Wv Medicaid Dental Coverage For Adults

Mountain Health Trust And The West Virginia Health Bridge Alternative Benefit Plan

Mountain Health Trust and the West Virginia Health Bridge Alternative Benefit Plan are the managed care organizations for the West Virginia Medicaid program. Once accepted into the program, you will receive a packet in the mail which will tell you which MCO program you are in. The main differences between the two programs are a few coverage limits. For example, the Health Bridge program does not include nursing home coverage and has a limit of 24 chiropractic treatments per year. On the other hand, the Health Bridge program allows for 30 physical and occupational therapy visits per year instead of the traditional 20, and 100 home health visits instead of 60. Whichever program you qualify for, you will receive detailed information about your coverage limits in the mail upon your acceptance.

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.

About Medicaid

Medicaid is the nations 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

• Seniors with low incomes
• Parents or caregivers with low incomes

Cms Learning Lab: Improving Oral Health Through Access

The Center for Medicaid and CHIP Services at the Centers for Medicare & Medicaid Services is hosting a series of webinars to support States and their collaborative partners to improve access to dental services for children enrolled in Medicaid and CHIP. The webinar materials are available below. For more information about the CMS Oral Health Initiative and the CMS Learning Lab webinars, see the .

Reducing Early Childhood Tooth Decay: Approaches in Medicaid May 27, 2015

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A 2018 research study determined that recipients who had vision care were more likely than those who didnt to hold full-time jobs and work longer hours.

Brandy Lipton, a UC Irvine public health associate professor and co-author of that study, said a reason that could explain the phenomenon is people with the additional coverage were more likely than their counterparts to drive to work.

We think that could be one thing behind the additional hours, Lipton said. You dont have to worry about catching public transportation at a certain time. You can just get in your car and go.

Dentists In Wv That Accept Expanded Medicaid

10/22/2021

Health Care for All WV created a resource to help WV residents with Medicaid access the new dental benefits. According to The National Institute for Health Care Management, dental care is a crucial part of physical health. Untreated gum disease can lead to heart disease, diabetes, and strokes. Many Americans lack access to affordable dental care and thus these issues go untreated. Learn more at

Part of the solution that HCFAWV has helped with setting in motion, is the passing of an expansion of Medicaid to cover $1000 a year in preventative dental care. They are hoping to expand the amount covered to keep our fellow West Virginians healthy and smiling.

Unfortunately, there previously hasnt been an easily accessible source of information about which dental offices in West Virginia are accepting new patients, and many book several months in advance. Health Care for All WV just finished a comprehensive list of every dentist in WV who is accepting this extended plan. It also includes the offices that only accept Medicaid for children to free up spaces for adults at the offices that accept the adult plan. All info to the offices including name, location, phone number, and any additional notes are now available through a specially created

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One In Five West Virginia Adults Will Gain Access To Dental Benefits On January 1

One of the most significant bills passed during the 2020 legislative session is expected to go into effect on January 1, 2021. SB 648 adds a dental benefit to the states adult Medicaid program, extending this important coverage to an estimated 310,733 West Virginia adults. The legislation provides for each adult Medicaid recipient to be eligible for up to $1,000 in dental care each calendar year, including preventive, diagnostic, and restorative services such as the provision of dentures, dental implants, bridges, and crowns, and corrective procedures like root canals.

Prior to the legislation, West Virginia was an outlier, offering only emergency extractions to adult Medicaid enrollees, with 36 states offering more extensive dental benefits to this population. This left many adults with no choice but to wait until a tooth was at the point of needing to be pulled to receive dental care. In addition to overall oral health, many chronic health conditions are impacted by untreated oral conditions, including atherosclerotic disease, osteoporosis, kidney disease, and pregnancy complications. Poor oral health, including loss of teeth, also impacts employability and absenteeism, worsening residents financial stability and our states economy.

Below is a breakdown of the estimated number of adults per county who will gain access to dental benefits when the legislation goes into effect on January 1.

Individuals Under Age 21

EPSDT is Medicaid’s comprehensive child health program. The program’s focus is on prevention, early diagnosis, and treatment of medical conditions. EPSDT is a mandatory service required to be provided under a state’s Medicaid program.

Dental services must be provided at intervals that meet reasonable standards of dental practice, as determined by the state after consultation with recognized dental organizations involved in child health, and at such other intervals, as indicated by medical necessity, to determine the existence of a suspected illness or condition. Services must include at a minimum, relief of pain and infections, restoration of teeth and maintenance of dental health. Dental services may not be limited to emergency services for EPSDT recipients.

Oral screening may be part of a physical exam, but does not substitute for a dental examination performed by a dentist as a result of a direct referral to a dentist. A direct dental referral is required for every child in accordance with the periodicity schedule set by the state. The Centers for Medicare & Medicaid Services does not further define what specific dental services must be provided, however, EPSDT requires that all services coverable under the Medicaid program must be provided to EPSDT recipients if determined to be medically necessary. Under the Medicaid program, the state determines medical necessity.

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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.

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Despite Reforms Medicaid Dental Care Still Leaves People With Expensive Problems

Until recently, West Virginias Medicaid offered no adult dental care except for emergency procedures like tooth extractions.

In March 2020, the Legislature revised the insurance program to add additional coverage. When the change took effect in January 2021, it gave recipients up to $1,000 of coverage for services like cleanings, root canals and dentures.

After that, Farlow started scheduling regular dentist appointments, checkups he hadnt been able to afford for about 15 years. But he quickly learned that his new dental insurance wont go very far. His dentist told him that, in the near future, he will need a full set of bottom dentures and four top teeth replaced he knows that type of procedure would far exceed $1,000.

I dont want to knock a gift, Farlow said. Its wonderful, great to have it. for the work I need, its not going to cover it in one year.

Jonathan Hill, a dentist who co-runs a private practice in Hurricane, said that Farlows experience is typical of many Medicaid recipients he treats.

In its current form, the states Medicaid program forces him and his patients to make difficult choices about which health problems they can and cant address.

I have multiple examples where a patient has 12 cavities but also hasnt had a cleaning in 10 years, he said. You just cant do everything you want to do, and that happens actually quite frequently.

Dental Insurance In West Virginia

West Virginia uses the federally facilitated health insurance marketplace HealthCare.gov for the sale of certified individual/family dental plans.

Not all insurers who offer medical plans through the West Virginia exchange include dental coverage with their health plans, but stand-alone dental plans are available for purchase that cover both adults and children.

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When Does Medicaid Cover Dental Care

Find Cheap Health Insurance Quotes in Your Area

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.

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.

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One Insurer Offers Stand

In 2022, there is only one insurer offering stand-alone individual/family dental coverage through the health insurance marketplace in West Virginia. These are dental plans that are not included with a medical plan and must be purchased separately:

• Delta Dental PPO

These plans can be purchased through HealthCare.gov during open enrollment or during a special enrollment period triggered by a qualifying life event. Exchange-certified stand-alone dental plans are compliant with the ACAs rules for pediatric dental coverage.

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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Does Medicaid Cover Dental Work For Adults In Your State

Determining whether Medicaid covers a specific dental procedure for adults in 2022 requires detective work. The included treatments vary by state, reason, plan, and cost of alternative methods.

First, each state has unique rules about which dental specialty areas they include.

Second, Medicaid is health insurance across the country, which means all recipients might enjoy benefits for medically necessary services.

Third, the least expensive alternative rule affects what your plan might pay for implants, dentures, orthodontia, and other services.

Finally, the Medicaid dental plan charged with processing claims for your family is the final authority not this article or any other.

Dental Benefits For Children In Medicaid

Medicaid covers dental services for all child enrollees as part of a comprehensive set of benefits, referred to as the Early and Periodic Screening, Diagnostic and Treatment benefit. Though oral screening may be part of a physical exam, it does not substitute for a dental examination performed by a dentist. A referral to a dentist is required for every child in accordance with the periodicity schedule set by a state.

Dental services for children must minimally include:

• Relief of pain and infections
• Restoration of teeth
• Maintenance of dental health

The EPSDT benefit requires that all services must be provided if determined medically necessary. States determine medical necessity. If a condition requiring treatment is discovered during a screening, the state must provide the necessary services to treat that condition, whether or not such services are included in a state’s Medicaid plan.

Each state is required to develop a dental periodicity schedule in consultation with recognized dental organizations involved in child health care. Dental services may not be limited to emergency services for children entitled to EPSDT.

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The Wv Medicaid Formulary And Prescription Drug Coverage

The West Virginia Medicaid program has a comprehensive prescription drug program. The drugs on the preferred drug list will act as your formulary. Youll also find information about prior authorization, meaning that there are certain drugs that you will need to have Medicaid approve before you retrieve your prescription at the Medicaid rate.

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 Hampshires Medicaid program, which currently only covers emergency dental care, will start providing extensive dental benefits on April 1.

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Free Clinics Offer Some Coverage But Only To Those Who Can Access Them

While some Medicaid patients seek out their annual $1,000 worth of care from private dentists like Hill, access to even that basic level of care is still an issue. Only about half of West Virginias 880-some dentists treated Medicaid patients last year, according to the states Board of Pharmacy and Bureau for Medical Services.

For those who cant get care from a dentist, or need work that exceeds their benefit, free clinics can fill gaps in certain areas of the state.

In Clarksburg, Health Access sits on a hill above the city center, just within eyeshot of old brick buildings downtown.

The idea in 1992 waswere going to take care of folks who are uninsured just for a short time until our government figures out what to do, said Josh Brown, Health Accesss executive director. Here we are 30 years later, and I dont think were any closer today than we were in 1992.

The West Virginia Department of Health and Human Resources supports nine comprehensive free clinics across the state, including Health Access. Inside its doors, uninsured and underinsured Harrison and Doddridge County residents receive free medical care ranging from chronic disease management to orthopedic medicine.

Every other Friday, that includes dental work. Roger Suter, a dentist who runs a nearby practice, treats patients for as much work as they need without the fear that theyll leave the clinic with a bill.

A New Oral Health Outlook For 2 Million Americans

Its a troubling reality youve likely read about before: Millions of Americans, especially those with lower incomes, people of color, and those living in rural communities, cannot secure the dental care they need due to a variety of factors, including cost, coverage, provider availability, and social determinants of health. As a result, there are wide disparities across racial, ethnic, and income groups. Those disparities result in poor oral health, which has been associated with higher risk for diabetes, cardiovascular disease and stroke, complications in pregnancy and childbirth, adverse mental health outcomes, and other conditions that are costly to treat.

But hope and significant activity is on the horizon.

During the 2022 legislative sessions, Hawaii, Kansas, Maryland, New Hampshire, and Tennessee enacted legislation and budget measures to create or expand Medicaid adult dental benefits, which can help reduce those disparities and improve much-needed access to dental care. That means that nearly 2 million people will soon be gaining access to Medicaid dental benefits.

Further, several other states have secured additional legislative and administrative victories for their Medicaid programs that will expand eligibility, coverage, and access to care.

How We Got Here

Advocates and policymaker champions work daily to try to change that.

Progress and Momentum in 2022

Heres a rundown of the latest developments from the 2022 legislative session:

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Pediatric Dental Benefits In West Virginia

The pediatric stand-alone dental policies available on the West Virginia marketplace will comply with the ACAs pediatric dental coverage rules. For residents, this means out-of-pocket costs for childrens dental care will not exceed $375 per child in 2022 , and there isnt a cap on medically-necessary dental services.

As is the case for all essential health benefits, the specific coverage requirements for pediatric dental care are guided by the states essential health benefits benchmark plan.

You can see details here for West Virginias benchmark plan, which does include coverage for both basic and major dental services for children.