How Does Medicaid Dental Coverage Work
In all of the United States, each state is required to have a Medicaid program that meets mandatory criteria set by the federal government. In all of the states, these minimum requirements do not include dental for adults, only for those who are under the age of 21.
However, after the passing of the Affordable Care Act, states can now extend those original benefits to offer more healthcare to a larger group of its residents. Many extensions include at least some adult dental coverage, and some even have full coverage. However, there are a few states which have no adult dental benefits added to their Medicaid program.
Depending on your state of residence, the type of care available to you is one of the following: none, emergency, limited, and comprehensive.
How Medicaid Works With Other Coverage
You may still qualify for Medicaid even if you have other health insurance coverage, and coordination of benefits rules decide who pays your bill first. In this case, your private insurance, whether through Medicare or employer-sponsored, will be the primary payer and pays your health care provider first. Medicaid comes in as second insurance to settle what your private insurance doesnt pay, up to its limit.
If you have both Medicaid and private health insurance, you should show both your private health insurance card and Medicaid card to your medical provider every time you receive services.
A health-service provider who accepts both your Medicaid and private insurance card wont bill you for copayments or deductibles.
Any money received from an insurance company or as compensation for a medical care lawsuit must be used to pay the health provider. If Medicaid already has covered the cost of care, you must make a refund to Medicaid. If your private insurance is through an employer-sponsored plan, you may be an eligible candidate for the Health Insurance Premium Payment program. HIPP is a voluntary program that may pay your insurance premium as long as you or a family member qualifies for Medicaid coverage.
If your service provider wont take your Medicaid and private insurance card, your insurance company may help you locate a doctor in its provider network.
Dental Coverage And Plans
Dental care is a covered service for eligible Medicaid members who are pregnant, disabled, blind, age 65 or older, eligible for Targeted Adult Medicaid and are receiving treatment in a Substance Use Disorder Treatment Program, or qualify for Early Periodic Screening, Diagnostic and Treatment . Learn more about dental benefits here.
If you need assistance finding a dentist, please call a Medicaid Health Program Representative at 1-866-608-9422.
Click here for more information about your dental benefits.
Medicaid has two dental plans. Both dental plans provide the same services. The plans may have different dentists. You must go to a dentist that takes your plan. You must choose a dental plan or one will be assigned. Call your plan or go to their website to find a dentist in your area. The Medicaid dental plans are below:
You may also use the Insure Kids Now search tool below or to find a dental provider. A Health Program Representative can also help you find a provider. Contact an HPR at 1-866-608-9422.
Pregnant women must choose a dental plan or one will be assigned. A dental plan is a managed group of dentists you must use for your dental care. Medicaid has two dental plans. Both dental plans provide the same services. The plans may have different dentists. You must go to a dentist that takes your plan. Call your plan or go to their website to find a dentist in your area. The Medicaid dental plans are below:
Premier Access: 1-877-541-5415
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Whats Preventing Many Individuals From Receiving Oral Care
When understanding the importance of oral health, its also essential to consider the factors prohibiting many individuals receiving preventive and treatment services.
One of the most significant factors keeping Americans from care is the cost of dental services. Having a tooth pulled or receiving jaw surgery is incredibly expensive.
If you dont have insurance or dental benefits on your insurance plan, you either go without care or pay out-of-pocket. Paying out-of-pocket often includes taking out a loan or borrowing money from a friend or family member.
Other factors keeping many Americans from receiving proper dental care may include lack of education regarding oral health, dental anxiety, and racial inequality.
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Can You Buy Dental Insurance While Youre On Medicaid
As a rule, Medicaid beneficiaries are not allowed to hold any type of private health insurance. Thus, a person who works for a wage low enough to qualify for Medicaid enrollment is usually prohibited from participating in an employer-provided medical insurance plan. This is also true for plans bought on a state health exchange. In most states, dental insurance is an exception to this rule.
Because dental care is not mandated to be part of any states Medicaid offering, many program participants are also allowed to shop for dental insurance supplements.
Older adults whose Medicare managed health plans include dental may also rely on Medicaid as a supplement for other benefits. By law, Medicaid is the insurance of last resort, which means that all other insurance coverage must be exhausted before a provider can invoice Medicaid for the unpaid remainder.
Remember that the states each have considerable leeway in how they manage their dental plans, so it is always best to check with a Medicaid worker in your state who can give you definitive information about whether your states Medicaid covers dental care or not.
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Talk To Your State Medicaid Agency
Once you have been enrolled in Medicaid, you need to know what your dental options are. As we mentioned before, each state has different dental care services that they will provide.
Schedule an appointment to meet with your Medicaid agency and discuss your options. Keep note of any questions you have. Once you meet with your Medicaid agency, write down important pieces of information you’ll need such as specific services, procedures, dental providers, and definitions.
Medicaid Vs Private Insurance
At their most basic, Medicaid and private insurance offer health coverage, but their inner workings are different. Medicaid is a state and federally funded program that covers the cost of medical services for low-income parents, children, pregnant women, older adults, those living with disabilities, and women with cervical or breast cancer. These individuals must meet the qualifying income requirements and satisfy other eligibility requirements.
Whether your income level qualifies you or your family for Medicaid depends on your household size and the program youre applying for.
Although the federal government sets the minimum standards for Medicaid, this program gives states a lot of flexibility to customize their programs, including whom to cover, the benefits to provide, and how health care services are delivered. While there are mandatory benefits states must cover, theres also room to cover additional optional benefits.
Payment rates for Medicaid providers and program administrative costs are low, which makes Medicaid a lower-cost coverage compared with private insurance. The result is that beneficiaries can enjoy more-comprehensive benefits at decreased out-of-pocket costs with Medicaid than with private health insurance. In fact, its cheaper to cover adults of similar health status through Medicaid than private insurance.
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Dental Services For Children
Apple Health pays for covered dental services for eligible children, age 20 and younger. The Academy of Pediatric Dentistry recommends all children see a dentist by 12 months of age. Be sure to check the Health Care Authoritys website for the most up to date and accurate list of what is covered services.
Some covered dental services include but are not limited to:
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 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.
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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:
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.
How Medicaid Works With Private Insurance
If you are already enrolled in private health insurance, Medicaid benefits are applied a little differently. While each state has its policies and eligibility requirements associated with Medicaid, individuals struggling to pay premiums can often combine their existing health insurance plan with Medicaid.
Once you have had a visit with your doctor or hospital, the benefits departments coordination determines which of your health insurance plans will be billed for the services. Typically, Medicaid is only charged once the coverage from the private insurer has reached its limits.
Medicaid will then allocate money towards the premium payment and disperse these funds to the individual each month in a check. Listing Medicaid as your primary health insurance provider while also being enrolled in a private health insurance plan will often delay billing. It can cause other issues that can delay benefits. Because Medicaid always is the second-payer option, listing it as such will ensure bills are sent to the correct spot and benefits continue as usual. More information can be found here: Coordination of Benefits & Third Party Liability | Medicaid
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Disadvantages Of Having Medicaid And Private Insurance
If youre eligible for Medicaid, youre no longer eligible for any premium tax credits on Obamacare coverage. As a result, rather than Medicaid saving you money, it could actually increase your premiums if you continue to carry the plan you bought from the Marketplace.
There could also be a disadvantage even if your private insurance plan isnt a Marketplace plan, but is provided by your employer. If you choose to keep Medicaid and your employer insurance, maintaining your employer-sponsored coverage likely means continuing to pay substantial costs for premiums.
How Much Does Medicare Advantage For Dental Coverage Cost
If you are looking for Medicare dental coverage, you may want to consider a Medicare Advantage plan. With a Medicare Advantage plan, you will most likely pay a copayment or coinsurance. This is the same as with any health insurance through the Affordable Care Act.
There also may be an annual limit on how much Medicare Advantage will cover for your dental care, so make sure you read your insurance contract and ask your provider if you have any specific questions pertaining to Medicare dental plans.
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Medically Necessary Dental Work
Since Medicaid is technically a primary health insurance program, it will include some procedures necessary for medical health. Some of the work included would be certain diseases, treatments required in correlation with other medical services covered in the program, and work required to fix non-biting injuries.
Currently, Medicaid will cover dental care when it is medically necessary for all 50 states. However, the state will be the one to determine if the procedure is a medical necessity.
Does Medicaid Cover Dental For Children
Let’s start with the good news. Dental help for children from low-income families is mandatory. States are required to provide dental benefits to children covered by Medicaid. So thankfully, they won’t have to suffer through toothaches and cavities.
The benefits required are listed under the Early and Periodic Screening, Diagnostic and Treatment benefit. If your child has Medicaid dental insurance, it must include:
- Pain relief and infection treatment
- Tooth restoration
- Dental health maintenance
- Any service that is determined to be medically necessary
It is mandatory for the state to cover the same services to children on Medicaid as would be covered by any other private insurance plan. That means a designated dentist, routine cleaning and screening for illnesses.
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Upcoming Changes To Dental Services In Florida Medicaid
In 2016, the Florida Legislature directed the Agency for Health Care Administration to enroll most Medicaid recipients into dental plans. Recipients will receive a dental plan based on the below schedule. The schedule is separated into phases by the recipients county location.
Recipients will begin to receive letters soon. They will be mailed out about 45 days before each phase starts. For example, recipients will begin to receive letters for Phase 1 in the middle of October. For more information, please click on the following link:
Lack Of Access To Dental Vision And Hearing Benefits Affects Enrollees Health
Untreated oral health problems or hearing or vision loss can pose serious risks for overall health. Absence of routine dental care can delay diagnosis of some serious health conditions such as HIV and certain infections and cancers and thereby lead to complications and more costly treatments later. Untreated cavities and gum disease can result in infections, tooth loss, and chronic pain. Lack of teeth, in turn, makes eating difficult, reduces quality of life in other ways, and often causes poor nutrition and related health problems. Gum disease is associated with increased risk of heart disease and stroke, higher mortality for those with kidney disease, higher risk of cancer, and more difficult diabetes management.
Individuals with a range of chronic conditions are more susceptible to oral disease, which can contribute to complications from these chronic conditions and exacerbate their symptoms, including diabetes and respiratory conditions. Untreated periodontal disease in pregnant people may also affect pregnancy outcomes.
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Unitedhealthcare Senior Care Options Plan
UnitedHealthcare SCO is a Coordinated Care plan with a Medicare contract and a contract with the Commonwealth of Massachusetts Medicaid program. Enrollment in the plan depends on the plans contract renewal with Medicare. This plan is a voluntary program that is available to anyone 65 and older who qualifies for MassHealth Standard and Original Medicare. If you have MassHealth Standard, but you do not qualify for Original Medicare, you may still be eligible to enroll in our MassHealth Senior Care Option plan and receive all of your MassHealth benefits through our SCO program.
What Dental Procedures Does Medicaid Cover
Medicaid typically covers some dental services for children, no such requirement exists for adult coverage. States decide what dental services they will cover for adults, so the benefits vary widely from state to state. Medicaid expansion in some states means that adults who previously werent eligible for any dental coverage through Medicaid may now get routine exams, cleanings, and some other basic services covered by Medicaid in their state. To find out if your state covers services like braces, dentures, root canals, wisdom teeth removal, or veneers, contact your local Medicaid office.
Many states limit coverage to only tooth extractions or to specific demographics, such as pregnant women. With the wide flexibility given to the states, many provide only emergency dental services for adult patients. Medicaid does not set a minimum requirement for the dental coverage states provide to adults like they do for children.¹²
As of September 2019, less than half of state Medicaid programs offered comprehensive adult dental benefits. But nearly all 47 states and the District of Columbia offered at least emergency services to their adult Medicaid patients. Emergency services include uncontrolled bleeding and traumatic injuries.¹³
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Does Medicare Cover Anything Dental
Although there is no primary coverage of dental care in Medicare, there is some limited insurance through Medicare Part A, which is hospital insurance. Medicare Part A will cover some dental procedures that happen in a hospital stay. For instance, if youre in a car wreck that damages your jaw and you go to the hospital, Medicare would cover any reconstruction of your jaw.
Medicare may also cover the following types of things:
- A dental exam in a hospital before a kidney transplant or heart valve replacement
- Dental services related to radiation treatment for some jaw-related diseases
- Dental splints and wiring needed after jaw surgery
- Jaw reconstruction if you have surgery to remove a tumor from your face
But if you need a complex dental surgery that has to be done in a hospital, Medicare would cover your hospital stay, but not the dental surgery.
Keep in mind that even if Medicare covers a procedure like the ones listed above, it wont cover any related dental care that might follow from something that happened in the hospital.
How Much Does Dental Care Cost
Regardless of which state you live in, dental procedures can be expensive. An average new patient exam, which usually includes X-rays, cancer screening, consultation and examination, frequently costs between $200 and $300. As high as this price is, even a simple extraction can cost several hundred dollars more.
Fillings, root canals and more extensive work routinely run into the thousands of dollars, which leaves people without dental insurance on the hook to pay hefty bills for needed care.
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