Medicaid Dental Coverage

Medicaid is a joint program by the Federal government and the States to provide health coverage for the impoverished, the aged and the disabled. Eligibility standards and requirements must be met in order for one to qualify for Medicaid coverage.

While dental services under Medicaid are an optional service for adults, it is a required element of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit for people below 21 years old.

EPSDT focuses on the prevention, early diagnosis and treatment of medical conditions and is a mandatory service under Medicaid. All states are mandated to provide comprehensive, preventive, restorative and emergency dental procedures to children less than 21 years of age. It is important to note however, that the definition for these services vary from one state to another.

Oral care and services must be provided at a standard of six-month interval established by your dentist and the EPSDT program. As indicated by medical necessity, the number or frequency of visits may be increased upon determination of the state. Basic dental services provided under Medicaid may include, but are not limited to, pain relief, treatment of infections, restoration of teeth, preventive dental care and specific dental procedures as deemed necessary by the state.

A direct dental referral is required for every child in conformity with the scheduled frequency of visits set by the state. The EPSDT program requires that all services that may be covered by Medicaid must be given to its beneficiaries especially if they are ascertained to be medically necessary even though the Centers for Medicare & Medicaid Services has not explicitly defined the dental care that must be afforded.

States have the option whether or not to provide dental care and services to adult Medicaid beneficiaries. The Federal government has not mandated any minimum requirements for adult dental coverage.

Many people see disadvantages to Medicaid dental coverage. One is the fact that very few dentists participate in the Medicaid dental program, and a thorough research needs to be done in order to locate a dentist who will accept Medicaid.

There are many reasons for this. Since Medicaid does not pay for all the costs of certain dental procedures, and the reimbursement rates are significantly lower than private insurance companies, many dentists opt out of participating in Medicaid programs.

Another reason for the low dentist participation rate is because Medicaid requires enrollment fees, non-standard billing forms and authorization prerequisites among others. These turn off dentists from wanting to take part in the Medicaid dental program.