Dental benefits.

  1. Law
  2. Utah Code
  3. Utah Health Code
  4. Medical Assistance Act
  5. Medical Assistance Programs
  6. Dental benefits.

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Affected by 63I-1-226 on 7/1/2028

Effective 5/5/2021
26-18-2.6. Dental benefits.
  • (1)
    • (a) Except as provided in Subsection (8), the division may establish a competitive bid process to bid out Medicaid dental benefits under this chapter.
    • (b) The division may bid out the Medicaid dental benefits separately from other program benefits.
  • (2) The division shall use the following criteria to evaluate dental bids:
    • (a) ability to manage dental expenses;
    • (b) proven ability to handle dental insurance;
    • (c) efficiency of claim paying procedures;
    • (d) provider contracting, discounts, and adequacy of network; and
    • (e) other criteria established by the department.
  • (3) The division shall request bids for the program's benefits at least once every five years.
  • (4) The division's contract with dental plans for the program's benefits shall include risk sharing provisions in which the dental plan must accept 100% of the risk for any difference between the division's premium payments per client and actual dental expenditures.
  • (5) The division may not award contracts to:
    • (a) more than three responsive bidders under this section; or
    • (b) an insurer that does not have a current license in the state.
  • (6)
    • (a) The division may cancel the request for proposals if:
      • (i) there are no responsive bidders; or
      • (ii) the division determines that accepting the bids would increase the program's costs.
    • (b) If the division cancels a request for proposal or a contract that results from a request for proposal described in Subsection (6)(a), the division shall report to the Health and Human Services Interim Committee regarding the reasons for the decision.
  • (7)Title 63G, Chapter 6a, Utah Procurement Code, shall apply to this section.
  • (8)
    • (a) The division may:
      • (i) establish a dental health care delivery system and payment reform pilot program for Medicaid dental benefits to increase access to cost effective and quality dental health care by increasing the number of dentists available for Medicaid dental services; and
      • (ii) target specific Medicaid populations or geographic areas in the state.
    • (b) The pilot program shall establish compensation models for dentists and dental hygienists that:
      • (i) increase access to quality, cost effective dental care; and
      • (ii) use funds from the Division of Family Health and Preparedness that are available to reimburse dentists for educational loans in exchange for the dentist agreeing to serve Medicaid and under-served populations.
    • (c) The division may amend the state plan and apply to the Secretary of Health and Human Services for waivers or pilot programs if necessary to establish the new dental care delivery and payment reform model.
    • (d) The division shall evaluate the pilot program's effect on the cost of dental care and access to dental care for the targeted Medicaid populations.
  • (9)
    • (a) As used in this Subsection (9), "dental hygienist" means an individual who is licensed as a dental hygienist under Section 58-69-301.
    • (b) The department shall reimburse a dental hygienist for dental services performed in a public health setting and in accordance with Subsection (9)(c) beginning on the earlier of:
      • (i) January 1, 2023; or
      • (ii) 30 days after the date on which the replacement of the department's Medicaid Management Information System software is complete.
    • (c) The department shall reimburse a dental hygienist directly for a service provided through the Medicaid program if:
      • (i) the dental hygienist requests to be reimbursed directly; and
      • (ii) the dental hygienist provides the service within the scope of practice described in Section 58-69-801.
    • (d) Before November 30 of each year in which the department reimburses dental hygienists in accordance with Subsection (9)(c), the department shall report to the Health and Human Services Interim Committee, for the previous fiscal year:
      • (i) the number and geographic distribution of dental hygienists who requested to be reimbursed directly;
      • (ii) the total number of Medicaid enrollees who were served by a dental hygienist who were reimbursed under this Subsection (9);
      • (iii) the total amount reimbursed directly to dental hygienists under this Subsection (9);
      • (iv) the specific services and billing codes that are reimbursed under this Subsection (9); and
      • (v) the aggregate amount reimbursed for each service and billing code described in Subsection (9)(d)(iv).
    • (e)
      • (i) Except as provided in this Subsection (9), nothing in this Subsection (9) shall be interpreted as expanding or otherwise altering the limitations and scope of practice for a dental hygienist.
      • (ii) A dental hygienist may only directly bill and receive compensation for billing codes that fall within the scope of practice of a dental hygienist.




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