Medicaid coverage on specaility dental, general dental

Medicaid Coverage of Dental Benefits for Adults

Key Points

• Poor oral health is widespread among adults in the United States and especially affects those with low incomes.

– Adults with incomes below 100 percent of the federal poverty level (FPL) are three times more likely to have untreated dental caries—commonly known as cavities—than adults with incomes above 400 percent FPL.

– Thirty-seven percent of adults age 65 and older with incomes below 100 percent FPL had complete tooth loss compared to 16 percent of those with incomes at or above 200 percent FPL.

• Individuals with a range of chronic conditions are more susceptible to oral disease.

Oral disease can also exacerbate chronic disease symptoms. Poor oral health can limit communication, social interaction, and employability.

• Medicaid programs are required to cover dental services for children and youth under age 21 but there are no minimum coverage requirements for adults. As a result, adult dental benefits vary widely across states. For example, as of February 2015:

– 19 states provided emergency-only adult dental benefits for non-pregnant,

non-disabled adults;
– 27 states covered preventive services;
– 26 states covered restorative services;
– 19 states covered periodontal services;
– 25 states covered dentures;
– 25 states covered oral surgery;
– 2 states covered orthodontia; and
– 9 states placed an annual dollar limit
on covered dental services.

• States change Medicaid coverage of adult dental benefits on a regular basis, cutting benefits when budgets are tight and expanding them when more funds are available.

• Initiatives to improve access to dental services include using mobile clinics and telehealth technologies, increasing the number of providers serving Medicaid enrollees, and funding demonstrations to encourage Medicaid enrollees to increase dental utilization. For example:

– In 2014, the Health Resources and Services Administration supported 238 school-based health center oral health activities through capital grants.

– The National Health Service Corps and some states offer student loan repayment assistance to dentists who commit to working in high-need, underserved, or rural areas.

– Minnesota and Alaska have amended state scope-of-practice laws to allow mid-level dental practitioners to provide dental services.

 Types of Adult Dental Services Covered for Non-Pregnant, Non-Disabled Adults under Medicaid, 2015

Type of service Number of states Services typically included Emergency only 18 Emergency extractions, other procedures for immediate pain relief

 More extensive 33

 Preventive 28 Examinations, cleanings, and sometimes fluoride application or sealants

 Restorative 26 Fillings, crowns, endodontic (root canal) therapy

 Periodontal 19 Periodontal surgery, scaling, root planing (cleaning below the gum line)

 Dentures 26 Full and partial dentures

 Oral surgery 25 Non-emergency extractions, other oral surgical procedures

 Orthodontia 2 Braces, headgear, retainers

Children’s Dental Services Covered by the All Kids Program or the Early Periodic Screening, Diagnosis and Treatment (EPSDT) Program:

Type of Service Frequency Age Range Additional Details

Exam   --     Every six months 0-20 years old Completion of mandated school dental exam form is considered part of the oral exam; Exam necessary even if no pain/problems exists

Cleaning    --     Every six months 0-20 years old Routine prophylaxis

Fluoride    -Three treatments every 12 months   -0-2 years old           every 12 months- One treatment 3-20 years old -

ealants Once per lifetime 5-17 years old

X-Rays -- One complete set every three years 0-20 years old

Fillings One per tooth per 12 months 0-20 years old

Crowns One per tooth per 60 months 0-20 years old Pre-authorization and x-ray documentation required*

Extractions -- 0-20 years old Removal of teeth free from pathology is not covered; some extractions require prior authorization*

Root Canals -- One per tooth per lifetime 0-20 years old Refer to the Dental Office Reference Manual (DORM) as additional guidance and limitations
may exist*


Specialty dentistry refers to services that are not covered under the Medicaid dental benefit but are covered for CSHCS enrollees who have a qualifying diagnosis that may include specialty dental services. Services include, but are not limited to, dental implants, orthodontia and specialty crown and bridge. All CSHCS beneficiaries do not qualify for specialty dental services. Qualification for specialty dental services is based on the specific diagnoses and treatment plan. Examples of CSHCS diagnoses that may qualify for specialty dental services include:

* Amelogenesis imperfecta, Dentinogenesis imperfecta

* Anodontia which has significant effect on function

* Cleft palate

* Ectodermal dysplasia, epidermolysis bullosa with significant tooth involvement

* Juvenile periodontosis

* Juvenile rheumatoid arthritis and related connective tissue disorders with jaw dysfunction secondary to tempromandibular joint arthritic involvement

* Post-operative care related to neoplastic jaw disease

* Severe malocclusion requiring orthognathic surgery

* Severe maxillofacial or craniofacial anomalies that require surgical intervention

* Traumatic injuries to the dental arches

To request approval as a CSHCS Specialty provider, dentists must contact MDHHS. (Refer to the Directory Appendix for contact information.)


General dentistry refers to services covered under the Medicaid dental benefit that may be covered for CSHCS enrollees who have a qualifying diagnosis that includes general dental services. Examples include, but are not limited to, diagnostic, preventive, restorative, endodontia, prosthodontia, and oral surgery. MDHHS may determine a beneficiary eligible for certain general dentistry services when the CSHCS qualifying diagnosis is related to conditions eligible for this coverage as identified below:

* Chemotherapy or radiation which results in significant dental side effects

* Cleft lip/palate/facial anomaly

* Convulsive disorders with gum hypertrophy

* Cystic Fibrosis

* Hemophilia and/or other coagulation disorders

* Pre- and post-transplant

To request approval as a CSHCS General Dentistry provider, dentists must contact MDHHS. (Refer to the Directory Appendix for contact information.)

NOTE: Hospital charges (e.g., general anesthesia, facility charges, etc.) may be covered for dental services provided through the inpatient or outpatient hospital facility for beneficiaries with certain CSHCS diagnoses even though CSHCS does not cover the dental care itself.


Beneficiaries enrolled in CSHCS with identified needs may be eligible to receive Care Coordination services.

Care Coordination services may be provided by the local health department. LHD staff includes registered nurses (RNs), social workers, or paraprofessionals under the direction and supervision of RNs.

Staff must be trained in the service needs of the CSHCS population and demonstrate skill and sensitivityin communicating with children with special needs and their families.

Care Coordination is not reimbursable for beneficiaries also receiving Case Management services during the same LHD billing period, which is usually a calendar quarter. In the event Care Coordination services are no longer appropriate and Case Management services are needed, the change in services may only be made at the beginning of the next billing period.

Families/beneficiaries can contact the LHD for assistance in obtaining Care Coordination services.

No comments:

Medical Billing Popular Articles