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Important Medicaid Updates

Former NYCDS President Edward Miller proposed that dentists should be able to provide smoking cessation counseling and get reimbursed for it. NYS Medicaid has expanded smoking cessation counseling to allow for an unlimited number of sessions. Read More

MEDICAID COVERAGE UPDATES: 

Expansion of Smoking Cessation Counseling 

Silver Diamine Fluoride Covered

We are pleased to report that an initiative spearheaded by former NYCDS President Edward Miller has been adopted by NYS Medicaid. Dr. Miller proposed that dentists should be able to provide smoking cessation counseling and get reimbursed for it. NYS Medicaid has expanded smoking cessation counseling to allow for an unlimited number of sessions. Details below.

Effective August 1, 2020, for Medicaid fee-for-service (FFS) and November 1, 2020, for Medicaid Managed Care (MMC), New York State Medicaid is expanding smoking cessation counseling (SCC) sessions to allow for as many sessions as medically necessary for all Medicaid members. Current coverage of smoking cessation counseling services will be modified to eliminate the limit of eight (8) SCC sessions per year.

For additional information regarding the smoking cessation counseling benefit, please refer to the following index of Medicaid Update topics: https://www.health.ny.gov/health_care/medicaid/program/update/medup-q-s.htm#smokingcess.

Questions:

Silver Diamine Fluoride (SDF) treatments are now covered by NYS Medicaid which can benefit children.

Effective August 1, 2020 for fee-for-service (FFS) and October 1, 2020, for Medicaid Managed Care (MMC) plans, the New York State (NYS) Medicaid program will begin coverage of silver diamine fluoride (SDF). This applies to MMC plans, including mainstream MMC plans, and HIV Special Needs Plans (HIV SNPs).

Clinical criteria for the use of SDF:

  • Stabilize non-symptomatic teeth with active carious lesion and no pulpal exposure

  • High caries risk (e.g. xerostomia, severe early childhood caries)

  • Treatment challenged by behavioral or medical management

  • Difficult to treat carious lesions

Criteria for reimbursement:

  • Covers individuals 0-20 years of age, inclusive.

  • For individuals 21 years of age and older, "D1354" is only approvable for those individuals identified with a recipient exception code of "RE 81" (TBI Eligible) or "RE 95" (Office for People With Developmental Disabilities/Managed Care Exemption).

  • Covers two (2) times per tooth within a 12-month period with a total of four (4) times per lifetime of the tooth.

  • Covers with topical application of fluoride ("D1206" or "D1208") when they are performed on the same date of service if "D1354" is being used to treat caries and "D1206" or "D1208" is being used to prevent caries.

  • Covers the application of SDF to five (5) teeth on the same date of service with more teeth considered in exceptional circumstances. Documentation supporting necessity must be submitted with the claim.

Providers are required to:

  • Fully disclose the risks and benefits of SDF use. Discuss treatment alternatives where appropriate. Obtain written consent.

The most common risks with the use of SDF should be highlighted to include:

  • Staining to treated lesion.

  • Staining to tooth colored restorations and crowns if SDF is applied to them (this color change is temporary and can be polished off).

  • Potential staining of clothes, skin, or gums if accidentally applied (staining of skin and gums will disappear in one to three weeks).

  • Metallic taste may occur (this will go away rapidly).

  • That if tooth decay is not arrested, the decay will progress, requiring reapplication of SDF, a filling, crown, possible root canal treatment, or extraction.

"D1354" interim caries arresting medicament application – per tooth $15.00

Conservative treatment of an active, non-symptomatic carious lesion by topical application of a caries arresting or inhibiting medicament and without mechanical removal of sound tooth structure.

Questions:

  • Questions regarding Medicaid FFS policy should be directed to the Office of Health Insurance Programs (OHIP), Division of Program Development and Management at(518) 473–2160, or dentalpolicy@health.ny.gov.

  • Questions regarding MMC reimbursement and/or documentation requirements should be directed to the enrollee's MMC
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