Section 1149.56. Payment limitations for orthodontic services

The following limits apply to payment for orthodontic services:

(1) Payment is made for only one Salzmann Index Evaluation per 12 month period per recipient.

(2) Payment for diagnostic aids requested by the Department under § 1149.54(7) (relating to payment policies for orthodontic services) will not exceed the fee for diagnostic aids which is listed under orthodontic exam in the MA Program fee schedule.

(3) Payment will not be made for quarters of orthodontia treatment initiated before March 1, 1980.

(4) Payment is made for only 8 quarters of treatment per lifetime except as noted in paragraph (5).

(5) For those persons who began orthodontic treatment prior to becoming eligible for MA, payment is made only for the difference between 8 quarters of care and quarters of care received prior to the person’s eligibility for MA.

(6) Payment for orthodontic services will not exceed $1,075. The fees paid for the initial orthodontic exam and treatment including the Salzmann Evaluation Index and the fees paid for the first quarter through the eighth quarter are listed in the Medical Assistance program fee schedule.

(7) Payment of the fee for each quarter as listed in the MA Program fee schedule is limited to one in each recipient’s lifetime.

(8) The amount of payment for each quarter of care is limited to the fee listed in the MA Program fee schedule.

The provisions of this § 1149.56 adopted January 25, 1985, effective January 15, 1985, 15 Pa.B. 255; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial pages (96124) to (96125).

Notation

Cross References

This section cited in 55 Pa. Code § 1149.54 (relating to payment policies for orthodontic services).