Revision 07-3


§19.1401 Dental Services


(a) The facility must assist residents in obtaining routine and 24-hour emergency dental care.

(1) At the time of admission, the facility must obtain the name of the resident's preferred dentist and record the name in the clinical record.
(2) At least annually, the facility must ask each resident and/or responsible party if they desire a dental examination at the resident's expense.
(3) The facility must make all reasonable efforts to arrange for a dental examination for each resident who desires one.
(4) The facility is not liable for the cost of the resident's dental care.
(5) Licensed-only facilities must maintain a list of local dentists for residents who require one.

(b) Medicaid-certified facilities also must provide or obtain from an outside resource, in accordance with §19.1906 of this title (relating to Use of Outside Resources), the following dental services to meet the needs of each resident:

(1) emergency dental services, which are limited to procedures necessary to control bleeding, relieve pain, and eliminate acute infection; operative procedures which are required to prevent the imminent loss of teeth; treatment of injuries to the teeth or supporting structures.
(A) Covered emergency dental procedures include, but are not limited to:
(i) alleviation of extreme pain in oral cavity associated with serious infection or swelling;
(ii) repair of damage from loss of tooth due to trauma (acute care only, no restoration);
(iii) open or closed reduction of fracture of the maxilla or mandible;
(iv) repair of laceration in or around oral cavity;
(v) excision of neoplasms, including benign, malignant and premalignant lesions, tumors and cysts;
(vi) incision and drainage of cellulitis;
(vii) root canal therapy. Payment is subject to dental necessity review and pre- and post-operative x-rays are required; and
(viii) extractions: single tooth, permanent; single tooth, primary; supernumerary teeth; soft tissue impaction; partial bony impaction; complete bony impaction; surgical extraction of erupted tooth or residual root tip.
(B) Routine restorative procedures are not considered emergency procedures. Dental services not covered include, but are not limited to:
(i) cleaning;
(ii) filling teeth with amalgam composite, glass ionomer, or any other restorative material;
(iii) cast or preformed crowns (capping);
(iv) restoration of carious or noncarious permanent or primary teeth, including those requiring root canal therapy;
(v) replacement or repositioning of teeth;
(vi) services to the alveolar ridges or periodontium of the maxilla and the mandible, except for procedures covered under subparagraph (A) of this paragraph; and
(vii) complete or partial dentures.
(2) assistance to the resident, if necessary:
(A) in making appointments, and
(B) by arranging for transportation to and from the dentist's office.
(3) prompt referral of residents with lost or damaged dentures to a dentist.
(4) coordination of dental services for pediatric residents age 12 months to 21 years, in accordance with Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) guidelines.

(c) Medicaid-certified facilities are not required to provide routine dental services.
(d) Payment for services provided on the teeth, gums, alveolar ridges, and supporting structures are not a benefit of the Texas Medicaid Program; however, recipients with applied income may use incurred medical expenses to pay for routine dental services and appliances.

§19.1402 Medicaid-Certified Nursing Facility Emergency Dental Services

(a) Emergency dental services. The Texas Department of Human Services (DHS) will reimburse nursing facilities the cost of emergency dental services provided to eligible Medicaid residents residing in Medicaid-contracted facilities or distinct parts.

(1) Recipients must be 21 years of age or older.
(2) Dental care for recipients under the age of 21 is covered under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program.
(3) Services reimbursed are subject to the limitations specified in §19.1401(b) of this title (relating to Dental Services).
(4) Emergency dental services may be provided only if the attending physician orders a dental consultation. See §19.1201 of this title (relating to Physician Services).

(b) Dental providers. Emergency dental services must be provided by a dentist licensed by the Texas State Board of Dental Examiners who, if not employed by the facility, contracts with the facility according to the specifications outlined in §19.1906 of this title (relating to Use of Outside Resources).
(c) Reimbursement for Emergency Dental Services. The cost of emergency dental services provided to eligible Medicaid residents residing in nursing facilities will be reimbursed to facilities, provided that the services are not reimbursable by the Medicaid claims processor or the EPSDT program.
(d) Payment of Claims.

(1) The facility must accept payment by DHS as payment in full for services. Neither the dentist nor the facility may charge an additional fee to the recipient, his family, or his trust fund, except that the dentist may charge the recipient for services that:
(A) the recipient requests; and
(B) are not reimbursable by the Texas Medical Assistance Program.
(2) Payments for emergency dental services are the lower of the:
(A) dentist's usual fee; or
(B) maximum fee as determined by the Texas Health and Human Services Commission (HHSC).
(3) DHS reimburses facilities for services properly rendered in accordance with applicable laws, regulations, and operational instructions. DHS may withhold or suspend payment for services that are not properly rendered.
(4) Nursing Facility Emergency Dental Services makes no payment for services that are available under any other Texas Medical Assistance Program.
(5) Complete and accurate claims for services must be received within 12 months from the date of service.
(6) Claims for services delivered before the effective date of this section must be submitted within 12 months of the effective date of this section.
(7) Adjustments to claims must be received by DHS's claims processor during the applicable 12-month period. Claims and adjustments rejected or denied during the 12-month period through no fault of the dentist may be paid upon approval by DHS.