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HF 1151

as introduced - 89th Legislature (2015 - 2016) Posted on 04/07/2015 12:28pm

KEY: stricken = removed, old language.
underscored = added, new language.
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A bill for an act
relating to human services; modifying medical assistance coverage and
reimbursement for dental services; authorizing development of a new dental
reimbursement system; convening a work group on oral health system
administrative simplification; covering basic dental screenings performed
by dental hygienists and dental therapists; appropriating money; amending
Minnesota Statutes 2014, sections 256B.0625, subdivisions 9, 14; 256B.76,
subdivision 2.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:

Section 1.

Minnesota Statutes 2014, section 256B.0625, subdivision 9, is amended to
read:


Subd. 9.

Dental services.

(a) Medical assistance covers dental services.

(b) Medical assistance dental coverage for nonpregnant adults is limited to the
following services:

(1) comprehensive exams, limited to once every deleted text beginfivedeleted text endnew text begin threenew text end years;

(2) periodic exams, limited to one per year;

(3) limited exams;

(4) bitewing x-rays, limited to one per year;

(5) periapical x-rays;

(6) panoramic x-raysnew text begin or full-mouth series of x-rays, if panoramic x-rays cannot be
taken
new text end, limited to deleted text beginonedeleted text endnew text begin oncenew text end every five years except (1) when medically necessary for the
diagnosis and follow-up of oral and maxillofacial pathology and trauma or (2) once every
two years for patients who cannot cooperate for intraoral film due to a developmental
disability or medical condition that does not allow for intraoral film placement;

(7) prophylaxis, limited to one per year;

(8) application of fluoride varnish, limited to one per year;

(9) posterior fillings, all at the amalgam rate;

(10) anterior fillings;

(11) endodontics, limited to root canals on the anterior and premolars only;

(12) removable prostheses, each dental arch limited to one every six years;

(13) oral surgery, limited to extractions, biopsies, and incision and drainage of
abscesses;

(14) palliative treatment and sedative fillings for relief of pain; deleted text beginand
deleted text end

(15) full-mouth debridement, limited to one every five yearsnew text begin; and
new text end

new text begin (16) nonsurgical treatment for periodontal disease, including scaling, root planing,
and routine periodontal maintenance procedures, limited to once per year
new text end.

(c) In addition to the services specified in paragraph (b), medical assistance
covers the following services for adults, if provided in an outpatient hospital setting or
freestanding ambulatory surgical center as part of outpatient dental surgery:

(1) periodontics, limited to periodontal scaling and root planing once every deleted text begintwo
years
deleted text endnew text begin yearnew text end;

(2) general anesthesia; and

deleted text begin (3) full-mouth survey once every five years
deleted text end

new text begin (3) a comprehensive oral examination and full-mouth series of x-raysnew text end.

(d) Medical assistance covers medically necessary dental services for children and
pregnant women. The following guidelines apply:

(1) posterior fillings are paid at the amalgam rate;

(2) application of sealants are covered once every five years per permanent molar for
children only;

(3) application of fluoride varnish is covered once every six months; and

(4) orthodontia is eligible for coverage for children only.

(e) In addition to the services specified in paragraphs (b) and (c), medical assistance
covers the following services for adults:

(1) house calls or extended care facility calls for on-site delivery of covered services;

(2) behavioral management when additional staff time is required to accommodate
behavioral challenges and sedation is not used;

(3) oral or IV sedation, if the covered dental service cannot be performed safely
without it or would otherwise require the service to be performed under general anesthesia
in a hospital or surgical center; and

(4) prophylaxis, in accordance with an appropriate individualized treatment plan, but
no more than four times per year.

(f) The commissioner shall not require prior authorization for the services included
in paragraph (e), clauses (1) to (3), and shall prohibit managed care and county-based
purchasing plans from requiring prior authorization for the services included in paragraph
(e), clauses (1) to (3), when provided under sections 256B.69, 256B.692, and 256L.12.

Sec. 2.

Minnesota Statutes 2014, section 256B.0625, subdivision 14, is amended to read:


Subd. 14.

Diagnostic, screening, and preventive services.

(a) Medical assistance
covers diagnostic, screening, and preventive services.

(b) "Preventive services" include services related to pregnancy, including:

(1) services for those conditions which may complicate a pregnancy and which may
be available to a pregnant woman determined to be at risk of poor pregnancy outcome;

(2) prenatal HIV risk assessment, education, counseling, and testing; and

(3) alcohol abuse assessment, education, and counseling on the effects of alcohol
usage while pregnant. Preventive services available to a woman at risk of poor pregnancy
outcome may differ in an amount, duration, or scope from those available to other
individuals eligible for medical assistance.

(c) "Screening services" include, but are not limited todeleted text begin,deleted text endnew text begin:new text end

new text begin (1) new text endblood lead testsdeleted text begin.deleted text endnew text begin; and
new text end

new text begin (2) oral health screenings, as defined by the Association of State and Territorial
Dental Directors (ASTDD), conducted by a licensed dental provider in collaborative
practice under section 150A.10, subdivision 1a, 150A.105, or 150A.106, to determine an
enrollee's need to be seen by a dentist for diagnosis and assessment to identify possible
signs of oral or systemic disease, malformation, or injury and the potential need for
referral for diagnosis and treatment. For purposes of this paragraph, oral health screenings
are limited to once per year, and the provider performing the screening must have an
agreement in effect that refers those needing necessary follow-up care to a licensed dentist
where the necessary care is provided.
new text end

(d) The commissioner shall encourage, at the time of the child and teen checkup or
at an episodic care visit, the primary care health care provider to perform primary caries
preventive services. Primary caries preventive services include, at a minimum:

(1) a general visual examination of the child's mouth without using probes or other
dental equipment or taking radiographs;

(2) a risk assessment using the factors established by the American Academies
of Pediatrics and Pediatric Dentistry; and

(3) the application of a fluoride varnish beginning at age one to those children
assessed by the provider as being high risk in accordance with best practices as defined by
the Department of Human Services. The provider must obtain parental or legal guardian
consent before a fluoride varnish is applied to a minor child's teeth.

At each checkup, if primary caries preventive services are provided, the provider must
provide to the child's parent or legal guardian: information on caries etiology and
prevention; and information on the importance of finding a dental home for their child
by the age of one. The provider must also advise the parent or legal guardian to contact
the child's managed care plan or the Department of Human Services in order to secure a
dental appointment with a dentist. The provider must indicate in the child's medical record
that the parent or legal guardian was provided with this information and document any
primary caries prevention services provided to the child.

Sec. 3.

Minnesota Statutes 2014, section 256B.76, subdivision 2, is amended to read:


Subd. 2.

Dental reimbursement.

(a) Effective for services rendered on or after
deleted text beginOctober 1, 1992, the commissioner shall make payments for dental services as follows:
deleted text end

deleted text begin (1) dental services shall be paid at the lower of (i) submitted charges, or (ii) 25
percent above the rate in effect on June 30, 1992; and
deleted text end

deleted text begin (2) dental rates shall be converted from the 50th percentile of 1982 to the 50th
percentile of 1989, less the percent in aggregate necessary to equal the above increases.
deleted text end

deleted text begin (b) Beginning October 1, 1999, the payment for tooth sealants and fluoride treatments
shall be the lower of (1) submitted charge, or (2) 80 percent of median 1997 charges.
deleted text end

deleted text begin (c) Effective for services rendered on or after January 1, 2000, payment rates for
dental services shall be increased by three percent over the rates in effect on December
31, 1999.
deleted text end

deleted text begin (d) Effective for services provided on or after January 1, 2002, payment for
diagnostic examinations and dental x-rays provided to children under age 21 shall be the
lower of (1) the submitted charge, or (2) 85 percent of median 1999 charges.
deleted text end

deleted text begin (e) The increases listed in paragraphs (b) and (c) shall be implemented January 1,
2000, for managed care.
deleted text end new text begin July 1, 2015, payment rates for dental services shall be paid at
the lower of (1) submitted charges; or (2) 50 percent of the 90th percentile of 2012 charges
submitted for the applicable CPT code. This rate does not apply to state-operated dental
clinics under paragraph (b).
new text end

deleted text begin (f)deleted text endnew text begin (b)new text end Effective for dental services rendered on or after October 1, 2010, by a
state-operated dental clinic, payment shall be paid on a reasonable cost basis that is based
on the Medicare principles of reimbursement. This payment shall be effective for services
rendered on or after January 1, 2011, to recipients enrolled in managed care plans or
county-based purchasing plans.

deleted text begin (g) Beginning in fiscal year 2011,deleted text endnew text begin (c)new text end If the payments to state-operated dental clinics
deleted text beginin paragraph (f)deleted text end, including state and federal shares, are less than $1,850,000 per fiscal
year, a supplemental state payment equal to the difference between the total payments
in paragraph deleted text begin(f)deleted text endnew text begin (b)new text end and $1,850,000 shall be paid from the general fund to state-operated
services for the operation of the dental clinics.

deleted text begin (h) If the cost-based payment system for state-operated dental clinics described in
paragraph (f) does not receive federal approval, then state-operated dental clinics shall be
designated as critical access dental providers under subdivision 4, paragraph (b), and shall
receive the critical access dental reimbursement rate as described under subdivision 4,
paragraph (a).
deleted text end

deleted text begin (i) Effective for services rendered on or after September 1, 2011, through June 30,
2013, payment rates for dental services shall be reduced by three percent. This reduction
does not apply to state-operated dental clinics in paragraph (f).
deleted text end

deleted text begin (j) Effective for services rendered on or after January 1, 2014, payment rates for
dental services shall be increased by five percent from the rates in effect on December
31, 2013. This increase does not apply to state-operated dental clinics in paragraph (f),
federally qualified health centers, rural health centers, and Indian health services.
deleted text end

new text begin (d)new text end Effective January 1, deleted text begin2014deleted text endnew text begin 2016new text end, payments made to managed care plans and
county-based purchasing plans under sections 256B.69, 256B.692, and 256L.12 shall
reflect the payment deleted text beginincreasedeleted text endnew text begin ratenew text end described in deleted text beginthisdeleted text end paragraphnew text begin (a)new text end.

Sec. 4. new text beginNEW DENTAL REIMBURSEMENT SYSTEM FOR MINNESOTA
HEALTH CARE PROGRAMS.
new text end

new text begin Subdivision 1. new text end

new text begin Development of new reimbursement system. new text end

new text begin The commissioner of
human services shall provide a grant to a public higher education institution dental school
to develop a new payment reimbursement system for oral health and dental services for
persons enrolled in medical assistance and MinnesotaCare. The new system must be
designed to achieve the following objectives:
new text end

new text begin (1) adequately compensate providers for the reasonable costs of providing
covered services, including compensating for the added costs or reduced productivity
or profitability of serving low-income, underserved, disadvantaged, or special needs
patients and populations;
new text end

new text begin (2) create incentives for a comprehensive approach to overall oral health, including
greater prevention, early identification and treatment, and cost-efficient management of
chronic oral health disease;
new text end

new text begin (3) increase access to and utilization by low-income and underserved patients,
populations, and communities, including rural communities;
new text end

new text begin (4) define, measure, and reward quality oral health care;
new text end

new text begin (5) promote coordination of oral health services with other health care services;
new text end

new text begin (6) provide reimbursement for teledentistry and the use of portable equipment;
new text end

new text begin (7) reduce preventable utilization of hospital emergency departments for the
treatment of dental conditions; and
new text end

new text begin (8) reduce administrative burdens and complexities for participating providers and
the state.
new text end

new text begin Subd. 2. new text end

new text begin Oversight committee. new text end

new text begin The grantee shall develop the new reimbursement
system described in this section in consultation with a stakeholder oversight committee
representing oral health providers, federally qualified health centers, safety net providers,
health plan companies, county-based purchasing plans, public health agencies, the
commissioners of human services and health, and experts and researchers in oral health care
financing, care delivery, prevention, and disease management. Members of the committee
shall be appointed by the commissioner of human services, in consultation with the grantee.
new text end

new text begin Subd. 3. new text end

new text begin Pilot project. new text end

new text begin As part of the grant to develop a new reimbursement system,
the grantee, in consultation with the commissioner of human services and the oversight
committee, shall create a simulation model to test the new dental reimbursement system.
The simulation model shall be developed to provide a sufficient assessment of statewide
implementation of the new reimbursement system in terms of populations served, types
of providers, practice settings, and geographic locations. The amount of payments made
for dental services provided as part of this simulation must not exceed the amount of
payments that would have been paid out for the services covered and the enrollees served
under the current reimbursement system.
new text end

new text begin Subd. 4. new text end

new text begin Report. new text end

new text begin The grantee, in consultation with the commissioner of human
services, shall submit a report to the chairs and ranking minority members of the house
of representatives and senate health and human services policy and finance committees
by December 15, 2016. The report must:
new text end

new text begin (1) describe the proposed reimbursement system and the activities undertaken to
develop the reimbursement system;
new text end

new text begin (2) review the findings and conclusions of research and analysis, including a review of
dental reimbursement systems and models used by other states, communities, or countries;
new text end

new text begin (3) summarize the results of modeling and testing that were undertaken to determine
the impact of the new reimbursement system on various types of providers and settings; and
new text end

new text begin (4) include a process, timeline, and budget for implementing the new reimbursement
system.
new text end

Sec. 5. new text beginORAL HEALTH SYSTEM ADMINISTRATIVE SIMPLIFICATION.
new text end

new text begin (a) The commissioner of human services shall convene a work group of
representatives of health plans companies, county-based purchasing plans, dental benefit
administrators who administer dental coverage for persons enrolled in Minnesota public
health care programs, and dental providers, including private practicing dentists and
community dental clinics, to identify and implement changes to reduce the administrative
burdens, costs, and complexities experienced by dental providers through greater
simplification and uniformity of forms, policies, procedures, and requirements across all
health plan companies, county-based purchasing plans, and dental benefit administrators.
The commissioner shall ensure that the changes recommended and agreed to by the work
group are implemented and are in compliance with applicable state and federal laws
and regulations.
new text end

new text begin (b) The commissioner shall submit a report to the chairs and ranking minority
members of the house of representatives and senate health and human services policy and
finance committees by February 1, 2016, on the activities and actions of the work group,
including changes agreed to and implemented by the members of the work group. If the
commissioner determines that there are changes that have not been implemented, these
changes must be identified in the report. The report shall also identify any changes that
were agreed to that require a legislative change before implementation can occur.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective the day following final enactment.
new text end

Sec. 6. new text beginAPPROPRIATION.
new text end

new text begin $....... in fiscal year 2016 is appropriated from the general fund to the commissioner
of human services for a grant for purposes of developing and testing a new dental
reimbursement system for persons enrolled in Minnesota public health care programs.
new text end