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Ohio Department of Medicaid Proposes Changes to Dental Reimbursement and Coverage Rule

Client Alert
July 29, 2024

The Ohio Department of Medicaid is proposing amendments to Ohio Administrative Code rule 5160-5-01 to do all of the following:

  • Procedure Code Updates
    • Update covered services based on new procedure codes added to the 2024 American Dental Association Code on Dental Procedures and Nomenclature.
  • Frequency Limitations and Coverage Clarifications
    • Amend frequency limitations, coverage clarifications, and service descriptions for: Dental exams, Prophylaxis, Imaging, Pin retention, Re-cementing, Re-bonding, Orthodontic treatments, Biopsy, Application of fluoride varnish.
  • Imaging Payments
    • Allow reimbursement for multiple bitewings taken in conjunction with a panoramic image.
  • Vaccine Administration
    • Discontinue payment for the administration of COVID-19 and human papillomavirus vaccines.
  • Pin Retention
    • Reimburse pin retention per tooth, with a maximum of three pins per tooth.
  • Re-cementing and Re-bonding Crowns
    • Remove the frequency limit for re-cementing and re-bonding crowns.
  • Orthodontic Treatment Payments
    • Ensure payment for comprehensive orthodontic treatment (D8080) covers the initial placement visit and the first quarter of treatment.
    • Allows seven calendar quarters of periodic orthodontic treatment visits (D8670) per course of treatment.
    • Prohibits reimbursement for D8670 in the same quarter as D8080.
  • Partial Dentures
    • Removes the restriction stating "A partial denture with a resin base may be covered only for a patient younger than 19".
  • Dental Evaluations and Prophylaxis
    • Clarifies that periodic dental evaluations and dental prophylaxis are covered once per 180 days for several special groups, including but not limited to:
      • Pregnant women
      • Foster children
      • Employed individuals with disabilities, regardless of age
    • Prior Authorization (PA) Requirements
      • The PA Required column will indicate when procedures are paid by report.
      • Prohibits reimbursement for excisional biopsies of salivary glands in conjunction with another biopsy on the same date of service.
    • Topical Fluoride Varnish Application
      • Adds the Current Procedural Terminology code for "Application of topical fluoride varnish by a physician or other qualified health care professional when performed in a nondental clinic or facility setting".

There will be a hearing on these proposed rule changes August 12, 2024. Please contact BMD Healthcare Member Daphne Kackloudis at dlkackloudis@bmdllc.com for questions or to help you prepare comments on the rules.

Ohio Department of MedicaidMedicaidHealthcare
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Corporate Transparency Act to be Re-evaluated

February 28, 2025Recent federal rulings have impacted the enforceability of the Corporate Transparency Act (CTA), which took effect on January 1, 2024. While reporting requirements were briefly reinstated, FinCEN has now paused enforcement and is reevaluating the CTA. Businesses are no longer required to submit reports until further guidance is issued. For updates and legal counsel, contact BMD Member Blake Gerney.Client Alert

Ohio Recovery Housing Operators Beware: House Bill 58 Seeks to Make Major Changes

February 26, 2025Ohio House Bill 58 proposes significant changes to recovery housing oversight, granting ADAMH Boards authority to inspect and investigate recovery residences. The bill also introduces a Certificate of Need (CON) program, requiring state approval for major facility changes. OMHAS will assess applications based on cost, quality, accessibility, and financial feasibility. The bill also establishes a recovery housing residence fund to support inspections. For more information, contact BMD attorneys Daphne Kackloudis or Jordan Burdick.
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