Texas Statutes
Subchapter B. Administrative Provisions
Section 32.054. Dental Services

Sec. 32.054. DENTAL SERVICES. (a) For purposes of this section, the "dental necessity" for a dental service or product is based on whether a prudent dentist, acting in accordance with generally accepted practices of the professional dental community and within the American Dental Association's Parameters of Care for Dentistry and within the quality assurance criteria of the American Academy of Pediatric Dentistry, as applicable, would provide the service or product to a patient to diagnose, prevent, or treat orofacial pain, infection, disease, dysfunction, or disfiguration.
(b) A dental service or product may not be provided under the medical assistance program unless there is a dental necessity for the service or product.
(c) In providing dental services under the medical assistance program, the commission shall:
(1) ensure that a stainless steel crown is not used as a preventive measure;
(2) require a dentist participating in the medical assistance program to document, through x-rays or other methods established by commission rule, the dental necessity for a stainless steel crown before the crown is applied;
(3) require a dentist participating in the medical assistance program to comply with a minimum standard of documentation and recordkeeping for each of the dentist's patients, regardless of whether the patient's costs are paid privately or through the medical assistance program;
(4) replace the 15-point system used for determining the dental necessity for hospitalization and general anesthesia with a more objective and comprehensive system developed by the commission; and
(5) take all necessary action to eliminate unlawful acts described by Section 36.002 in the provision of dental services under the medical assistance program, including:
(A) aggressively investigating and prosecuting any dentist who abuses the system for reimbursement under the medical assistance program; and
(B) conducting targeted audits of dentists whose billing activities under the medical assistance program are excessive or otherwise inconsistent with the billing activities of other similarly situated dentists.
(d) In setting reimbursement rates for dental services under the medical assistance program, the executive commissioner shall:
(1) provide for reimbursement of a behavior management fee only if:
(A) the patient receiving dental treatment has been previously diagnosed with an intellectual or developmental disability or a mental disability or disorder, and extraordinary behavior management techniques are necessary for therapeutic dental treatment because of the patient's uncooperative behavior; and
(B) the dentist includes in the patient's records and on the claim form for reimbursement a narrative description of:
(i) the specific behavior problem demonstrated by the patient that required the use of behavior management techniques;
(ii) the dentist's initial efforts to manage the patient's behavior through routine behavior management techniques; and
(iii) the dentist's extraordinary behavior management techniques subsequently required to manage the patient's behavior; and
(2) redistribute amounts made available through limitation of the behavior management fee under Subdivision (1) to other commonly billed dental services for which adequate accountability measures exist.
(e) The commission shall develop the minimum standard described by Subsection (c)(3) in cooperation with the State Board of Dental Examiners.
(f) To prevent serious medical conditions and reduce emergency room visits necessitated by complications resulting from a lack of access to dental care, the commission shall provide medical assistance reimbursement for preventive dental services, including reimbursement for one preventive dental care visit per year, for an adult recipient with a disability who is enrolled in the STAR+PLUS Medicaid managed care program. This subsection does not apply to an adult recipient who is enrolled in the STAR+PLUS home and community-based services (HCBS) waiver program. This subsection may not be construed to reduce dental services available to persons with disabilities that are otherwise reimbursable under the medical assistance program.
Added by Acts 2001, 77th Leg., ch. 1470, Sec. 1.01, eff. Sept. 1, 2001. Renumbered from Human Resources Code Sec. 32.053 by Acts 2003, 78th Leg., ch. 1275, Sec. 2(98), eff. Sept. 1, 2003.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 4.129, eff. April 2, 2015.
Acts 2021, 87th Leg., R.S., Ch. 820 (H.B. 2658), Sec. 6, eff. September 1, 2021.
Acts 2021, 87th Leg., R.S., Ch. 954 (S.B. 1648), Sec. 6, eff. September 1, 2021.

Structure Texas Statutes

Texas Statutes

Human Resources Code

Title 2 - Human Services and Protective Services in General

Subtitle C - Assistance Programs

Chapter 32 - Medical Assistance Program

Subchapter B. Administrative Provisions

Section 32.021. Administration of the Program

Section 32.0211. Restrictions on Executive Commissioners, Former Members of a Board, Commissioners, and Their Business Partners

Section 32.0212. Delivery of Medical Assistance

Section 32.0213. Nursing Facility Bed Certification and Decertification

Section 32.0214. Designations of Primary Care Provider by Certain Recipients

Section 32.0215. Home or Community Care Providers: Civil Monetary Penalties

Section 32.022. Medical and Hospital Care Advisory Committees

Section 32.023. Cooperation With Other State Agencies

Section 32.0231. Announcement of Funding or Program Change

Section 32.024. Authority and Scope of Program; Eligibility

Section 32.0241. Review of Waiver Request

Section 32.0242. Verification of Certain Information

Section 32.0244. Nursing Facility Beds in Certain Counties

Section 32.0245. Nursing Facility Beds for Certain Facilities Treating Alzheimer's Disease

Section 32.02451. Additional Personal Needs Allowance for Guardianship Expenses of Certain Recipients

Section 32.0246. Medical Assistance Reimbursement for Certain Behavioral Health and Physical Health Services

Section 32.02471. Medical Assistance for Certain Former Foster Care Adolescents Enrolled in Higher Education

Section 32.024715. Streamlined Eligibility Determination Process for Certain Former Foster Care Youth

Section 32.0249. Mental Health Screenings in Texas Health Steps Program

Section 32.025. Application for Medical Assistance

Section 32.0251. Eligibility Notification and Review for Certain Children

Section 32.0255. Transitional Medical Assistance

Section 32.0256. Continuation of Medical Assistance for Certain Individuals

Section 32.026. Certification of Eligibility and Need for Medical Assistance

Section 32.0261. Continuous Eligibility

Section 32.026101. Determination of Eligibility by Health Care Exchanges Prohibited

Section 32.02611. Exclusion of Assets in Prepaid Tuition Programs and Higher Education Savings Plans

Section 32.02613. Life Insurance Assets; Life Insurance Policy Conversion

Section 32.0262. Eligibility Transition

Section 32.0263. Health Care Orientation

Section 32.0264. Suspension and Reinstatement of Eligibility for Children in Juvenile Facilities

Section 32.0265. Notice of Certain Placements in Juvenile Facilities

Section 32.0266. Suspension, Termination, and Automatic Reinstatement of Eligibility for Individuals Confined in County Jails

Section 32.027. Selection of Provider of Medical Assistance

Section 32.0275. Military Medical Treatment Facilities and Affiliated Health Care Providers; Reimbursement

Section 32.028. Fees, Charges, and Rates

Section 32.0281. Rules and Notice Relating to Payment Rates

Section 32.0282. Public Hearing on Rates

Section 32.0284. Calculation of Payments Under Certain Supplemental Hospital Payment Programs

Section 32.0285. Calculation of Medical Education Add-on for Reimbursement of Teaching Hospitals That Provide Behavioral Health and Physical Health Services

Section 32.029. Methods of Payment

Section 32.0291. Prepayment Reviews and Payment Holds

Section 32.031. Receipt and Expenditure of Funds

Section 32.0311. Drug Reimbursement Under Certain Programs

Section 32.03115. Reimbursement for Medication-Assisted Treatment for Opioid or Substance Use Disorder

Section 32.0312. Reimbursement for Services Associated With Preventable Adverse Events

Section 32.0313. Induced Deliveries or Cesarean Sections Before 39th Week

Section 32.0314. Reimbursement for Durable Medical Equipment and Supplies

Section 32.03141. Authority of Advanced Practice Registered Nurses and Physician Assistants Regarding Durable Medical Equipment and Supplies

Section 32.0315. Funds for Graduate Medical Education

Section 32.0316. Electronic Transactions; Medicaid

Section 32.0317. Reimbursement for Services Provided Under School Health and Related Services Program

Section 32.032. Prevention and Detection of Fraud and Abuse

Section 32.0321. Surety Bond

Section 32.0322. Criminal History Record Information; Enrollment of Providers

Section 32.033. Subrogation

Section 32.034. Contract Cancellation; Notice and Hearing

Section 32.035. Appeals

Section 32.036. Program Payments Nonassignable and Exempt From Legal Process

Section 32.038. Collection of Insurance Payments

Section 32.0381. Icf-Iid Payment Rates

Section 32.039. Damages and Penalties

Section 32.0391. Criminal Offense

Section 32.040. Identification of Husband or Alleged Father

Section 32.042. Information Required From Health Insurers

Section 32.0421. Administrative Penalty for Failure to Provide Information

Section 32.0422. Health Insurance Premium Payment Reimbursement Program for Medical Assistance Recipients

Section 32.0423. Recovery of Reimbursements From Health Coverage Providers

Section 32.0424. Requirements of Third-Party Health Insurers

Section 32.04242. Payor of Last Resort

Section 32.0425. Reimbursement for Wheeled Mobility Systems

Section 32.043. Procurement Rules for Public Disproportionate Share Hospitals

Section 32.044. Group Purchasing for Disproportionate Share Hospitals

Section 32.045. Enhanced Reimbursement

Section 32.046. Sanctions and Penalties Related to the Provision of Pharmacy Products

Section 32.0461. Vendor Drug Program; Competitive Bidding

Section 32.0462. Vendor Drug Program; Pricing Standard

Section 32.0463. Medications and Medical Supplies

Section 32.047. Prohibition of Certain Health Care Service Providers

Section 32.048. Managed Care Information and Training Plan

Section 32.049. Managed Care Contract Compliance

Section 32.050. Dual Medicaid and Medicare Coverage

Section 32.051. Misdirected Billing

Section 32.052. Waiver Programs for Children With Disabilities or Special Health Care Needs

Section 32.0531. Pace Program Team

Section 32.0532. Pace Program Reimbursement Methodology

Section 32.0533. Data Collection: Pace and Star + Plus Medicaid Managed Care Programs

Section 32.054. Dental Services

Section 32.055. Catastrophic Case Management

Section 32.0551. Optimization of Case Management Systems

Section 32.056. Compliance With Texas Health Steps Comprehensive Care Program

Section 32.0561. Maternal Depression Screening

Section 32.057. Contracts for Disease Management Programs

Section 32.058. Limitation on Medical Assistance in Certain Alternative Community-Based Care Settings

Section 32.059. Use of Respiratory Therapists for Respiratory Therapy Services

Section 32.061. Community Attendant Services Program

Section 32.062. Admissibility of Certain Evidence Relating to Nursing Institutions

Section 32.063. Third-Party Billing Vendors

Section 32.0641. Recipient Accountability Provisions; Cost-Sharing Requirement to Improve Appropriate Utilization of Services

Section 32.067. Delivery of Comprehensive Care Services to Certain Recipients of Medical Assistance

Section 32.068. In-Person Evaluation Required for Certain Services

Section 32.069. Chronic Kidney Disease Management Initiative

Section 32.070. Audits of Providers

Section 32.0705. External Audits of Certain Medicaid Contractors Based on Risk

Section 32.071. Recipient and Provider Education

Section 32.072. Direct Access to Eye Health Care Services

Section 32.073. Health Information Technology Standards

Section 32.074. Access to Personal Emergency Response System

Section 32.075. Employment Assistance and Supported Employment

Section 32.076. Substitute Dentists