Revision 18-2; Effective September 3, 2018

Dental services are those services provided by a dentist to preserve teeth and meet the medical needs of the member. Dental services must be provided by a dentist licensed by the State Board of Dental Examiners and enrolled as a Medicaid provider with Texas Medicaid & Healthcare Partnership (TMHP). The managed care organization (MCO) service coordinator arranges the needed dental services for STAR+PLUS Home and Community Based Services (HCBS) program members with licensed and enrolled dentists.

The MCO must discuss with the STAR+PLUS HCBS program member any available resources to cover the expense of dental services and consider those resources before authorizing dental services through STAR+PLUS HCBS program. If dental services are on the individual service plan (ISP), the MCO must authorize and coordinate a referral to a dental provider within 90 days of request by the member, unless there is documentation that the member requested a later date.

6510 Allowable Dental Services

Revision 18-2; Effective September 3, 2018

Allowable dental services include:

  • emergency dental treatment procedures necessary to control bleeding, relieve pain and eliminate acute infection;
  • preventative procedures required to prevent the imminent loss of teeth;
  • treatment of injuries to the teeth or supporting structures;
  • dentures and the cost of fitting and preparing for dentures, including extractions, molds, etc.; and
  • routine and preventative dental treatment.

The managed care organization (MCO) must ensure dental requests meet the criteria for allowable services before authorizing services, except in an emergency situation. Dental services are provided by STAR+PLUS Home and Community Based Services (HCBS) program when no other financial resource for such services is available and when all other available resources, with the exception of value-added services (VAS). VAS are not required to be used prior to waiver services. VAS vary by MCO.

The state allows a member to select a relative or legal guardian, other than a spouse, to be the member's provider for this service if the relative or legal guardian meets the requirements to provide this type of service. Payments for dental services are not made for cosmetic dentistry.

The annual cost limit of this service is $5,000 per individual service plan (ISP) year. The $5,000 cap may be waived by the MCO upon request of the member only when the services of an oral surgeon are required.

6520 Documentation of Dental Services by a Dentist

Revision 21-2; Effective August 1, 2021

The managed care organization (MCO) or its contractor must ensure all requests for dental treatments include documentation by a professional dentist of the need for dental services. A dentist must determine the medical necessity (MN) for dental treatment and submit a detailed treatment plan to the MCO to document the MN and all specific dental procedures to be completed. The dentist may not bill the STAR+PLUS Home and Community Based Services (HCBS) program member for the remainder of the cost over the approved amount.

Form H1700-2, Individual Service Plan – Addendum, must be completed by the MCO to document the medical need for requested STAR+PLUS HCBS program items or services. MN for dental services is completed by the professional dentist, as described above.

6530 Time Frames for Initiation of Dental Services

Revision 20-1; Effective March 16, 2020

The managed care organization (MCO) must work with the member to identify a dental provider or contracted provider no later than the first day of the member’s individual service plan (ISP). The MCO must send an authorization to the dentist within seven days of receipt of the dental treatment plan. Services must be initiated within 90 days of treatment plan development unless the member or dentist has a documented preference for a later initiation date.