Texas Child Medicaid Plans Undergo Significant Changes Effective
Alterations Impact Traditional Child Medical Plans While Exempting Foster Care and CHIP Plans
Texas, August 29, 2023 – In a move aimed at enhancing the efficiency and accessibility of healthcare for children, Texas is set to introduce several noteworthy modifications to its Child Medicaid plans effective September 1, 2023. These changes apply exclusively to Traditional Child Medical Plans and do not extend to Foster Care or CHIP (Children’s Health Insurance Program) Plans. The adjustments will affect all insurance providers catering to Child Medicaid patients in the state, including TMHP, MCNA, Dentaquest, and United Health Care.
Summary of the Key Changes:
Medically Necessary Services
Texas Medicaid MCOs are committed to providing all medically necessary, Medicaid-covered services to enrolled members. However, it’s crucial to note that administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may vary between MCOs and differ from traditional Medicaid (fee-for-service). Providers are urged to contact the specific MCO of the member for detailed information regarding these procedures.
Dental Preventive Services: Caries Arresting Medicament
One significant change involves the application of caries arresting medicament (procedure code D1354) for Texas Health Steps clients aged birth through six years. This benefit will be limited to once per lifetime per TID (A-T and 3, 14, 19, and 30) when performed by any provider in an office setting. Notably, procedure code D1354 will be denied if billed on the same date of service for the same TID as procedure code D1351 or D1352 by any provider. Providers have been reminded that only silver diamine fluoride may be used for procedure code D1354.
Dental Education and Counseling: Tobacco Counseling and Oral Hygiene Instruction
Tobacco counseling (procedure code D1320) is considered an integral part of all dental procedures and cannot be billed separately. Furthermore, oral hygiene instruction (procedure code D1330) is limited to services provided within the office setting
Reimbursement for Exceeding Benefit Limitations
Providers are now encouraged to submit documentation supporting medical necessity for dental services exceeding benefit limitations. This documentation should be maintained in the client’s medical record.
Preventive Procedure Codes: Important Changes
Several changes are set to be implemented for preventive procedure codes. The topical application fluoride (procedure codes D1206 or D1208) will now be limited to once every six months, regardless of the provider. Procedure codes D1110, D1120, D1206, and D1208 will be denied when billed as emergency claims.
Similarly, procedure codes D1110 and D1120 will no longer be reimbursed to orthodontists and oral maxillofacial surgeon providers. Procedure code D1208 will no longer be reimbursed to orthodontists, oral maxillofacial surgeons, and Texas Health Steps Dental Group providers for in-office services. Additionally, it will not be reimbursed to any provider for services rendered in inpatient and outpatient hospital settings.
Dental Sealants: Important Modifications
Several changes are now implemented for dental sealants as well. Procedure code D1351’s age range will be updated to include clients aged 1 through 20 years. Procedure codes D1351 and D1352 will be limited to once per lifetime, per TID, regardless of the provider.
On the same lines, reimbursement for procedure codes D1351 and D1352 will be on a per-tooth basis, with TID and surface identification (SID) required on the claim form. Procedure code D1351 will be denied if billed on the same date of service for the same permanent TID as procedure code D1352, by any provider. Similarly, procedure codes D1351 and D1352 will be denied if billed as emergency claims. Procedure code D1351 will no longer be reimbursed to orthodontists and oral maxillofacial surgeons.
Space Maintainers: Critical Updates
Space maintainers play a crucial role in preventing tooth movement for specific age groups. They are a benefit of Texas Medicaid in various situations.
- After the premature loss of a deciduous/primary first and/or second molar (TID A, B, I, and J) for clients aged 1 through 12 years (procedure codes D1510 and D1516).
- After the premature loss of a deciduous/primary first and/or second molar (TID K, L, S, and T) for clients aged 1 through 12 years (procedure codes D1510 and D1517).
- After the premature loss of a deciduous/primary second molar (TID A, J, K, and T) for clients aged 3 through 7 years (procedure code D1575).
Several key changes have been implemented for space maintainers. Procedure codes D1510, D1520, D1553, D1556, and D1575 are now limited to once per lifetime, per quadrant, by any provider. Other procedure codes D1516, D1517, D1526, and D1527 are limited to once per lifetime, per procedure code, by any provider.
Similarly, procedure code D1553 will be denied if procedure code D1510 was reimbursed within the previous rolling year, same quadrant, by the same provider. Procedure code D1551 will be denied if procedure code D1516 was reimbursed within the previous rolling year, by the same provider. Also, Procedure code D1552 will be denied if procedure code D1517 was reimbursed within the previous
These changes reflect a concerted effort to improve the quality of healthcare for children under Texas’s Medicaid program while maintaining a responsible and cost-effective approach. They aim to streamline the delivery of essential dental services and ensure that medical resources are allocated efficiently.
Parents and guardians of children covered by these plans are encouraged to communicate with their insurance providers and healthcare professionals to understand the implications of these changes on their child’s healthcare.
For more detailed information and guidance on these changes, practice administration is advised to contact their insurance providers. It’s essential to stay informed and ensure a smooth transition to the new dental preventive services benefits effective September 1, 2023.
References:
1. Texas Health Steps Dental Preventive Benefits to Change September 1, 2023
2. Correction to “Texas Health Steps Dental Preventive Benefits to Change September 1, 2023
