Division of Medicaid and Medical Assistance

Statutory Authority: 31 Delaware Code, §512 (31 Del.C., §512)



Title XIX Medicaid State Plan, Early and Periodic Screening, Diagnostic, and Treatment Program

In compliance with the State's Administrative Procedures Act (APA - Title 29, Chapter 101 of the Delaware Code), and with 42CFR §447.205, and, under the authority of Title 31 of the Delaware Code, Chapter 5, Section 512, Delaware Health and Social Services (DHSS) / Division of Medicaid & Medical Assistance (DMMA) is proposing to amend the Title XIX Medicaid State Plan related to the reimbursement methodology for specialized dental services under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program.

Any person who wishes to make written suggestions, compilations of data, testimony, briefs or other written materials concerning the proposed new regulations must submit same to Sharon L. Summers, Policy & Program Development Unit, Division of Medicaid & Medical Assistance, 1901 North DuPont Highway, P.O. Box 906, New Castle, Delaware 19720-0906 by April 30, 2006.

The action concerning the determination of whether to adopt the proposed regulation will be based upon the results of Department and Division staff analysis and the consideration of the comments and written materials filed by other interested persons.

Summary of Proposed Amendment

Statutory Authority

• 42 CFR §441 Subpart B, Early and Periodic Screening, Diagnostic, and Treatment Services (EPSDT) of Individuals Under Age 21

• Social Security Act 1905(r), Early and Periodic Screening, Diagnostic, and Treatment Services

Amending the Following State Plan Page

Attachment 4.19-B, Page 19


The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) service is Medicaid's comprehensive and preventive child health program for individuals under the age of 21. EPSDT was defined by law as part of the Omnibus Budget Reconciliation Act of 1989 (OBRA 89) legislation and includes periodic screening, vision, dental, and hearing services. In addition, section 1905(r)(5) of the Social Security Act (the Act) requires that any medically necessary health care service listed at section 1905(a) of the Act be provided to an EPSDT recipient even if the service is not available under the State's Medicaid plan to the rest of the Medicaid population.

Summary of Proposed Amendment

To facilitate access to EPSDT dental services for Medicaid recipients and to facilitate provider participation in the program, DMMA proposes changes to its reimbursement methodology.

Traditionally, the Department of Public Health (DPH) reimbursed orthodontists for orthodontic care provided to Medicaid children under age 21. This state plan amendment (SPA) will enable the DMMA to assume that responsibility.

Currently, specialized dental services are reimbursed a percentage of charges for routine dental services. DMMA proposes to reimburse a fee-for-service under Medicaid for orthodontic related services.

The proposed amendment to the state plan is subject to approval by the Centers for Medicare and Medicaid Services (CMS).




Page 19

Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services are reimbursed as follows:

1. Screening services - fee-for-service.

2. Treatment services - fee-for-service.

3. Dental Treatment - reimburse a percentage of charges for routine dental services.

4. Specialized Dental Services - reimburse a percentage of charges for routine dental services (a) a percentage of charges for non-orthodontic related services and (b) a flat fee-for-service for orthodontic related services.

(a) Percentage of Charges for non-orthodontic services – The State pays 85% of billed charges for medically necessary non-orthodontic dental care, determined by: 1) the consideration that 65-70% of the usual & customary rate is nationally known to account for the dental provider’s actual costs; and, 2) an allowance of an additional mark-up to permit a reasonable and fair profit and as incentive for providers to participate in the Medicaid Program in order to create adequate access to dental care.

(b) Flat Fee-for-Service for orthodontic services – The State identifies three primary orthodontic-related services that encompass orthodontic reimbursement: 1) Pre-orthodontic treatment visit; 2) Comprehensive orthodontic treatment of the adolescent dentition; and, 3) Periodic orthodontic treatment visit. Rates for each orthodontic service are determined by adopting the 75th percentile of orthodontic rates paid by the Division of Public Health Special Dental Program, which, compare favorably to commercial coverage and encourage provider participation and adequate access to orthodontic care. Care provided outside of these three services will be reimbursed at a percentage of charges. Medicaid reimbursement for these three orthodontic services will be the lower of the submitted charges or the established Medicaid rate.

9 DE Reg. 1506 (04/01/06) (Prop.)