Medicaid Dental Benefits

There are many people that are enrolled in Medicaid and receive benefits, but are not aware of the fact that there are dental benefits available.  Dental benefits are available as an option to individuals over the age of 21 who are enrolled in Medicaid.  These benefits are a required benefit for individuals under 21.  They are a component of the Early Periodic Screening and Diagnostic Treatment (EPSDT) portion of Medicaid. 

EPSDT is a mandatory program through Medicaid and it focuses on prevention, early diagnoses and treatment, beginning with children and continuing through the age of 21.  Dental services must be provided through this program in an effort to watch for any problems or illnesses and address them before they become worse, or before they become chronic conditions.  At the very least, services must include relieving the child of pain and eliminating infection, restoring teeth and helping children and young adults maintain dental health.  While some plans (usually private) only deal with emergency dental issues, this is not the case with EPSDT.  EPSDT must provide regular services and not only help people when there is an emergency.  The idea is that regular treatment will diminish or eliminate dental emergencies, thus keeping the system efficient and not creating additional problems for the client either.

The state sets up dental referrals at various intervals and the dentist is required to do a thorough exam, not just an oral screening only.  ESPDT requires that all services covered by the Medicaid program must be provided to recipients as long as they are Medically Necessary procedures or services.  In other words, if you have a cavity or need a root canal and it is necessary to be fixed, those services are covered.  If, however, you are thinking of getting implants or special veneers, these services might not be covered, since they are often considered “cosmetic” procedures – not only by Medicaid, but by private dental insurance plans, as well.  If a condition is discovered during an exam or screening, the state is obligated to provide treatment for that condition, even if it is not covered through the state’s dental coverage.

For further information and answers to your questions, contact Centers for Medicare and Medicaid Services (CMS).  You can find them on the web at www.Medicare.gov and www.Medicaid.gov. or you can call them at 1-800-633-4227 (1-800-Medicare).

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