California § 14132.88 - Notwithstanding subdivision (h) of Section 14132 and to the extent funds are made

§ 14132.88. Notwithstanding subdivision (h) of Section 14132 and to the extent funds are made

(a) Notwithstanding subdivision (h) of Section 14132 and to the extent funds are made available in the annual Budget Act for this purpose, the following are covered benefits for beneficiaries 21 years of age or older under this chapter: (1) One dental prophylaxis cleaning per year. (2) One initial dental examination by a dentist. (b) The following are covered benefits for beneficiaries under 21 years of age under this chapter: (1) Two dental prophylaxis cleanings per year. (2) Two periodic dental examinations per year. (c) For persons 21 years of age or older, laboratory-processed crowns on posterior teeth are a covered benefit when medically necessary to restore a posterior tooth back to normal function based on the criteria specified in the Medi-Cal Dental Manual of Criteria. (d) Any prefabricated crown made from ADA-approved materials may be used on posterior teeth and may be reimbursed as a stainless steel crown. (e) Covered dental benefits and accompanying criteria for receipt of those dental benefits under the Medi-Cal program shall be identified in the Medi-Cal Dental Manual of Criteria. Notwithstanding subdivision (h) of Section 14132, the department shall evaluate all covered dental benefits, including those listed in this section and in the Medi-Cal Dental Manual of Criteria, for evidence-based practices consistent with the American Academy of Pediatric Dentistry and the American Dental Association guidelines. (f) (1) Except as provided in paragraph (2), the department shall require pretreatment radiograph documentation on posttreatment claims to establish the medical necessity for dental restorations. The pretreatment documentation required under this subdivision is intended to reduce fraudulent claims for unnecessary dental fillings. In order to avoid any undue barriers to accessing dental care, the department shall stipulate that the pretreatment radiograph documentation for posttreatment claims will be required only when there are four or more dental fillings being completed in any 12-month period. (2) For any beneficiary who is under four years of age, or who, regardless of age, has a developmental disability, as defined in subdivision (a) of Section 4512, radiographs or photographs that indicate decay on any tooth surface shall be considered sufficient documentation to establish the medical necessity for treatment provided. (3) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section, in whole or in part, by means of provider bulletins, plan letters, or other similar instructions, without taking regulatory action. (g) This section shall be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available.