101, 301, 303, 501, 503, 504, and 701) The Department of Health, Bureau of Health Services Financing proposes to amend LAC 50:XXV. Chapters 1 and 5 in the Medical Assistance Program as authorized by R.S. 36:254 and pursuant to Title XIX of the Social Security Act. This proposed Rule is promulgated in accordance with the provisions of the Administrative Procedure Act, R.S. 49:950 et seq. The Department of Health, Bureau of Health Services Financing proposes to amend the provisions governing the Adult Denture Program. Act 629 of the 2026 Regular Session of the Louisiana Legislature requires Medicaid to cover dental procedures when they are medically necessary for a Medicaid beneficiary to receive another Medicaid-covered service. This proposed Rule adds those provisions to the Louisiana Administrative Code. The proposed Rule text below has been drafted utilizing plain language principles to ensure clarity and accessibility for all users. It has also been reviewed and tested for compliance with web accessibility standards. Title 50 PUBLIC HEALTH—MEDICAL ASSISTANCE Part XXV. Adult Denture and Medically Integrated Dental Care Chapter 1.General Provisions §101.Prior Authorization A.The services specified in Chapter 5 of this Part are covered through the Adult Denture and Medically Integrated Dental Care Program (the Adult Dental Program). B.Prior authorization is required for: 1.adult denture services marked by an asterisk (*) in Section 501 of this Part; and 2.adult dental care that a treating provider determines is medically necessary for treating other Medicaid-covered health conditions, procedures or services. C.All prior authorization requests shall be sent to the beneficiary’s Dental Program Benefits Manager. AUTHORITY NOTE:Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act. HISTORICAL NOTE:Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 31:80 (January 2005), repromulgated LR 31:1589 (July 2005), amended by the Department of Health, Bureau of Health Services Financing, LR 52: Chapter 3.Provider Participation and Beneficiary Qualifications §301.Participation Requirement A.Provider participation is limited to dentists licensed and authorized to practice dentistry in the state of Louisiana and enrolled in the Medicaid Program as a dental provider. AUTHORITY NOTE:Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act. HISTORICAL NOTE:Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 31:80 (January 2005), repromulgated LR 31:1589 (July 2005), amended by the Department of Health, Bureau of Health Services Financing, LR 52: §303.Beneficiary Qualifications A.Medicaid beneficiaries who are 21 years of age and older and whose Medicaid coverage includes the full range of Medicaid services are eligible for the Adult Dental Program. B.The following beneficiaries are not eligible for the adult dental program: 1.beneficiaries whose Medicaid eligibility is limited to only the following Medicare Savings Program: a.Specified Low-Income Medicare Beneficiary (SLMB); b.Qualified individual (QI); c.Qualified Medicare Beneficiary (QMB); 2.adult beneficiaries who are certified for Medicaid in the Medically Needy Program; 3.pregnant women who are certified with presumptive eligibility; 4.any beneficiary 21 years or older whose Medicaid coverage does not include the full range of Medicaid benefits. AUTHORITY NOTE:Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act. HISTORICAL NOTE:Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 31:80 (January 2005), repromulgated LR 31:1589 (July 2005), amended by the Department of Health, Bureau of Health Services Financing, LR 52: Chapter 5.Covered Services §501.Adult Dental Services A.The following services are reimbursable under the Adult Dental Program: 1.comprehensive oral examination only in conjunction with denture construction*; 2.intraoral radiographs, complete series only in conjunction with denture construction*; 3. - 6.... 7.maxillary partial denture, resin base (including clasps in conjunction with an opposing full denture*; 8.mandibular partial denture, resin base (including clasps in conjunction with an opposing full denture*; 9. - 19.... 20.unspecified removable prosthodontic procedure, by report*; and 21.dental services that a treating provider determines is medically necessary to clear or prepare a beneficiary to receive a Medicaid-covered medical procedure or service*. AUTHORITY NOTE:Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act. HISTORICAL NOTE:Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 31:81 (January 2005), repromulgated LR 31:1589 (July 2005), amended by the Department of Health, Bureau of Health Services Financing, LR 52: §503.Denture Replacement and Denture Reline A.Only one complete or partial denture per arch is allowed in an eight-year period. The eight-year time period begins from the date that the previous complete or partial denture for the same arch was delivered. A combination of two complete or partial denture relines per arch or one complete or partial denture and one reline per arch is allowed in an eight-year period, as prior authorized by the bureau or its designee. B.... C.Cast partial dentures continue to be a noncovered service in the Adult Dental Program. AUTHORITY NOTE:Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act. HISTORICAL NOTE:Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 31:81 (January 2005), repromulgated LR 31:1589 (July 2005), amended by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 36:2039 (September 2010), amended by the Department of Health, Bureau of Health Services Financing, LR 52: §504.Medically Integrated Dental Services A.Effective for dates of services on or after January 1, 2027, coverage for procedures deemed medically necessary to support the treatment of a Medicaid-covered medical procedure are available when prior authorized. 1.Covered dental services under this provision are limited to services medically necessary to clear or prepare a beneficiary to receive a Medicaid-covered medical procedure. B.To be prior authorized, documentation must include exchange of information and care coordination between the treating medical professional (physician or other non-physician practitioner) and the furnishing dentist. Absent such coordination and documentation demonstrating a clinical relationship between the dental and covered medical services, the dental treatment shall not meet criteria for medically integrated dental services. AUTHORITY NOTE:Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act. HISTORY NOTE:Promulgated by the Department of Health, Bureau of Health Services Financing, LR 52: Chapter 7.Reimbursement §701.Fees A.Fees for these services shall be reimbursed as established in the Adult Dental Program fee schedule.