AGENDA ITEM: 2.a - Texas Health and Human Services



00TO: Health and Human Services Commission Executive CouncilDATE:February 20, 2020 FROM:Manda Hall, MD, Associate Commissioner, Community Health Improvement DivisionAGENDA ITEM: 2.aSUBJECT: Oral Health Improvement Program BACKGROUND: ? Federal ? Legislative ? Other: Program InitiativeThe repeal of rules and new rules in Texas Administrative Code Title 25, Chapter 49, are necessary to accurately reflect program activities and functions of the Oral Health Improvement Program, due to changes implemented by Senate Bill 200 and Senate Bill 219, 84th Legislature, Regular Session, 2015. The proposal complies with Texas Government Code, §2001.039, regarding Agency Review of Existing Rules.The repealed rules included direct client services, which are no longer offered due to lack of funding, and any remaining dental services are provided by HHSC post transformation. The Oral Health Improvement Program remained at DSHS as a public health program that promotes oral health and reduces the burden of dental disease through evidence-based public health initiatives, including oral health education and preventive interventions. The program also conducts oral health surveillance activities, analyzes data from multiple sources, and disseminates findings to stakeholders. ISSUES AND ALTERNATIVES:There are no anticipated concerns for this rule proposal. STAKEHOLDER INVOLVEMENT:Stakeholders for the Oral Health Improvement Program include various organizations related to dentistry, public health, schools and school districts, nurses and other healthcare providers, home visitors, and community health workers. The draft rules were posted from October 4, 2019 to October 18, 2019, on the Health and Human Services Rulemaking webpage for informal review and shared with stakeholders. An informal comment was received, but no changes to the rules were recommended from the comment. FISCAL IMPACT:? None SERVICES IMPACT STATEMENT:The proposed rules should not impact the Health and Human Services client population, as the Oral Health Improvement Program has not provided direct services for many years. The program will continue to improve oral health across the state through evidence-based public initiatives.RULE DEVELOPMENT SCHEDULE:February 20, 2020Present to HHSC Executive CouncilJuly 2020Publish proposed rules in Texas Register August 2020Publish adopted rules in Texas RegisterAugust 2020Effective dateTITLE 25HEALTH SERVICESPART 1DEPARTMENT OF STATE HEALTH SERVICESCHAPTER 49ORAL HEALTH IMPROVEMENT PROGRAMSUBCHAPTER AGENERAL PROVISIONSPROPOSED PREAMBLEThe Executive Commissioner of the Texas Health and Human Services Commission (HHSC), on behalf of the Department of State Health Services (DSHS), proposes the repeal of §§49.1 - 49.10, 49.13 - 49.18, concerning the Oral Health Program; and new §§49.1 - 49.6, concerning the Oral Health Improvement Program.BACKGROUND AND PURPOSEThe purpose of the proposal is to repeal and replace Chapter 49, in accordance with Texas Government Code, §2001.039, regarding Agency Review of Existing Rules. The repeal and new rules are necessary to accurately reflect current program activities and functions of the Oral Health Improvement Program, due to changes implemented by Senate Bill 200 and Senate Bill 219, 84th Legislature, Regular Session, 2015. The repealed rules included direct client services, which are no longer offered due to lack of funding, and any remaining dental services are provided by HHSC post transformation. The Oral Health Improvement Program remains at DSHS as a public health program that promotes oral health and reduces the burden of dental disease through evidence-based public health initiatives, including oral health education and preventive interventions. The program also conducts oral health surveillance activities, analyzes data from multiple sources, and disseminates findings to stakeholders. SECTION-BY-SECTION SUMMARYThe proposed repeal of §§49.1 - 49.10, 49.13 - 49.18 removes language that included fee-for-service program information that is no longer in service. This language included details on how dentists could participate in the program, who could receive services, and how dentists were to be compensated. DSHS no longer provides direct services. Proposed new §49.1 describes the purpose and application of the Texas Oral Health Improvement Act, Texas Health and Safety Code, Chapter 43 (Act). Proposed new §49.2 provides definitions of terms used within the chapter. Proposed new §49.3 describes public oral health screening and surveillance activities to be conducted by the Oral Health Improvement Program across the State of Texas. Proposed new §49.4 describes that a memorandum of understanding is required to work with schools and school districts.Proposed new §49.5 describes program priorities that are determined based on data, research, public health principles, and other factors.Proposed new §49.6 describes implementation of program activities.FISCAL NOTEDonna Sheppard, Chief Financial Officer, has determined that for each year of the first five years that the rules will be in effect, enforcing or administering the rules does not have foreseeable implications relating to costs or revenues of state or local governments. GOVERNMENT GROWTH IMPACT STATEMENT DSHS has determined that during the first five years that the rules will be in effect:(1) the proposed rules will not create or eliminate a government program;(2) implementation of the proposed rules will not affect the number of DSHS employee positions;(3) implementation of the proposed rules will result in no assumed change in future legislative appropriations; (4) the proposed rules will not affect fees paid to DSHS; (5) the proposed rules will create new rules;(6) the proposed rules will repeal existing rules;(7) the proposed rules will not change the number of individuals subject to the rules; and(8) the proposed rules will not affect the state’s economy. SMALL BUSINESS, MICRO-BUSINESS, AND RURAL COMMUNITY IMPACT ANALYSIS Donna Sheppard, has also determined that there will be no adverse economic effect on small businesses, micro-businesses, or rural communities. The rules do not impose any additional costs on small businesses, micro-businesses, or rural communities that are required to comply with the rules.LOCAL EMPLOYMENT IMPACTThe proposed rules will not affect a local economy.COSTS TO REGULATED PERSONS Texas Government Code, §2001.0045 does not apply to these rules because the rules are necessary to protect the health, safety, and welfare of the residents of Texas; and does not impose a cost on regulated persons.PUBLIC BENEFIT AND COSTSManda Hall, M.D., Community Health Improvement Division Associate Commissioner, has determined that for each year of the first five years the rules are in effect, the public benefit will be to improve oral health across the state through evidence-based public health initiatives. Reducing the burden of dental disease improves school attendance and learning in children and improves work productivity and employability in adults. It also reduces dental-related emergency department visits. Donna Sheppard, has also determined that for the first five years the rules are in effect, there are no anticipated economic costs to persons who are required to comply with the proposed rules, because the rules do not impose any additional costs to participants in the Oral Health Improvement Program. TAKINGS IMPACT ASSESSMENTDSHS has determined that the proposal does not restrict or limit an owner's right to his or her property that would otherwise exist in the absence of government action and, therefore, does not constitute a taking under Texas Government Code, §2007.043. PUBLIC COMMENT Written comments on the proposal may be submitted to Brittany Akl, Program Operations Coordinator, P.O. Box 149347, Mail Code 1818, Austin, Texas 78714-4397; or by email to dental@dshs.; or by fax to (512) 776-7256. To be considered, comments must be submitted no later than 31 days after the date of this issue of the Texas Register. Comments must be: (1) postmarked or shipped before the last day of the comment period; (2) hand-delivered before 5:00 p.m. on the last working day of the comment period; or (3) faxed or emailed before midnight on the last day of the comment period. If last day to submit comments falls on a holiday, comments must be postmarked, shipped, or emailed before midnight on the following business day to be accepted. When faxing or emailing comments, please indicate "Comments on Proposed Rule 19R002 in the subject line.STATUTORY AUTHORITYThe new sections and repeals are authorized by Texas Health and Safety Code, Texas Oral Health Improvement Act, Chapter 43; Texas Education Code, §22.0834; and Texas Government Code, §531.0055, and Texas Health and Safety Code, §1001.075, which provides for the Executive Commissioner of the Health and Human Services Commission to adopt rules for the operation and provision of services by the health and human services agencies.The new sections and repeals implement Texas Government Code, §531.0055, Texas Education Code, §22.0834, and Texas Health and Safety Code, Chapter 43 and Chapter 1001.This agency hereby certifies that this proposal has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.TITLE 25HEALTH SERVICESPART 1DEPARTMENT OF STATE HEALTH SERVICESCHAPTER 49ORAL HEALTH IMPROVEMENT PROGRAMSUBCHAPTER AGENERAL PROVISIONS§49.1. Purpose and Application.The rules in this chapter implement the Texas Oral Health Improvement Act, Texas Health and Safety Code, Chapter 43 (Act). The Act authorizes the Department of State Health Services Oral Health Improvement Program to implement activities for eligible individuals to prevent oral disease and associated health risks through surveillance and oral health promotion and education. The program is led by the State Public Health Dental Director.§49.2. Definitions.The following words and terms, where used in this chapter, have the following meanings, unless the context clearly indicates otherwise.(1) Dental hygienist--An individual licensed by the State Board of Dental Examiners to practice dental hygiene in the State of Texas.(2) Dental sealant--A thin, plastic coating painted on the chewing surfaces of teeth to prevent tooth decay.(3) Dentist--An individual licensed by the State Board of Dental Examiners to practice dentistry in the State of Texas.(4) Department--The Department of State Health Services.(5) Fluoride varnish--A highly concentrated form of fluoride applied to the surface of teeth to prevent tooth decay, remineralize weakened teeth, and treat hypersensitivity.(6) Health risk--Any attribute or factor that presents a danger or hazard to health.(7) Oral health--Health affecting the structures of the mouth, including the hard and soft tissues such as teeth, jaws, gums, vestibule, tongue, cheeks, lips, floor and roof of the mouth, and adjacent masticatory structure.(8) Oral health promotion--Activity that supports or provides active encouragement for the furtherance of oral hygiene, dental care, and conditions conducive to good oral health.(9) Program--The Oral Health Improvement Program at the department.(10) Public health--Protection and improvement of community health through organized community effort.(11) Screening--A non-comprehensive visual observation of the oral cavity to assess oral health status.(12) Silver diamine fluoride--Topical liquid applied to dental caries (cavities) to relieve sensitivity and prevent further progression of tooth decay.(13) State Public Health Dental Director--A Texas licensed dentist who leads the Oral Health Improvement Program at the department.(14) Surveillance--Observation of a population group, condition, or ongoing activity in order to gather information.§49.3. Oral Health Improvement Program.The department may perform public oral health screening and surveillance across the State of Texas.(1) Regional dental teams perform open mouth screening to assess the oral health of individuals.(2) Regional dentists issue written findings, which may include recommendation for a comprehensive exam.(3) The data collected from oral health surveillance may include:(A) demographic data;(B) dental history;(C) history of tooth decay;(D) presence of dental sealants; and(E) early and urgent dental needs.§49.4. Oral Health Improvement Program in Schools.The program contracts with schools and school districts through a memorandum of understanding and adheres to the Texas Education Code, §22.0834.§49.5. Oral Health Improvement Program Priorities.Program priorities are determined based on data, research, public health principles, and other factors. Priorities may include:(1) oral health surveillance;(2) oral disease prevention;(3) oral health education and promotion;(4) oral health subject matter expertise for the department, other agencies, and other organizations; or (5) facilitation of access to oral health services.§49.6. Implementation of Oral Health Improvement Program Activities.(a) The implementation of any and all program activities is subject to the availability of funds. The program identifies populations based on socioeconomic need, limited access to dental providers, and other risk factors.(b) Program conducts oral health surveillance activities based on priorities determined by the program and may include:(1) collecting data through visual, open-mouth screening, survey, or other means as defined in policy; and (2) preparing statistical or other public health reports based on surveillance data.(c) Oral disease prevention activities may include open-mouth screening, community water fluoridation, fluoride varnish applications, silver diamine fluoride applications, or dental sealants.(d) Oral health promotion and education topics may include the improvement of home care, the importance of dental check-ups, the relationship between oral health and general health, the prevention and detection of oral cancer, and the improvement of perinatal oral health. Activities may include:(1) public health education to promote the prevention of oral disease;(2) initiation and expansion of preschool, school, and adult education programs;(3) organization of continuing health education for health providers; and (4) preventive health education information for the public.(e) Oral health subject matter expertise includes providing information and guidance to the department and other agencies and organizations regarding oral health and oral disease prevention. Activities may include:(1) assisting in the development of oral health training materials;(2) providing feedback on policies or programs with an oral health component; and(3) ensuring public health policies and procedures include oral health components.(f) Program shall work to facilitate access to oral health services by informing the public of available services and promoting better distribution of dentists and other oral health professionals throughout the State of Texas.(g) Program activities must adhere to the Dental Practice Act, Texas Occupations Code, Chapters 251 - Chapter 267.(h) The department may implement activities through contracts or interagency agreements with entities that may include academic institutions, professional associations, or nonprofit organizations.TITLE 25HEALTH SERVICESPART 1DEPARTMENT OF STATE HEALTH SERVICESCHAPTER 49ORAL HEALTH PROGRAMSUBCHAPTER AGENERAL PROVISIONS§49.1. Purpose and Application.The rules in this chapter implement the Texas Oral Health Improvement Act, Health and Safety Code, Chapter 43 (Act). The Act authorizes the Department of State Health Services (department) to provide treatment benefits for eligible individuals; oral disease prevention services; and oral health promotion and education. The Act also provides for administration of the program which includes dental surveillance activities.§49.2. Definitions.The following words and terms, where used in this chapter, have the following meanings, unless the context clearly indicates otherwise.(1) Action--Denial, modification, suspension, or termination of fee-for-service (FFS) oral health treatment benefits or participation rights of an applicant or a recipient.(2) Administrative review--A secondary level of review available to applicants, recipients, and providers who want to resolve a conflict, or appeal an administrative sanction or a denied claim.(3) Administrative sanctions--Penalties imposed on a provider who fails to comply with rules, policies, procedures, or standards, which may include recoupment or adjustment of payments, payment hold, or termination of the provider's contract.(4) Applicant--A person applying to receive FFS oral health treatment benefits, but for whom eligibility has not been established.(5) Business day--Normal department operating hours from 8:00 a.m. - 5:00 p.m., Monday through Friday, with the exception of state and federal holidays.(6) Conflict--The proposed modification, suspension, or termination of a contract with a provider.(7) Dentist--An individual licensed by the Texas State Board of Dental Examiners (TSBDE) to practice dentistry in the State of Texas.(8) Dentally accepted standards--Operating in accordance with the laws relating to the practice of dentistry, the rules of the TSBDE, and standards of practice.(9) Eligible individual--An individual who meets the criteria necessary to receive oral health treatment benefits under the Act and the rules in this chapter.(10) Emergency care--Oral health treatment services for relief of pain and infection, including extractions and basic restorative services to prevent premature loss of teeth.(11) FFS--The department's fee-for-service oral health treatment benefits, administered by the department's Oral Health Program.(12) FFS oral health treatment benefits manual (manual)--A compilation of policies, procedures, and instructions prepared by the department's Oral Health Program for FFS oral health treatment benefits, to be used by providers of oral health treatment services. Participating providers will receive a copy of the manual and any updates, changes, and amendments, and must comply with its requirements.(13) Non-provider--A dentist or physician licensed to practice under Texas state law but not currently under contract with the department to provide oral health treatment benefits.(14) Oral Health Program--A program comprised of central office staff and regional dental teams.(15) Oral health treatment benefits--Preventive or treatment services affecting the structures of the mouth, including the hard and soft tissues such as teeth, jaws, gums, vestibule, tongue, cheeks, lips, floor and roof of the mouth, and adjacent masticatory structure.(16) Other benefit--A benefit to which an individual is entitled, other than a benefit provided under the Act, for the payment of costs of oral health treatment benefits, including benefits available from:(A) an insurance policy, group oral health plan, or prepaid oral care plan;(B) Title XVIII or Title XIX of the Social Security Act, as amended (42 U.S.C. §1395 et seq. and 42 U.S.C. §1396 et seq.);(C) the Veteran's Administration;(D) the Civilian Health and Medical Program of the Uniformed Services;(E) worker's compensation or any other compulsory employer's insurance program;(F) a public program created by federal law, state law, or the ordinances or rules of a municipality or political subdivision of the state; or(G) a cause of action for dental or oral health treatment benefits expenses or a settlement or judgment based upon the cause of action, if the expenses are related to the need for treatment benefits provided under the Act.(17) Physician--An individual licensed by the Texas Medical Board to practice medicine in the State of Texas.(18) Provider--A person with whom the department contracts to provide oral health treatment services under the Act.(19) Recipient--A person approved as eligible to receive oral health treatment benefits.(20) State dental director--A Texas licensed dentist who serves as the manager of the Oral Health Program, or that person's designee.(21) State fiscal year--The period from September 1 through August 31 of the following year.(22) Support--The contribution of money or services necessary for a person's maintenance, including food, clothing, shelter, transportation, and health care.(23) Third-party nominator--A person aware of an applicant's economic condition who refers the applicant to the Oral Health Program for oral health treatment benefits. Third-party nominators include school administrators, school nurses, social workers, city or county officials, public health clinics, community health centers, dentists, physicians, hospitals, or any other source acceptable to the Executive Commissioner of the Health and Human Services Commission.§49.3. Oral Health Program Priorities.(a) The provision of any and all oral health services is subject to the availability of funds.(b) The department determines at the beginning of each biennium the categories of persons that will have priority for oral health services under the program, based upon available funding. The department may change program priorities at any time.§49.4. Methods of Delivering Oral Health Services.Delivery of oral health services may be accomplished by any of the following methods.(1) The department may provide or contract for oral health services, which may be limited to preventive services or oral health education and promotion activities.(2) The department may contract with providers to provide FFS oral health treatment for eligible individuals. Requirements for provider participation and reimbursement are set forth in the manual.TITLE 25HEALTH SERVICESPART 1DEPARTMENT OF STATE HEALTH SERVICESCHAPTER 49ORAL HEALTH PROGRAMSUBCHAPTER BRECIPIENT PARTICIPATION IN FFS ORAL HEALTH TREATMENT BENEFITS§49.5. Application Process for FFS Oral Health Treatment Benefits.(a) An applicant for oral health treatment benefits must be referred to the Oral Health Program by a third-party nominator who knows the individual's economic condition.(b) Each applicant for oral health treatment benefits must complete or cause to be completed an application form, which shall include the following information for the individual needing treatment:(1) personal information, including name, address, birthdate, gender, and ethnicity;(2) a statement from the referring third-party nominator that oral health treatment is necessary to prevent or reduce the probability of pain, infection, or disease of a dental nature; and(3) a statement by the applicant or the person responsible for the applicant's support that:(A) treatment benefits are requested;(B) the applicant is a bona fide resident of Texas and the family income does not exceed the financial guidelines as required in §49.6 of this title (relating to Eligibility Requirements for Referral);(C) the applicant is not eligible for another program or other benefit providing dental care; and(D) the applicant or the person responsible for the applicant's support is financially unable to pay for all or part of the cost of the necessary oral health treatment benefits.(c) Each applicant who will be referred for oral health treatment benefits, as described in §49.7 of this title (relating to Eligibility Requirements to Receive FFS Oral Health Treatment Benefits), must have his/her application prior authorized in accordance with policies and procedures, as defined in the manual.(d) The denial of any application must be in writing and must include the reason(s) for such denial. Unless the application is denied because Oral Health Program funds are reduced, curtailed, or unavailable, the individual applying for oral health treatment benefits has the right to an administrative review and a due process hearing in accordance with Subchapter D of this chapter (relating to Appeals Process for FFS Oral Health Treatment Benefits and Services).(e) An individual has the right to reapply for FFS oral health treatment benefits at any time when there is a change of situation or condition.§49.6. Eligibility Requirements for Referral for FFS Oral Health Treatment Benefits.(a) In order for a person to be eligible for referral for oral health treatment benefits, the applicant must meet the following criteria:(1) the person must be a bona fide resident of Texas, which is a person who:(A) is physically present within the geographic boundaries of the state;(B) has an intent to remain within the state;(C) maintains a physical residence with an address within the state; and(D) does not claim residency in any other state or country; or(2) the person is:(A) residing in Texas and his/her parent(s), conservator, guardian, or caretaker, with whom the person consistently resides, is a bona fide resident of Texas; or(B) residing in Texas and is the legal dependent spouse of a bona fide resident.(b) The person must establish a financial need for oral health treatment benefits, which is based on family income, in accordance with the manual.(1) The family income used to determine eligibility is the gross annual income of the applicant and his/her spouse, if applicable, or the gross annual income of person(s) legally obligated to support the applicant;(2) Gross annual income includes earned wages, pensions or retirement benefits, child support payments received, alimony, unemployment compensation, worker's compensation, income from rental properties, or any monies received on a regular basis for family support purposes; and(3) Income guidelines are based on current United States Department of Agriculture poverty guidelines for determining eligibility for free meals (e.g., school free lunch program guidelines), which are incorporated by reference.§49.7. Eligibility Requirements to Receive FFS Oral Health Treatment Benefits.(a) Following prior authorization of an application in accordance with §49.5 of this title (relating to Application Process for FFS Oral Health Treatment Benefits), an applicant will be referred for a dental examination to determine whether the applicant is eligible to receive oral health treatment benefits. With the exception described in §49.13 of this title (relating to FFS Oral Health Treatment Services by Non-Providers), a prior authorized applicant will be referred to a provider for this examination.(1) The examining provider must certify to the department that he/she has examined the applicant and that the applicant is eligible to receive oral health treatment benefits in accordance with the manual.(A) If the applicant meets the eligibility requirements to receive oral health treatment benefits, the provider will perform the treatment in accordance with the manual.(B) If the applicant does not meet the eligibility requirements to receive oral health treatment benefits, the provider will be paid only for the examination services provided, in accordance with the manual.(2) Notwithstanding the provisions of paragraph (1) of this subsection, the final determination concerning an applicant's eligibility to receive oral health treatment benefits is made by the state dental director, in accordance with the manual.(b) The applicant's initial eligibility date shall be the date upon which the application was prior authorized, as described in §49.5 of this title, and will be effective for the remainder of the state fiscal year. Eligibility must be re-established for any subsequent state fiscal year in which oral health treatment benefits are sought, in accordance with the policies, procedures, and Oral Health Program priorities in effect at that time. To maintain eligibility for oral health treatment benefits throughout a state fiscal year, the individual must continue to meet the eligibility requirements set forth in §49.6 of this title (relating to Eligibility Requirements for Referral for FFS Oral Health Treatment Benefits).§49.8. Denial, Modification, Suspension, and Termination of FFS Oral Health Treatment Benefits.(a) Any person requesting or receiving oral health treatment benefits may be notified that such benefits may be denied, modified, suspended, or terminated if:(1) information in the application is erroneous or falsified;(2) the person is not eligible;(3) required personal information is not provided;(4) obligated reimbursement to the Oral Health Program is not provided;(5) Oral Health Program funds are reduced or curtailed; or(6) Oral Health Program priorities are modified.(b) The Oral Health Program will notify in writing the applicant or recipient or the person legally obligated to support the applicant or recipient of the action proposed to be taken and the reasons for such proposed action. The applicant or recipient shall have the right to an administrative review and/or a due process hearing in accordance with Subchapter D of this chapter (relating to Appeals Process for FFS Oral Health Treatment Benefits and Services) unless the action resulted from the reduction or cessation of oral health treatment benefits funds.§49.9. Financial Obligations and Recovery of Costs for FFS Oral Health Treatment Benefits.(a) An individual is not eligible to receive oral health treatment benefits furnished under the Act to the extent that the individual or any person who has the legal obligation to support the individual is eligible for some other benefit that would pay for all or part of the benefits.(b) An individual who applies for or receives oral health treatment benefits furnished under the Act must inform the department at the time of application and at any time during a period of eligibility to receive oral health treatment benefits of any other benefit to which the individual or any person who has the legal obligation to support the individual may be entitled.(c) An individual who has received oral health treatment benefits covered by some other benefit, or any person who has a legal obligation to support that individual, must reimburse the department to the extent of the oral health treatment benefits furnished when the other benefit is received.(d) The eligibility requirement in subsection (a) of this section may be waived by the state dental director in certain individually considered cases where its enforcement will deny oral health treatment benefits to a class of otherwise eligible individuals because of conflicting state, local, or federal laws or regulations.(e) The department may recover the cost of oral health treatment provided under the Act from:(1) a person who does not pay or reimburse the department as required under the Act and the rules in this chapter; or(2) from any third party who has a legal obligation to pay other benefits and to whom notice of the obligation has been given.(f) At the request of the commissioner, the attorney general may bring suit in the appropriate court of Travis County, Texas, on behalf of the department. The court may award attorney's fees, court costs, and interest accruing from the date on which the department provides the service to the date the department is reimbursed pursuant to a judgment in favor of the department.TITLE 25HEALTH SERVICESPART 1DEPARTMENT OF STATE HEALTH SERVICESCHAPTER 49ORAL HEALTH PROGRAMSUBCHAPTER CPROVIDER PARTICIPATION IN FFS ORAL HEALTH TREATMENT BENEFITS§49.10. Provider Participation Requirements to Provide FFS Oral Health Treatment Services.The department adopts by reference the manual, which includes all applicable policies, procedures, and any updates, changes, and amendments. A copy of the manual is provided to each participating provider. Additional copies can be obtained by contacting the Department of State Health Services, Oral Health Program, Mail Code 1938, P.O. Box 149347, Austin, Texas 78714-9347, or by email at dental@dshs.state.tx.us. Providers must meet the following criteria in order to provide FFS oral health treatment services:(1) agree to comply with all applicable program policies, procedures, rules, and requirements;(2) agree to accept FFS oral health treatment benefit fees as payment in full;(3) treat all applicants and recipients without discrimination;(4) ensure that recipients of FFS oral health treatment benefits or persons legally responsible to support recipients of FFS oral health treatment benefits are not billed for the difference between the provider's regular fees and those paid by the Oral Health Program; and(5) be licensed to practice dentistry in Texas and in good standing with the TSBDE.§49.13. FFS Oral Health Treatment Services by Non-Providers.The department may pay a non-provider for emergency care, in accordance with the manual, in cases where oral health treatment benefit providers are not available or able to provide the emergency care and when delay in providing care would be detrimental to the recipient's health.§49.14. Payment of FFS Oral Health Treatment Services Claims.(a) Payment will not be made to providers or non-providers for services not authorized in accordance with the manual and the rules in this chapter. Payment for any service may be made only after the service has been delivered.(b) Provider claims will be processed and considered for payment in accordance with the manual. Claims will be denied if the claim:(1) contains incomplete or inaccurate information; or(2) is not submitted in accordance with the manual.(c) A provider claim that has been denied may be reconsidered for payment if the provider resubmits the claim with appropriate corrections, within 30 business days, or requests an administrative review, as described in §49.16 of this title (relating to Administrative Review). In order to receive an administrative review of the denied claim, the provider must request the administrative review in writing and return the claim, with the alleged error identified, to the Oral Health Program no later than 20 business days after the date of the notice of denial, accompanied by appropriate documentation for review.§49.15. Administrative Sanctions.Any provider who fails to provide and maintain quality services, fails to meet or exceed dentally accepted standards, or who violates policies and procedures or the rules in this chapter, may be subject to administrative sanctions, as determined appropriate by the state dental director. A provider may request an administrative review, as described in §49.16 of this title (relating to Administrative Review), if a written request is received by the Oral Health Program no later than 20 business days after the date of the notice of administrative sanction.TITLE 25HEALTH SERVICESPART 1DEPARTMENT OF STATE HEALTH SERVICESCHAPTER 49ORAL HEALTH PROGRAMSUBCHAPTER DAPPEALS PROCESS FOR FFS ORAL HEALTH TREATMENT BENEFITS AND SERVICES§49.16. Administrative Review.(a) An administrative review is available under the following circumstances:(1) an applicant or recipient receives notice of a proposed action; or(2) a provider receives notice of an administrative sanction, conflict, or denied claim.(b) No later than 20 business days after the date of notice of the action, conflict, sanction, or claim denial, the aggrieved person may request an administrative review. The request must be made in writing and received by the Oral Health Program within the required timeframe. Additional information bearing on the decision to be reviewed may be submitted at this time. Failure to make a timely request for an administrative review is deemed to be a waiver of the right to administrative review.(c) Upon timely receipt of a request for an administrative review, an administrative review team will review and consider all relevant materials submitted by the Oral Health Program and the aggrieved person. The administrative review team will affirm or reverse the decision being appealed and respond in writing to the aggrieved person, giving the reason(s) for the decision.§49.17. Due Process Hearing.(a) A due process hearing is available under the following circumstances:(1) an applicant or recipient receives notice of a proposed action or an administrative review team decision that supports the department; or(2) a provider receives notice of a conflict with the department or an administrative review team decision that supports the department regarding a conflict.(b) A request for a due process hearing is not contingent upon initially requesting an administrative review. If a request for a hearing is made without first requesting an administrative review, the right to an administrative review is deemed to be waived.(c) The affected individual has 20 days after receiving the notice to request a hearing on the proposed action. It is a rebuttable presumption that a notice is received five days after the date of the notice. Unless the notice letter specifies an alternative method, a request for a hearing shall be made in writing and mailed to the following address: Department of State Health Services, Oral Health Program, Mail Code 1938, P.O. Box 149347, Austin, Texas 78714-9347. If an individual who is offered the opportunity for a hearing does not request a hearing within the prescribed time for making such a request, the individual is deemed to have waived the hearing and the action may be taken.§49.18. Hearing Process.Appeals and administrative hearings will be conducted in accordance with the department's fair hearing rules at §§1.51 - 1.55 of this title (relating to Fair Hearing Procedures). ................
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