Lifetime Limitation for Restorations and Stainless Steel Crowns

Back in August, a notice appeared on the TMHP website that Texas Medicaid was going to impose a lifetime limit for restorations and stainless steel crowns on September 1.

Lifetime limits

The notice said:

Effective for dates of service on or after September 1, 2018, lifetime limitations for restorations and stainless steel crowns will change for Texas Health Steps.

The lifetime limitation for restorations and stainless steel crowns for primary teeth may be reimbursed up to $149.12 per tooth ID.

The lifetime limitation for direct restorations and stainless steel crowns for anterior permanent teeth may be reimbursed up to $155.27 per tooth ID.

The lifetime limitation for direct restorations and stainless steel crowns for posterior permanent teeth may be reimbursed up to $155.27 per tooth ID.

This, of course, created a great deal of consternation amongst dentists and we received emails about this.

Correction published

However, later in August, a new notice clarifying the old one was published.

It said:

This is a correction to the article titled “Restorations and Stainless Steel Crowns Limitations Will Change for Texas Health Steps Effective September 1, 2018,” which was published on this website August 6, 2018.

The article indicated that, effective for dates of service on or after September 1, 2018, lifetime limitations for restorations and stainless steel crowns will change for Texas Health Steps. The article was intended to communicate that there will be a change in reimbursement for traditional Medicaid (Fee For Service) claims only, based on rate reductions effective for dates of service on or after September 1, 2018. The article does not represent a change in policy and is being corrected as follows:

Restorations and stainless steel crowns for primary teeth may be reimbursed up to $149.12 per tooth ID.

Direct restorations and stainless steel crowns for anterior permanent teeth may be reimbursed up to $155.27 per tooth ID.

Direct restorations and stainless steel crowns for posterior permanent teeth may be reimbursed up to $155.27 per tooth ID.

Providers must continue to submit claims in accordance with established guidelines.

Dental Managed Care Organizations (DMOs) will continue to administer claims in accordance with requirements outlined in the Uniform Managed Care Manual.

Providers may refer to the current Texas Medicaid Provider Procedures Manual, Children’s Services Handbook, subsection 4.2.2.3 “Therapeutic Services,” for additional information on dental therapeutic services.

Confirmation from an HHSC official

Some providers are wondering if this is a precursor to a similar change for DMOs, despite the second last paragraph above.

TDMR was able to speak to an HHSC official with knowledge of the situation.  They assured us that this lifetime limit is meant for the small percentage of Medicaid children that fall under fee-for-service and has nothing to do with DMOs.