Sec. 10.09.05.04. Covered Services

A. The Program covers the following medically necessary dental services for participants younger than 21 years old, and effective January 1, 2017, eligible former foster care participants younger than 26 years old, including but not limited to the following:

(1) Emergency, preventive, diagnostic, and treatment services;

(2) Semiannual cleaning, fluoride treatment and examination;

(3) Pit and fissure sealants for the occlusal surfaces of posterior permanent teeth that are without decay;

(4) Orthodontic care for conditions which:

(a) Have adjusted case scores of at least 15 points on the Handicapping Labio-Lingual Deviations Index (HLD) Table No. 4; and

(b) Cause dysfunction due to a handicapping malocclusion that is supported by comprehensive pretreatment orthodontic records, which include at a minimum:

(i) Cephalometric head film with analysis;

(ii) Panoramic or full series periapical radiographs;

(iii) Extra-oral and intra-oral photographs;

(iv) Clinical summary with diagnosis;

(v) HLD score sheets from attending orthodontist; and

(vi) Treatment plan;

(5) Consultations for participants who meet the requirements of §A(1), (2), (3), or (4) of this regulation;

(6) Drugs dispensed or injectable drugs administered by the dentist within the limitations of COMAR 10.09.03;

(7) Oral Health assessment by an EPSDT certified provider, and if determined medically necessary, the application of fluoride varnish for children 9 months old through 5 years old;

(8) General anesthesia during dental procedures, when it is medically necessary; and

(9) Fluoride varnish.

B. The Program covers the following medically necessary dental services for pregnant participants and REM participants 21 years old or older:

(1) Periodic, limited, and comprehensive oral examinations;

(2) X-rays, including:

(a) Single first and each additional intraoral periapical film;

(b) Single, two, three, or four film bitewings, which are limited to:

(i) Two per patient per year for REM participants 21 years old or older; or

(ii) One per patient per year for pregnant participants 21 years old or older; and

(c) One panoramic radiographic image every 36 months;

(3) Prophylaxis for adults, which is limited to:

(a) One per patient per 3 months for REM participants 21 years old or older; or

(b) One per patient per 6 months for pregnant participants 21 years old or older;

(4) Topical application of fluoride, which is limited to:

(a) One application per patient per 6 months for REM participants 21 years old or older; or

(b) One application per patient per year for pregnant participants 21 years old or older;

(5) Amalgam restorations for permanent teeth for one, two, three, four, or more surfaces, which are limited to one identical restoration per tooth per 36 months;

(6) Resin restorations for anterior permanent teeth for one, two, three, four, or more surfaces or involving incisal angle, which are limited to one identical restoration per tooth per 36 months;

(7) Other restorative services including:

(a) Recementing of crowns, which is limited to two times for the same crown;

(b) Prefabricated stainless steel crown for permanent teeth;

(c) Fillings - sedative, interim or temporary filling; and

(d) Pin retention - per tooth, in addition to restoration;

(8) Pulp capping, direct and indirect, excluding final restoration;

(9) Gingovectomy or gingivoplasty - per quadrant, which is limited to two quadrants per year per patient;

(10) Periodontal scaling and root planning - per quadrant;

(11) Full mouth debridement, which is limited to one per patient per 2 years, and may not be completed on the same day as prophylaxis;

(12) Periodontal maintenance - following active periodontal therapy, which is limited to two per patient per year;

(13) Adjustment of complete maxillary and mandibular denture;

(14) Adjustment of partial maxillary and mandibular denture;

(15) Recementing of bridge, which is limited to two times for the same bridge;

(16) Extractions of:

(a) Coronal remnants for deciduous teeth; and

(b) Erupted tooth or exposed root;

(17) Biopsy of oral tissue, hard or soft;

(18) Alveoplasty, in conjunction or not in conjunction with extractions-per quadrant;

(19) Incision and drainage of abscess intraoral; and

(20) Palliative emergency treatment of dental pain that is not associated with recently rendered service.

C. As provided for in the budget, the Program covers the following medically necessary dental services, up to $800 per calendar year, for dual eligible participants who are 21 through 64 years old:

(1) Periodic, limited, and comprehensive oral examinations;

(2) X-rays, including:

(a) Single first and each additional intraoral periapical film limited to six per patient per 12 months;

(b) Single, two, three, or four film bitewings which is limited to one per patient per 12 months; and

(c) One panoramic radiographic image every 36 months;

(3) Prophylaxis for adults, which is limited to one per patient per 6 months;

(4) Amalgam restorations for permanent teeth for one, two, three, four, or more surfaces, which is limited to one identical restoration per tooth per 36 months;

(5) Resin restorations for anterior permanent teeth for one, two, three, four, or more surfaces or involving incisal angle, which are limited to one identical restoration per tooth per 36 months; and

(6) Simple or surgical extractions of an erupted tooth or roots.

D. The Program shall reimburse for covered services in §§A-C of this regulation if:

(1) The services are rendered in:

(a) The dentist’s office;

(b) The participant’s home;

(c) A general acute hospital;

(d) A skilled or intermediate care nursing facility;

(e) A free-standing clinic;

(f) An EPSDT certified provider’s office;

(g) An approved mobile dental unit; or

(h) A Medicare-certified ambulatory surgical center;

(2) The services are provided by the dentist or one of the following:

(a) Another licensed dentist in his employ;

(b) A dental hygienist or dental assistant, provided that the individual rendering the service is:

(i) In the dentist's employ or in the employ of a public health program;

(ii) Under general supervision; and

(iii) Within the scope of his training or certification for the purpose of assisting in the provision of dental services; or

(c) An EPSDT certified provider for the purpose of applying fluoride varnish;

(3) The services are clearly related to the participant’s individual dental care needs as ameliorative, diagnostic, curative, palliative, preventive, or rehabilitative services; and

(4) The services are adequately described on the participant’s dental care record.