DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Prevention Services Division – Rules promulgated by the Colorado Board of Health SERVICE GRANTS FOR THE DENTAL ASSISTANCE PROGRAM 6 CCR 1015-8 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] _________________________________________________________________________

1.1 Definitions

1) "Advisory Committee" means the Dental Advisory Committee created in Section 25-21-107.5, C.R.S.

2) "Department" means the Department of Public Health and Environment 3) "Eligible Senior" means an adult who is eligible for old age pension dental assistance Program as defined in section 25-21-103, C.R.S.

4) "Qualified Grantee" means an entity that either provides comprehensive dental and oral health services or that can administer funds for such services through sub-grants, awards, or reimbursement processes that comply with the federal "Health Insurance Portability and Accountability Act of 1996", 42 U.S.C. sec. 1320d to 1320d-8.

5) "Service grant" means a grant awarded by the Department to a qualified grantee pursuant to this article.

1.2 Application requirements

1) At a minimum, all applications for service grants submitted to the Department shall contain the following information:

1. A) Compliance with the definition of "qualified grantee" as defined in Section 1.1(4).
2. B) Demonstrates an established relationship with or willingness to coordinate with local community organizations serving eligible seniors. Evidence of this relationship may be demonstrated by, but is not limited to, a Memorandum of Agreement with local community organizations serving eligible seniors or, minutes for regular meetings with local community organizations serving eligible seniors that will be submitted to the Department on a semi-annual basis.
3. C) Defined service area.
4. D) A plan for outreach to include:
   1. i. A plan for marketing the available services to eligible seniors within the defined service area; and ii. A plan for meeting needs of eligible seniors in contiguous service areas should they not be served by another qualified grantee.
5. E) A description of plan for verifying eligibility of seniors.
6. F) An operating budget that designates a procedure for prioritization of funds to meet the needs of those eligible seniors most in need.
7. G) A description of the applicant's ability to comply with and monitor the implementation of the grant requirements, which includes a statement whether the applicant will charge a copayment to eligible seniors and certifying that the copayment shall not exceed twenty percent of the cost of the services provided.
8. H) Demonstration of capacity to implement and administer the program specified in Section 2(1).

2) A successful applicant for participation in the program shall sign a contract with the Department or a Purchase Order with a scope of work that complies with the State's Procurement Rules in 24-101- 101 to 24-112-101, C.R.S.. The terms of the service grant contract/purchase order shall be determined by the Department and shall include, but need not be limited to, the following:

1. A) The total amount of grant to qualified grantee;
2. B) The qualified grantee's agreement to provide care to eligible seniors for the length of the grant;
3. C) The qualified grantee's agreement to provide the Department with semi-annual reports. At a minimum, the reports shall include:
   1. i. The number of eligible seniors served;
   2. ii. The types of dental and oral health services provided; and iii. The amount of co-payments charged and received.
4. D) Reasonable penalties and other enforcement remedies available to the Department in the event the qualified grantee breaches contract or purchase order;
5. E) The qualified grantee's agreement to notify the department if there is a decrease in eligible seniors served; and F) The time period of the grant.

1.3 Review of Application

1) The initial review will be done by the Department to determine whether the application is complete and to ensure the grantee meets the requirements of the definition previously stated in 1.1(4).

2) After initial review of applications, the dental advisory committee will review applications, and then submit their recommendations to the Department.

3) The Department will consider the recommendations made by the dental advisory committee, but is not bound by them. In the event the Department disagrees with the committee's findings, it will provide a written statement of its rationale to both the applicant and the committee for their reference.

Allowable Procedures and Fees for Dental Services 2.1 Effective October 30, 2012 and through such time that the Board of Health approves a new effective provider procedures and fee schedule, a qualified grantee, as defined in Section 1.1 of these regulations, may charge fees, not to exceed the maximum allowable fee, and perform the procedures for an eligible senior as set forth in Section 2.3.

2.2 Nothing in this part shall prohibit a qualified grantee from charging less than the allowable fee or reducing the amount of the patient co-payment set forth in Section 2.3. Any reduction in the amount of the patient co-payment shall be at the discretion of the qualified grantee.

2.3 TABLE OF ALLOWABLE PROCEDURES AND FEES

CDT 2007-2008 Procedure Description Maximum Allowable Program Payment Fee Diagnostic 0120 Periodic Oral Evaluation $ 20 $ 16 – Est. Pt.

0140 Limited Oral Evaluation $ 31 $ 25 0150 Comprehensive Oral $ 32 $ 26 Exam 0220, 0230 Periapical – single film; $ 12 $ 10

1. ea. Addtl 0270 Bitewing – single film $ 12 $ 10 0272 Bitewings – two films $ 19 $ 15 0273 Bitewings – three films $ 23 $ 18 0274 Bitewings – four films $ 27 $ 22 0210,0330 Full mouth (periapical or $ 53 $ 42 panorex)

0470 Diagnostic casts $ 44 $ 35 Preventive 1110 Prophylaxis (Adult) $ 38 $ 30 1204 Topical Fluoride (w/out $ 16 $ 13 prophy)

1206 Topical Fluoride Varnish $ 16 $ 13 Restorative 2140 Amalgam – one surface $ 27 $ 22 2150 Amalgam – two surfaces $ 55 $ 44 2160 Amalgam – three surfaces $ 82 $ 66 2161 Amalgam – four + $ 110 $ 88 surfaces 2330 Resin – one surface, $ 44 $ 35 anterior 2331 Resin – two surface, $ 88 $ 70 anterior 2332 Resin – three surface, $ 98 $ 78 anterior 2335 Resin – four surface, $ 133 $ 106 incisal angle 2391 Resin – one surface, $ 44 $ 35 posterior 2392 Resin – two surface, $ 88 $ 70 posterior 2393 Resin – three surface, $ 98 $ 78 posterior 2394 Resin – four surface, $ 133 $ 106 posterior Periodontics 4210 Gingivectomy/gingivopla $ 165 $ 132 sty (Four or more contiguous teeth)

4211 Gingivectomy/gingivopla $ 99 $ 79 sty (One to three contiguous teeth)

4341 Scaling and Root Planing $ 165 $ 132 4355 Gross Debridement $ 78 $ 62 Prosthetics (Patient co-pay for these services are not to exceed 10%) 5110 Complete denture, $ 781 $ 703 maxillary 5120 Complete denture, $ 781 $ 703 mandibular 5211 Partial denture, maxillary $ 594 $ 535 – resin 5212 Partial denture, $ 594 $ 535 mandibular – resin 5510, 5610 Repair broken $ 99 $ 89 denture/partial base 5520, 5640 Replace missing or $ 89 $ 80 broken teeth 5630 Replace or repair broken $ 129 $ 116 clasp 5650 Add tooth to partial $ 109 $ 98 5660 Add clasp to partial $ 135 $ 122 5710, 5711 Rebase complete denture $ 282 $ 254 5720, 5721 Rebase partial denture $ 282 $ 254 5730, 5731, Reline denture – chair- $ 180 $ 162 side 5740, 5741 Reline partial – chair-side $ 180 $ 162 5750, 5751 Reline denture – $ 229 $ 206 laboratory 5760, 5761 Reline partial – $ 229 $ 206 laboratory Oral Surgery 7140 Extraction erupted tooth $ 79 $ 71 or exposed root 7210 Surgical removal of $ 135 $ 121 erupted tooth 7250 Surgical removal of $ 128 $ 115 residual tooth roots 7286 Biopsy, soft tissue $ 129 $ 103 7310 Alveoloplasty $ 120 $ 96 (w/extractions) (Four or more teeth)

7311 Alveoloplasty $ 110 $ 99 (w/extractions)

7320 Alveoloplasty (w/out $ 120 $ 96 extractions)(Four or more teeth)

7321 Alveoloplasty (w/out $ 110 $ 99 extractions)

7510 Incision and drainage of $ 95 $ 86 abscess 9110 Palliative treatment – $ 49 $ 44 minor procedure _________________________________________________________________________ Editor’s Notes History Sections 2.1 – 2.3 eff. 12/30/2008.

Entire rule eff. 10/30/2012.