Original Notice.

Preproposal statement of inquiry was filed as WSR 00-22-083.

Title of Rule: WAC 388-535-1230 Crowns.

Purpose: To clarify that Medicaid does not cover laboratory-processed, or specially fitted, crowns for posterior teeth. The department is reviewing and updating all of chapter 388-535 WAC, Dental-related services. However, there is an immediate need to clearly state in rule the policy regarding crowns (especially special crowns for posterior teeth), so the department is proposing to amend WAC 388-535-1230 Crowns, as soon as possible and amend the remainder of the chapter at a later date.

Statutory Authority for Adoption: RCW 74.08.090, 74.09.035, 74.09.500, 74.09.520.

Statute Being Implemented: RCW 74.09.500, 74.09.520, 42 U.S.C. 1396d(a), C.F.R. 440.100 and 440.225.

Summary: The department added language to this section to clarify that laboratory-processed (or specially fitted) crowns for posterior teeth are not covered. The department also rewrote subsections of this section to make them clearer, without changing policy.

Reasons Supporting Proposal: To clarify department policy regarding noncoverage for laboratory-processed, or specially fitted, crowns for posterior teeth, as well as clarify policy regarding coverage, prior authorization requirements for other crowns, and what is included in the reimbursement for crowns.

Name of Agency Personnel Responsible for Drafting: Ann Myers, DPS/RIP, P.O. Box 45533, Olympia, WA 98504-5533, (360) 725-1345; Implementation: Sharon Morrison, DHSQS, P.O. Box 45506, Olympia, WA 98504-5506, (360) 725-1671; Enforcement: Carree Moore, DPS/FSS, P.O. Box 45530, Olympia, WA 98504-5530, (360) 725-1653.

Name of Proponent: Department of Social and Health Services, Medical Assistance Administration, governmental.

Rule is necessary because of state court decision, letter from Wn. Thomas McPhee, Judge, re: Gonzales v. DSHS, Thurston County Cause No. 00-2-00839-0 and Well - Alphonso v. DSHS, Thurston County Cause No. 00-2-00469-6.

Explanation of Rule, its Purpose, and Anticipated Effects: The proposed rule clarifies that the department does not cover laboratory-processed, or specially fitted, crowns for posterior teeth. Although this is not a change in current policy, the policy is not stated clearly enough to avoid some confusion, so the proposed amendment is designed to clearly state department policy. The proposed rule also more clearly states current policy regarding coverage, prior authorization requirements for other crowns, and what is included in the reimbursement for crowns.

Proposal Changes the Following Existing Rules: The department added a statement to the rule listed above to clarify that the department does not cover laboratory-processed, or specially fitted, crowns, for posterior teeth. Other subsections in WAC 388-535-1250 were rewritten to be clearer and more easily understood.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The department has analyzed the proposed rule, and concludes that because the proposed amendment does not change, but clarifies, current policy, there will be no more than a minor impact on the businesses affected by the rule.

RCW 34.05.328 does not apply to this rule adoption. The department has analyzed the proposed rule, and concludes that because it does not change, but clarifies, current policy, it does not meet the definition of a "significant legislative rule." However, the department did prepare an analysis for this rule. It is available by contacting Ann Myers, Regulatory Improvement Program Manager, Medical Assistance Administration, P.O. Box 45533, Olympia, WA 98504, (360) 725-1345.

Hearing Location: Lacey Government Center (behind Tokyo Bento Restaurant), 1009 College Street S.E., Room 104-B, Lacey, WA 98503, on February 27, 2001, at 10:00 a.m.

Assistance for Persons with Disabilities: Contact Kelly Cooper, Rules Coordinator, by February 20, 2001, phone (360) 664-6094, TTY (360) 664-6178, e-mail coopeKD@dshs.wa.gov.

Submit Written Comments to: Identify WAC Number, Kelly Cooper, Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 664-6185, by February 27, 2001.

Date of Intended Adoption: Not earlier than February 28, 2001.

January 24, 2001

Bonita H. Jacques, Chief

Office of Legal Affairs

(a) Stainless steel, and

(b) Nonlaboratory resin for primary anterior teeth.

(2) MAA does not cover laboratory-processed crowns for posterior teeth.

(3) MAA requires prior authorization for the following crowns, which are limited to single restorations for permanent anterior (upper and lower) teeth ((and require prior authorization by MAA)):

(a) Porcelain fused to a high noble metal;

(b) Porcelain fused to a predominately base metal;

(c) Porcelain fused to a noble metal;

(d) Porcelain with ceramic substrate;

(e) Full cast high noble metal;

(f) Full cast predominately base metal;

(g) Full cast noble metal; and

(h) Resin (laboratory).

(((3))) (4) Criteria for covered crowns as described in subsections (1) and (3) of this section:

(a) Crowns may be authorized when the ((tooth meets the criteria of)) crown is dentally necessary.

(b) Coverage is based upon a supportable five year prognosis that the client will retain the tooth if the tooth is crowned. The provider must submit the following client information:

(i) The overall condition of the mouth;

(ii) Oral health status;

(iii) Patient maintenance of good oral health status;

(iv) Arch integrity; and

(v) Prognosis of remaining teeth (that is, no more involved than periodontal case type II).

(c) Anterior teeth must show traumatic or pathological destruction to loss of at least one incisal angle.

(((4))) (5) The laboratory processed crowns described in subsection (((2))) (3) are covered:

(a) ((Are covered)) Only when a lesser service will not suffice because of extensive coronal destruction, and treatment is beyond intracoronal restoration;

(b) Only once per permanent tooth in a five year period;

(((b) Are covered))

(c) For endodontically treated anterior teeth only after satisfactory completion of the root canal therapy. Post-endodontic treatment X-rays must be submitted for prior authorization of these crowns((; and

(c) Including tooth and soft tissue preparation, amalgam or acrylic build-ups, temporary restoration, cement base, insulating bases, impressions, and local anesthesia; and

(d) Are covered when a lesser service will not suffice because of extensive coronal destruction, and treatment is beyond intracoronal restoration)).

(6) MAA reimburses only for covered crowns as described in subsections (1) and (3) of this section. The reimbursement is full payment; all of the following are included in the reimbursement and must not be billed separately:

(a) Tooth and soft tissue preparation;

(b) Amalgam or acrylic build-ups;

(c) Temporary restoration;

(d) Cement bases;

(e) Insulating bases;

(f) Impressions;

(g) Seating; and

(h) Local anesthesia.

[Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 USC 1396d(a), CFR 440.100 and 440.225. 99-07-023, 388-535-1230, filed 3/10/99, effective 4/10/99.]

Washington State Code Reviser's Office