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DHS Issues Important Clarification on Benefit Limit Exception Process for Adults on Medicaid

Janice Meinert

Pennsylvania's Department of Human Services (DHS) recently issued new guidance in the form of an Operations Memorandum that further strengthens protections for adult Medicaid recipients seeking dental care beyond the basic benefit limits. This latest clarification builds on important changes made to the dental Benefit Limit Exception (BLE) process in 2021 and provides added protections for patients with qualifying medical conditions.

 

Background on Pennsylvania's Adult Dental Benefits

Since 2011, adults aged 21 and older on Medicaid receive limited dental benefits, which include cleanings and exams every six months, x-rays, extractions, and one set of dentures per lifetime. For additional services such as root canals, crowns, periodontal treatments (like deep cleanings), endodontic services, or additional dentures, patients need approval through a benefit limit exception (BLE) process.

 

Dental BLE Process Streamlined in 2021

In April 2021, Pennsylvania simplified the BLE process for patients with certain medical conditions (listed below). Under that streamlined process, if a Medicaid recipient had any of five specific medical conditions previously documented in their claims history, the state and Medicaid managed care plans would not require additional medical documentation to support the BLE request.  The five qualifying conditions are:

  1. Diabetes
  2. Coronary artery disease (or risk factors for the disease)
  3. Cancer of the face, neck, and throat (stage 2 or above)
  4. Intellectual disability
  5. Pregnancy or post-partum period
     

If the condition was not previously identified on a claim, the insurance plan would notify the dental provider that supporting medical documentation was needed to review the BLE request.  For more information and to read our post about the streamlined dental BLE process back in 2021, click here.

 

New Clarification Offers Stronger Protections

The recent Operations Memorandum releasd in June provides important new clarifications that strengthen patient BLE protections for dental care in the following ways:

  1. Automatic BLE Approval for Qualifying Conditions
    DHS has now determined that the documented presence of any of the five medical conditions "constitutes sufficient evidence that the member has met one or more of the BLE criteria and the BLE should be approved." This means that if you have any of those conditions documented in your medical claims or records, your BLE request should be approved.
     
  2. Protection Against "Cheaper Alternative" Requirements
    The new guidance includes a crucial protection for those seeking dental treatment: managed care organizations cannot require you to accept alternative or less expensive services (such as extraction instead of a root canal) when you have a qualifying condition and the requested services are determined to be medically necessary and clinically appropriate. They can only suggest alternatives if the requested service is determined not to be medically necessary.
     
  3. Improved Process for Incomplete Forms
    Medicaid managed care plans cannot automatically deny BLE requests due to “procedural defects” like an incomplete BLE form. They must first check their own records for missing information and work with patient’s dentist to correct any problems with the forms.
     
  4. Two-Step Process: BLE Approval vs. Medical Necessity
    It's important to understand that BLE approval is just the first step—getting a BLE approved does not mean the service is automatically approved.  The requested dental service must also meet the criteria for medical necessity, defined as services that will:
     a) Prevent the onset of an illness, condition, injury, or disability; OR
     b) Reduce or ameliorate the effects of an illness, condition, injury, or disability; OR
     c) Help maintain maximum functional capacity in performing daily activities

 

 

What These Changes Mean for Medicaid Recipients

These recent changes represent another important step forward in ensuring that Medicaid recipients with serious health conditions can access the dental care they need to maintain their overall health and well-being. As a result of the recent clarification, if you have any of the five qualifying medical conditions:

  1. Your BLE should be approved based on your condition alone
  2. You should not need to provide additional medical documentation if the condition is already in your Medicaid insurance claims history
  3. Your dentist cannot be forced to offer only cheaper alternatives like extractions if the recommended treatment is medically necessary
  4. The focus should be on whether the dental treatment is medically necessary, rather than whether you qualify for an exception

 

Getting Help

If you experience problems with a dental BLE request or believe your Medicaid plan is not following the new BLE requirements, contact PHLP's Helpline at 1-800-274-3258 or staff@phlp.org.