The benefit changes were effective September 30, 2011, and apply only to adults (age 21 and older), NOT to children. Additionally, the dental benefit changes will not apply to adults who live in nursing, intermediate care or mental retardation facilities or have other related conditions.
The state recognizes that limiting these services could result in serious health complications for some adults, and for that reason they are also implementing a benefit limit exceptions (BLE) process whereby the DPW may approve services affected by the dental limits. We recommend you visit DPW’s website for detailed information.
The managed care companies (MCOs) that administer MA under the “Health Choices” model, have to provide, at a minimum, the same coverage as the state. Since the changes are new, many of the MCOs have not decided if they might offer enhanced coverage as compared to the state. We recommend that you contact each company to verify their dental plans.
Medically necessary services not listed under the basic plan may be submitted for pre-authorization but such requests can be refused. You should carefully review those services listed on the DPW (Access or Health Choices) fee schedule as it applies to adults. You can then determine if the list of services will meet what you consider to be an acceptable level of care for your patients.