E. Persons other than small businesses, non-small businesses, state, or local government entities ("person" means any individual, partnership, corporation, association, governmental entity, or public or private organization of any character other than an agency):
Other persons are expected to see an increase in revenue and out-of-pocket savings due to the expansion of services, but this increase cannot be measured with current data available on the quantity or types of services that individuals eligible under EPSDT and pregnant and postpartum women may require.
F. Compliance costs for affected persons:
The department does not expect compliance costs for UUSOD because it is only seeding the money, accounted for in SB 2 (2025), and not treating additional patients. There is a network of dentists or providers throughout the state to provide necessary dental care.
Further, the department does not expect additional compliance costs to other entities because there is only a change in funding the program from general funds to seed money provided by UUSOD.
G. Regulatory Impact Summary Table (This table includes only fiscal impacts the agency was able to measure. If the agency could not estimate an impact, it is excluded from this table but described in boxes A through F.)
Regulatory Impact Summary Table
H. Department head comments on fiscal impact and approval of regulatory impact analysis:
The Commissioner of the Department of Health and Human Services, Tracy S. Gruber, has reviewed and approved this regulatory impact analysis.
Citation Information
7. Provide citations to the statutory authority for the rule. If there is also a federal requirement for the rule, provide a citation to that requirement:
Public Notice Information
9. The public may submit written or oral comments to the agency identified in box 1.
A. Comments will be accepted until:
10. This rule change MAY become effective on:
NOTE: The date above is the date the agency anticipates making the rule or its changes effective. It is NOT the effective date.
Agency Authorization Information
Agency head or
designee and title:
Tracy S. Gruber, Commissioner
R414. Health and Human Services, Integrated Healthcare.
R414-49. Dental, Oral, and Maxillofacial Surgeons and Orthodontia.
R414-49-1. Authority and Purpose.
(1)(a) Sections 26B-1-213, 26B-3-108, and 26B-3-[108]208 authorize this rule. (b) A service provided under this rule is authorized by a federal Section 1115 waiver of Medicaid requirements approved by the Centers for Medicare and Medicaid Services. (2) This rule [provides a]defines the scope of dental, oral, and maxillofacial surgery and orthodontia services for Medicaid members[ in accordance with Section 26B-3-208].R414-49-2. Definitions.
Terms used in this rule are defined in Rule R414-1. Additionally:
(1) "Acute" means referring to a disease or illness of sudden onset and brief course, not chronic. ([1]2) "Anterior tooth" means tooth numbers: (a) 6 through 11;
(b) 22 through 27;
(c) C through H; and
(d) M through R.
(3) "Chronic" means a persistent condition in relation to a disease or illness. ([2]4)(a) "Dental service[s]" [whether furnished in a hospital, an office, a skilled nursing facility, or anywhere else, ]means a covered service[s] performed within the scope of a Medicaid-enrolled dental provider's license as defined in Title 58, Occupations and Professions. (b) A dental service may occur whether furnished in a hospital, an office, a skilled nursing facility, or elsewhere. (5) "Diagnosis" means the identification of a disease or condition. ([3]6) "Posterior tooth" means tooth numbers: (a) 1 through 5;
(b) 12 through 21;
(c) 28 through 32;
(d) A through B;
(e) I through L; and
(f) S through T.
(7) "PRISM" means Provider Reimbursement Information System for Medicaid. R414-49-3. Client Eligibility Requirements. (1) Comprehensive, preventive, and medically necessary diagnostic and treatment services are available to members eligible under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program. (2) Comprehensive dental benefits are available to adult members 21 years of age and older. (3) For individuals enrolled in the Emergency Services Program for Non-Citizens, coverage is limited to the treatment of a qualifying emergency dental condition as outlined in Subsection R414-49-5(5). R414-49-[3]4. [Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)]Program Access Requirements. (1) A Medicaid-enrolled provider who is also affiliated with the University of Utah School of Dentistry Medicaid Associated Provider Program shall perform each dental service. (2) A provider shall verify a member's eligibility for dental services through the Medicaid eligibility system on each date of service before the rendering of a dental or surgical procedure. (3) A provider shall determine the coverage, limitations, quantity limits, and prior authorization (PA) requirements for each service before delivery. (4) Any service requiring PA must obtain approval before the service is provided. Medicaid does not cover services provided without an approved PA. (5) A provider may verify the coverage of a particular service based on a member's enrollment eligibility status by using the PRISM Coverage and Reimbursement Code Look-up Tool found on the Utah Medicaid website. (6) Further details, clinical criteria, and guidance for the coverage of dental services are outlined in the Dental, Oral Maxillofacial, and Orthodontia Services Utah Medicaid Provider Manual. (7) To ensure member access, a provider must maintain accurate directory information in the PRISM portal, including specialty and linguistic capabilities. (8) Any dental service, including a medical necessity exception, is provided through a fee-for-service delivery system.[This section defines the scope of dental services available to a member who is eligible under the EPSDT program and includes comprehensive and preventive health care services. (1) Dental services shall only be available through a Medicaid-enrolled dental provider that complies with relevant laws and policy. (2) Dental services shall only be provided within the parameters of generally accepted standards of dental practice and may be subject to any limitation or exclusion established by Medicaid. (3) Dental services may be subject to any limitation or exclusion of medical necessity and utilization control considerations or conditions. (4) Medicaid shall reimburse up to one evaluation for each member each day, even if more than one provider is involved from the same office or clinic. Medicaid may not cover multiple exams for the same date of service. (5) Medicaid includes in the global payment, and may not reimburse separately, any denture adjustment performed by the original provider within six months of a member receiving a denture. (6) Medicaid may cover third-molar extractions when at least one of the third molars has documented pathology that requires extraction. By discretion, a provider may remove any remaining third molar during the same procedure. (7) Medicaid shall cover the treatment of a temporomandibular joint fracture but may not cover other temporomandibular joint treatments. (8) A laboratory or pathologist must submit a claim directly to Medicaid for payment of laboratory services. (9) Medicaid may not cover the following dental services: (a) cast crowns, porcelain fused to metal, on posterior permanent teeth or on primary teeth; (b) consultation or second opinions not requested by Medicaid; (d) extraction of primary teeth at or near the time of exfoliation, as evidenced by mobility or loosening of the teeth; (e) fixed bridges or pontics; (f) general anesthesia for removal of an erupted tooth; (q) temporary dentures or temporary stayplate partial dentures;(r) tooth transplantation; (s) treatment for temporomandibular joint syndrome, sequela, subluxation, or other therapies; and (t) services provided without prior authorization. (11) A Medicaid member may choose to upgrade a covered service to a non-covered service if the member assumes responsibility for the difference in fees for covered anterior stainless steel crowns that are deciduous to non-covered anterior stainless steel crowns with composite facings added or commercial or lab-prepared facings.] R414-49-[5]6. [Adult Members 21 Years of Age and Older and Not Eligible on the Basis of Pregnancy]Reimbursement Methodology. The department reimburses dental services as outlined in attachment 4.19-B of the Utah Medicaid State Plan, incorporated by reference in Rule R414-1.[This section defines the scope of dental services available to an adult member who is 21 years of age or older and not eligible on the basis of pregnancy. (1) Services are authorized by a federal waiver of Medicaid requirements approved by the Centers for Medicare and Medicaid Services and allowed under Section 1115 of the Social Security Act. (2)(a) Dental services shall only be available through an enrolled dental provider that complies with relevant laws and policy. (b) Dental services shall only be available through the University of Utah School of Dentistry and its associated in-state provider network. (3) Dental services shall only be provided within the parameters of generally accepted standards of dental practice and may be subject to any limitation or exclusion established by Medicaid. (4) Dental services may be subject to any limitation or exclusion of medical necessity and utilization control considerations or conditions. (5) Medicaid shall reimburse up to one evaluation for each member each day, even if more than one provider is involved from the same office or clinic. Medicaid may not cover multiple exams for the same date of service. (6) Medicaid includes in the global payment, and may not reimburse separately, any denture adjustment performed by the original provider within six months of a member receiving a denture. (7) Medicaid may cover third-molar extractions when at least one of the third molars has documented pathology that requires extraction. By discretion, a provider may remove any remaining third molar during the same procedure; (8) Medicaid shall cover the treatment of a temporomandibular joint fracture but may not cover other temporomandibular joint treatments. (9) A laboratory or pathologist must submit a claim directly to Medicaid for payment of laboratory services. (10) Medicaid may not cover the following dental services: (a) consultation or second opinions not requested by Medicaid; (c) extraction of primary teeth at or near the time of exfoliation, as evidenced by mobility or loosening of the teeth; (d) fixed bridges or pontics; (e) general anesthesia for removal of an erupted tooth; (g) limited orthodontic treatment, including removable appliance therapies; (h) nitrous oxide analgesia; (i) occlusal appliances, habit control appliances, or interceptive orthodontic treatment; (j) oral sedation for behavior management; (l) procedures such as arthrostomy, meniscectomy, or condylectomy; (m) pulpotomies or pulpectomies on permanent teeth, except in the case of an open apex; (n) removable appliances in conjunction with fixed banded treatment; (p) temporary dentures or temporary stayplate partial dentures; (q) tooth transplantation; (r) treatment for temporomandibular joint syndrome, sequela, subluxation, or other therapies; and (s) services provided without prior authorization. R414-49-6. Emergency Dental. This section defines the scope of dental services available to members who are otherwise eligible under the Medicaid program. (1) Emergency dental services shall only be available through a Medicaid-enrolled dental provider that complies with relevant laws and policy. (2)(a) An emergency dental service is the treatment of a sudden and acute onset of a dental condition that requires immediate treatment when delay in treatment would jeopardize or cause permanent damage to a person's dental or medical health. (b) An emergency dental service is limited to the treatment of: (ii) drainage of an abscess.] KEY: Medicaid
Date of Last Change: [April 1, 2025]2026 Notice of Continuation: May 29, 2024
Authorizing, and Implemented or Interpreted Law: 26B-1-213; 26B-3-108; 26B-3-208
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