D.C. Mun. Regs. tit. 29, § 964
964.1 Subject to requirements established in this section, the Department of Health Care Finance (DHCF) shall reimburse dental services provided to the following eligible populations:
(a) Medicaid beneficiaries under the age of twenty-one (21);
(b) Medicaid beneficiaries residing in intermediate care facilities for persons with intellectual and developmental disabilities (ICF/IDD) or enrolled in the 1915(c) Home and Community Based Waiver for Persons with Developmental Disabilities; or
(c) Medicaid beneficiaries twenty-one (21) years and over who do not live in an institution.
964.2 Medicaid beneficiaries under the age of twenty-one (21) shall be eligible to receive medically necessary dental services as a required component of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit.
964.3 Dental services for individuals under age twenty-one (21) shall be provided at intervals that meet reasonable standards of dental practice as determined by the DHCF after consultation with recognized dental organizations involved in child health.
964.4 Dental services for individuals under the age of twenty-one (21) shall include at a minimum, relief of pain and infections, restoration of teeth and maintenance of dental health.
964.5 Dental services shall not be limited to emergency services for EPSDT beneficiaries.
964.6 Medicaid beneficiaries under the age of twenty-one (21) shall be eligible to receive medically necessary orthodontic services subject to the requirements set forth in § 964.7.
964.7 Before delivering an orthodontic service, each provider shall request prior authorization. To be eligible for orthodontia services, the beneficiary's dental or orthodontia provider shall demonstrate that the beneficiary meets at least one (1) of the following criteria:
(a) Has an adjusted score greater than or equal to fifteen (15) on the Handicapping Labio-Lingual Deviation (HLS) Index;
(b) Exhibits one (1) or more of the following Automatic Qualifying Condition(s) that cause dysfunction due to a handicapping malocclusion and is supported by evidence in the beneficiary's treatment records:
(1) Cleft palate deformity;
(2) Cranio-facial anomaly;
(3) Deep impinging overbite:
(4) Crossbite of individual anterior teeth;
(5) Severe traumatic Deviation; or
(6) Overjet greater than nine millimeters (9 mm) or mandibular protrusion greater than three and one half millimeters (3.5 mm); or
(c) Has otherwise established a medical need for orthodontic treatment that is supported by comprehensive dental records including, but not limited to:
(1) Upper and lower study models;
(2) Cephalometric head film with analysis;
(3) Panoramic or full series periapical radiographs;
(4) Extra oral and intra oral photographs;
(5) Clinical summary with diagnosis; and
(6) Treatment plan.
964.8 Providers of dental services, with the exception of providers for children's fluoride varnish shall be dentists or dental hygienists working under the supervision of a dentist, who meet the following requirements:
(a) Provide services consistent with the scope of practice authorized pursuant to the District of Columbia Health Occupations Revisions Act of 1985, effective March 25, 1986 (D.C. Law 6-99; D.C. Official Code §§ 3-1201, et seq. (2007 Repl. & 2011 Supp.)); or consistent with the applicable professional practices act within the jurisdiction where services are provided; and
(b) Have a current District of Columbia Medicaid Provider Agreement that
authorizes the provider to bill for dental services for the covered populations.
964.9 A dental provider, primary care physician, or pediatrician may administer preventive fluoride varnish treatment to children, unless expressly prohibited by the scope of practice in the state where the physician is licensed.
964.10 Effective for services rendered on or after January 1, 2013, reimbursement for dental procedure codes for non-institutionalized adults shall be reduced. Reimbursement for dental services shall be made according to the District of Columbia Medicaid fee schedule available online at http://www.dc-medicaid.com and shall cover all services related to the procedure.
964.11 Medicaid beneficiaries residing in an ICF/IDD shall be eligible to receive medically necessary dental services.
964.12 Reimbursement for dental services provided to an ICF/IDD beneficiary shall be consistent with the District of Columbia Medicaid fee schedule for beneficiaries receiving dental services under the 1915 (c) Home and Community Based Waiver and available online at http://www.dc-medicaid.com and as described in 29 DCMR § 936.10.
964.13 Medicaid beneficiaries age twenty-one (21) years and over who do not live in an institution, shall be eligible to receive the following medically necessary dental services:
(a) General preventive services, including semi-annual routine cleaning and oral hygiene instruction;
(b) Emergency, surgical and restorative services including root canal treatment, limited to two (2) molars per year;
(c) Denture reline and rebase, limited to two (2) over a five (5) year period unless additional services are prior authorized;
(d) Complete radiographic survey, including full, panoramic and bitewing x-rays, limited to one (1) per year unless additional services are prior authorized;
(e) Periodontal scaling and root planing where the case is classified within the criteria established by the American Academy of Periodontology;
(f) Initial placement or replacement of a removal prosthesis where damage is due to circumstances beyond the beneficiary's control; and
(g) Removable partial prosthesis, subject to a recipient meeting conditions specified in the billing manual.
964.14 Medicaid beneficiaries age twenty-one (21) years and over shall not be eligible to receive the following services:
964.15 Any dental service for a beneficiary age twenty-one (21) years or older that does not live in an institution and requires inpatient hospitalization or general anesthesia shall be prior authorized by DHCF.
964.16 Definitions. For purposes of this section, the following terms shall have the meanings ascribed:
Beneficiary – An individual who is eligible to receive dental services under Public Welfare
DHCF programs, including Medicaid fee-for-service, managed care, and waivers.
Dental Hygienist – A person who is licensed as a dental hygienist pursuant to the District of Columbia Health Occupations Revisions Act of 1985, effective March 25, 1986 (D.C. Law 6-99; D.C. Official Code §§ 3-1201, et seq. (2007 Repl. & 2011 Supp.)) or licensed as a dental hygienist in the jurisdiction where the services are provided.
Dentist – A person who is licensed as a dentist pursuant to the District of Columbia Health Occupations Revisions Act of 1985, effective March 25, 1986 (D.C. Law 6-99; D.C. Official Code §§ 3-1201, et seq. (2007 Repl. & 2011 Supp.)) or licensed as a dentist in the jurisdiction where the services are provided.
Treatment Plan – A written plan that includes diagnostic findings and treatment recommendations resulting from a comprehensive evaluation of the dental health needs of a beneficiary with a developmental disability.
SOURCE: Final Rulemaking published at 50 DCR 7549 (September 5, 2003); as amended by Final Rulemaking published at 53 DCR 1699 (March 10, 2006); as amended by Final Rulemaking published at 54 DCR 5593 (June 8, 2007); as amended by Emergency and Proposed Rulemaking published at 58 DCR 7566 (August 19, 2011)[EXPIRED]; as amended by Final Rulemaking published at 59 DCR 2151(March 16, 2012); as corrected by Errata Notice published at 59 DCR 2297 (March 23, 2012); as amended by Final Rulemaking published at 60 DCR 6652 (May 10, 2013).