DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
601 East 12th Street, Suite 355
Kansas City, Missouri 64106
Division of Medicaid and Children's Health Operations
April 5, 2016

Brian Kinkade, Director,
Department of Social Services
Broadway State Office Building
P.O. Box 1527
Jefferson City, MO 65102-1527
RE: TN 16-0001
Dear Mr. Kinkade:
We have reviewed the proposed amendment to Attachments 4.19-B and 3.1-A of your Medicaid
State Plan submitted under Transmittal Number (TN) 16-0001. Effective January 1, 2016, this
amendment adds coverage of additional adult dental services.
We conducted our review of your submittal according to the statutory requirements at sections
1902(a)(2), 1902(a)(13), 1902(a)(30), and 1903(a) of the Social Security Act (The Act) and the
regulations at 42 CFR 447 Subpart C. Before we can continue processing this amendment, we
need additional or clarifying information.
The regulation at 42 CFR 447.252(b) requires that the State Plan include a comprehensive
description of the methods and standards used to set payment rates. Section 6002 of the State
Medicaid Manual explains the State Plan must be comprehensive enough to determine the required
level of FFP, and to allow interested parties to understand the rate setting process as well as the
items and services paid through these rates. Further, since the Plan is the basis for Federal financial
participation, it is important that the Plan's language be clear and unambiguous. Therefore, we
have the following questions/concerns regarding TN 16-0001:
Reimbursement Questions
1. Please remove the language in the effective date language that says “and any annual
periodic adjustments to the fee schedule” from Att. 4.19B.
Coverage Questions
2. Page 15, Dental Services: Please clarify, are there limits to the covered procedure codes?
If so, please include any limitations on the plan page.
3. Additionally, please clarify what is meant by the prophylaxis age: 13-125. Is the state
limiting prophylaxis to individuals 13 and over? If so, this does not comport with
EPSDT requirements. This service should be available to all children under age 21 when
medically necessary.

 Page 2 – Brian Kinkade
4. Page 15-1, Physical Therapy and Related Services: Please clarify what the state means
regarding the coverage of therapies. Specifically, that therapies are “reimbursed as
separate, independent practitioner services”. Under which benefit category is the state
referring to for reimbursement?
We are requesting this additional/clarifying information under provisions of section 1915(f) of the
Social Security Act (added by PL 97-35). This has the effect of stopping the 90-day clock for
CMS to take action on the material. A new 90-day clock will not begin until we receive your
response to this request.
In accordance with our guidelines to all State Medicaid directors dated January 2, 2001, if we have
not received the State’s response to our request for additional information within 90 days from the
date of this letter, we will initiate disapproval action on the amendment. In addition, because this
amendment was submitted after January 2, 2001 and is effective after January 1, 2001, please be
advised that we will continue to defer Federal financial participation (FFP) for State payments
made in accordance with this amendment until it is approved. Upon approval, FFP will be
available for the period beginning with the effective date through the date of approval.
If you have any questions, please contact Kevin Slaven at (816) 426-5925.
Sincerely,

4/5/2016

X James G. Scott
Associate Regional Administrator
for Medicaid and Children’s Health Operations
Signed by: James G. Scott -A

cc:
Jennifer Tidball