When Does Medicaid Cover Dental Care?
When Does Medicaid Cover Dental Care?
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Medicaid is required by federal law to provide regular and comprehensive dental services to children and young adult enrollees under age 21.
For adults aged 21 and older, Medicaid is not required to provide dental care, giving state Medicaid programs the option of determining whether to provide dental coverage. As a result, Medicaid dental coverage for adults varies from state to state, sometimes dramatically.
Medicaid dental coverage for children and young adults
Medicaid dental coverage for populations under the age of 21 must include the following:
- Relief of pain and infections
- Restoration of teeth
- Maintenance of dental health
This means Medicaid will cover preventative services such as check-ups, cleanings, x-rays and sealants. It also covers restorative services such as fillings, crowns, root canals, oral surgery and emergency procedures.
In other words, dental services for children and young adults cannot be limited to emergency services. The services must be comprehensive and at intervals that meet reasonable standards of dental practice.
There are other requirements as well. If a condition requiring treatment is discovered during a medical screening, the state Medicaid program has to provide the necessary services to treat that condition, regardless of whether that condition is covered under the state’s Medicaid plan.
Medicaid dental coverage for adults
All but three state Medicaid programs provide at least some dental services for adults, with coverage ranging from only emergency care to comprehensive care, according to the National Academy for State Health Policy (NASHP).
Emergency adult dental care
Eight states provide only emergency services as defined by NASHP, which are dental services that are provided for the relief of pain and infection under defined emergencies. A beneficiary, for example, who walks into an emergency room with an abscess in their mouth would qualify for emergency dental work.
States where Medicaid provides only emergency dental services for adults:
- New Hampshire
Limited adult dental care
Fourteen states provide limited Medicaid dental benefits for adults, which means Medicaid covers fewer than 100 diagnostic, preventive and restorative procedures recognized by the American Dental Association (ADA). This means you'll typically have coverage for cleanings, x-rays, fillings, emergency care and minor restorative procedures. However, major restorative procedures are usually not covered.
States where Medicaid provides limited dental care for adults:
- South Carolina
Comprehensive adult dental care
Twenty-five states and the District of Columbia provide Medicaid dental coverage that's considered extensive, meaning it includes more than 100 diagnostic and preventive services as well as minor and major restorative procedures approved by the ADA.
States where Medicaid provides extensive dental care for adults:
- District of Columbia
- New Jersey
- New Mexico
- New York
- North Carolina
- North Dakota
- Rhode Island
- South Dakota
- West Virginia
Some state Medicaid programs providing extensive or limited benefits have $1,000 annual caps per beneficiary. This means if your dental bills exceed $1,000 in a given year, these Medicaid programs will not provide coverage beyond the $1,000 limit.
No adult dental coverage
In three states, Medicaid does not provide dental benefits for most adults.
However, two of those states — Maryland and Tennessee — while not currently providing dental benefits for their general, adult Medicaid populations, provide dental benefits for pregnant beneficiaries.
Coverage disparities between states
One of the most striking features of state Medicaid dental coverage for adult Medicaid populations lies in the wide coverage disparities from state to state.
New York and New Jersey, for example, provide extensive coverage of adult dental benefits under Medicaid. Pennsylvania and Delaware provide limited Medicaid dental benefits.
Similarly, Missouri provides limited Medicaid adult dental benefits for its general Medicaid population, while Montana provides extensive Medicaid dental benefits.
Upcoming expansion of Medicaid dental coverage
Of the three states not providing any benefits for their general populations, two states, Tennessee and Maryland, are in the process of extending Medicaid dental benefits to their general populations.
Tennessee passed a budget this year that includes $25.5 million for adult dental benefits under Medicaid. Maryland also plans to provide limited dental benefits for its adult Medicaid population in January. This will leave Alabama as the only state not offering some form of dental coverage for adults enrolled in Medicaid.
In addition, New Hampshire’s Medicaid program, which currently only covers emergency dental care, will start providing extensive dental benefits on April 1.
Dental coverage during pregnancy
Many Medicaid programs have taken steps to make it easier for pregnant women to access dental services under Medicaid. This is because oral health problems can result in lower birth weights and preterm births.
This may mean that your state covers an expanded set of dental services for Medicaid enrollees who are pregnant. For example, Michigan's Medicaid program only offers limited dental benefits for the general population of adults, but those who are pregnant have extensive coverage.
If you're pregnant, it's also usually easier to qualify for Medicaid and its dental benefits. For example, California's Medicaid program, Medi-Cal, is typically only available for those who earn up to 138% of the federal poverty level, which is a limit of $18,755 per year for an individual. However, those who are pregnant can qualify for Medi-Cal and its dental benefits with an income of up to $28,947 per year for an individual, which is 213% of the federal poverty level.
Does Medicaid cover dental implants?
In most cases, Medicaid does not cover dental implants.
Medicaid considers dental implants a cosmetic procedure, not something essential to the health and well-being of the patient, making dental implants a costly and unnecessary treatment option from Medicaid’s perspective. A single dental implant can cost more than $3,000.
In rare cases, Medicaid will pay for dental implants if you or your health care providers can show that the implants are medically necessary, which is defined and determined by the state Medicaid program.
The onus is on the patient’s providers — a dentist or physician or a combination of both — to prove that the implants are medically necessary.
Children and young adults
It may be easier for children and young adults under age 21 to prove that dental implants are medically necessary because of the required Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. This program is intended to avert major medical complications down the road by diagnosing and treating medical issues and conditions early in the treatment process.
If a dentist or a physician can show that dental implants are necessary as part of your EPSDT benefit, Medicaid is more likely to pay for at least some of the cost of the implants.
Medicaid beneficiaries who are 21 or older are not able to rely on the EPSDT benefit, making it more difficult to prove that dental implants are a medical necessity. Nevertheless, there may be instances where Medicaid will pay for dental implants such as:
- When dental implants are necessary to prevent bone atrophy caused by certain diseases such as diabetes, osteoporosis or digestive disorders
- When dental implants are needed to strengthen your jaw after an accident impacting your jaw
- When patients are losing teeth as a result of decay or periodontal disease
It all depends on the state Medicaid program. Note that nearly 70% of Medicaid beneficiaries are covered under managed care plans that contract with state Medicaid programs to provide benefits. This means you and your health care providers may have to make a case for dental implants to an insurance company or dental benefits administrator working on behalf of your state’s Medicaid program.
How to find a dentist that accepts Medicaid
Finding a dentist who accepts Medicaid patients can be challenging. According to some estimates, less than 40% of the nation’s dentists accept Medicaid patients because of low Medicaid reimbursement rates.
- Children: The government website InsureKidsNow.gov is one of the best places to find a dentist who accepts Medicaid or the Children's Health Insurance Program (CHIP). On the website, you can search by location, dental specialty, language spoken and if the dentist is accepting new patients.
- Adults: For those 21 or older, logging on to your state's Medicaid website can help you locate which dentists accept Medicaid and what dental services Medicaid covers in your state. If you are enrolled in a Medicaid managed care plan, you can log on to your insurance company's website to find available dentists.
- Seniors: Those who are dual-enrolled in Medicaid and a Medicare Advantage plan can find the list of dentists and covered services by logging into their Medicare Advantage plan account.
The cost of dental care and coverage specifics can vary widely. To help prepare for the cost of treatment, find out beforehand how much Medicaid will pay and how much you will have to pay directly. Also check if your Medicaid dental plan has a spending cap on how much it will pay for your dental care. And ask if the dental office is willing to put you on a payment plan if costs exceed what you can pay at the point of service.
Which dental chains accept Medicaid?
Even though it may be difficult to find dentists who accept Medicaid patients, it is encouraging to note that some of the largest dental provider organizations in the country contract with state Medicaid programs. This includes Liberty Dental Plan and DentaQuest. Aspen Dental practices do not accept Medicaid patients.
|DentaQuest||Yes, in 30 states|
|Liberty Dental||Yes, through select Medicaid programs including those in California, Nevada, Florida and New York|
Dental schools and clinics
Dental clinics and dental schools may also serve as viable alternatives for Medicaid patients. Dental clinics often provide services for Medicaid beneficiaries at very low costs. They're also a good option for dental care without insurance.
Many dental schools run clinics, allowing their dental students to treat Medicaid beneficiaries under the watchful eye of their instructors. The future dentists receive hands-on training, and in exchange, Medicaid patients are charged little or nothing for dental services. School-run clinics are more prevalent in urban areas.
Medicaid is the nation’s public health insurance program for people with low incomes, covering 82 million adults, pregnant women, children, seniors and disabled individuals at little or no cost.
Each state operates its own Medicaid program, designing and administering its program within federal guidelines. Medicaid programs are funded through a combination of state and federal funds. Medicaid programs must provide health care services for the following population groups to receive federal funding.
- Pregnant women with low incomes
- Children of low-income families
- Children in foster care
- People with disabilities
- Seniors with low incomes
- Parents or caregivers with low incomes
Frequently asked questions
Does Medicaid cover dental care for adults?
Nearly all Medicaid programs provide at least some dental benefits for Medicaid recipients 21 and over. However, the level of Medicaid dental benefits varies from state to state, sometimes dramatically, because states decide whether to provide dental benefits and the extent of those benefits for their adult populations.
Does Medicaid cover children’s dental care?
Yes. State Medicaid programs are required to cover most dental services for Medicaid-eligible beneficiaries under the age of 21 as part of the Early and Periodic Screening, Diagnostic, and Treatment benefit.
What dental services are covered by Medicare?
Regular and comprehensive care is always covered for children and young adults under the age of 21. This includes fillings, extractions and even dentures if necessary. For adults, dental coverage varies by state, so where you live determines what dental services are covered.
Coverage rules and expansionary policies are based on a 2022 survey of state Medicaid coverage of dental services by the National Academy for State Health Policy (NASHP). Additional sources include Medicaid.gov, state Medicaid agencies and the U.S. Department of Health & Human Services (HHS).
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