Finding a local dentist that accepts Medicaid is an enormous challenge, especially for adults needing specialized care for major oral health problems.
Getting appropriate treatment from a qualified provider is hit or miss for many reasons. It is easy to get lost in a maze of government red-tape.
Low-income patients often need a roadmap to help them navigate the twists and turns and an early-warning system of possible roadblocks.
First, understand why many dentists do not take Medicaid. Then, identify neighborhood specialists – if covered in your state. And finally, locate the provider directory published by the administrator of your plan to compare the lists.
Why Dentists Don’t Take Medicaid
Five primary reasons explain why many dentists might not accept Medicaid for adults for a specific oral care procedure.
- Reimbursement rates are meager compared to private plans
- Providers cannot balance bill for any remaining charges
- The least costly alternative guideline rules out profitable treatments
- Many programs do not cover the services patients need most
- Multiple plans in each region split the participating providers
Grasping how these factors play out in your region can shorten the time needed to find a local dentist with the qualifications to treat your precise condition.
Dental assistance programs are the primary alternative for low-income adults unable to find a dentist willing to take Medicaid because of one of the reasons noted above. Most often, your plan will not cover the needed procedure.
Two approaches might help you pay for expensive oral care you cannot afford.
- Free clinics and dental schools could lower costs for low-income patients
- Grants programs might offset a portion of expenses if you qualify
The dental services covered by Medicaid varies state-to-state. The inclusion or exclusion of benefits for a specific treatment is the primary factor determining whether a neighborhood dentist might accept you as a patient.
Take any specialized service, and the odds are about 50% that your plan might cover the treatment. For example, only twenty-six states include coverage for major restorative procedures: cavities, dentures, root canals, etc.
A dental specialist is highly unlikely to take Medicaid if it does not pay for the type of treatment you need.
Each state also contracts with several private insurance companies to administer multiple Medicaid plans with unique provider networks. Even if a dentist accepts Medicaid, the provider still might not take you as a patient if the office does not participate with your specific plan.
Providers might participate in one plan, all plans, or none at all. Therefore, verifying network status with the private company administering your policy is critical.
This chart illustrates the intersection point you must find. The following sections on specialties and plan variations narrow things down.
Medicaid Dental Providers
The first step to finding local dental providers that accept Medicaid for adults is determining whether your state covers a specific procedure and then finding a nearby specialist.
A prosthodontist is a dentist that specializes in the treatment of facial disorders and missing teeth. For example, you might consult with a prosthodontist if you need implants, dentures, bridges, crowns, or need to correct temporomandibular disorders (TMJ/TMD).
However, implants never qualify for payment because of the least costly alternative rule.
The American College of Prosthodontists publishes a directory of members, which is a reasonable first step when narrowing down your search. Afterward, make sure to cross-reference state coverage, brand names, and administering companies.
An endodontist is a dentist specializing in the cause, diagnosis, prevention, and treatment of tooth pulp diseases. For example, you might consult an endodontic specialist when you need a root canal.
The American Association of Endodontists publishes an online member directory, helping you find a local office. However, you may still need to cross-reference your state’s coverage, the program brand name, and outsourced administrator.
An oral and maxillofacial surgeon treats diseases, injuries, and defects of the mouth, teeth, jaws, face, head, and neck. For example, you might seek an oral surgeon to perform a bone graft or an apicoectomy after a failed root canal.
However, oral surgery coverage has two components that impact your ability to verify whether an office accepts Medicaid as payment in full for all possible services. For example, bony-impacted wisdom tooth extractions fall into both categories.
- The health insurance component addresses medically necessary procedures uniformly across the country
- The dental insurance component addresses traditional oral care treatments in only twenty-four states
The American Association of Oral and Maxillofacial Surgeons (AAOMS) publishes an online member directory, which provides a starting point for finding a local office. Again, make sure to cross-reference state coverage, brand names, and administering companies.
An orthodontist is a dentist that specializes in moving teeth and aligning jaws so that patients can bite, chew, and speak comfortably and effectively. For example, you might seek out an orthodontist if a malocclusion interfered with one of these functions.
However, Medicaid covers elective orthodontic braces for adults in only Oregon and the District of Columbia. The limited coverage means that patients in the remainder of the country will have to pay for braces, headgear, Invisalign, and retainers themselves as an out-of-pocket expense.
The American Association of Orthodontics maintains an online directory of members, a good starting point for patients with medically necessary needs: the braces treat an injury, disease, or symptom such as sleep apnea.
A periodontist is a dentist specializing in the care and treatment of gum disease and other oral inflammation areas. For example, you might consult a periodontist if you need deep cleaning (scaling and root planing) or gum surgery.
The American Academy of Periodontology publishes an online member directory, which serves as a starting point for a local office. Be sure to cross-reference this list with your state’s coverage parameters and the regional brands and administrator companies.
Emergency dentists provide immediate treatment to stop ongoing tissue bleeding and alleviate severe pain or infection. For example, you might need to book an appointment with an emergency dentist after you accidentally chip or dislodge a tooth and your gums will not stop hemorrhaging.
Fortunately, Medicaid covers emergency dentistry in all fifty states. Therefore, your task becomes quickly finding a local office that takes Medicaid, which leads us to the next section: how to identify your agency or company and locate their online provider directory.
Medicaid Dental Plans
The second step to finding a local dental office accepting Medicaid for adults is uncovering the provider directory of your plan’s correct agency or third-party administrator.
This task is often more challenging because you have to sort through the confusing maze of brand names and the frequent outsourcing of functions to private companies. Plus, Medicaid offers a myriad of programs.
The company managing your plan is often the final authority on whether a specific dentist accepts Medicaid in your area. Many government agencies outsource the administrative functions of this public program to private organizations.
Then, some of these independent companies handle all tasks, 100% themselves, and other times they subcontract with yet another organization specializing in oral care.
Because Medicaid is primarily healthcare for low-income families, the regional agencies often outsource administrative functions to private organizations specializing in this industry.
Therefore, you may need to identify the third-party administrator connected with the healthcare component and isolate the online provider directory associated with your plan. This list of private companies and their states of operation might prove helpful.
- Aetna Better Health: CA, FL, IL, KS, KY, LA, MD, MI, NJ, NY, OH, PA, TX, WV, VA
- Amerigroup: NJ
- Anthem: CA, IN, KY, NV, VA, WI
- Blue Cross Blue Shield: is a national federation of affiliated companies using this trade name, operating in twenty-four states
- Caresource: GA, IN, OH
- Emblemhealth: NY
- Fidelis: NY
- Healthfirst: NY
- Humana: FL, IL, KY
- Meridian: IL, IA, MI
- Metroplus: Five boroughs of NCY – Bronx, Brooklyn, Manhattan, Queens, and Staten Island
- Molina: CA, FL, ID, IL, KY, MI, MS, NM, NY, OH, SC, TX, UT, WA, WI
- MVP: NY, VT
- United Healthcare: Offers plans across the country
- UPMC Health Plan: PA
- Sunshine Health: FL
- Staywell: FL
- Wellcare: AZ, FL, GA, HI, KY, MO, NE, NJ, NY, SC
In many cases, the healthcare organizations noted above do not have expertise in oral care. Therefore, they outsource the administrative aspects of dental insurance to companies that specialize in this area.
As a result, your ultimate authority on whether a particular dentist takes Medicaid might be the provider directory published by a dental benefits administrator. One of these outfits could be your final destination.
- Delta Dental
- Managed Care of North America (MCNA)
Many government agencies dream up creative brand names, adding a layer of confusion when identifying a local dentist accepting Medicaid. Many have more than one program with unique branding.
The chart below serves as a common starting point. Searching by any of these branded names might take you to a government-run website. From there, you must find the private dental benefits administrator connected to your plan and locate the correct provider directory.
|State||Brand 1||Brand 2|
KY Health Choices
NJ Family Care
Finally, Medicaid offers numerous programs designed for specific groups, adding yet another layer of complexity when searching for nearby dentists that take your plan.
Enrolling in one of these special programs could expand or contract your access to dental benefits.
- Pregnancy Medicaid covers pregnant women who meet income eligibility rules
- Dual Eligible Special Needs Plans (DSNP) for people who have Medicare also
- Children’s Health Insurance Plans (CHIP) covers kids when parents earn too much
Break the problem down into bite-size chunks when looking for a local dentist that accepts your Medicaid plan for the precise treatment you need. A blanket approach is unlikely to lead to your destination.
First, the state where you live dictates the types of oral care benefits available. Many providers will not take you as a patient if your plan does not cover the recommended procedures.
Second, the provider directory published by the private insurance company is the ultimate authority. However, finding this resource could prove tricky because of the many different third-party administrators and confusing array of brand names to sort through.
Be persistent and follow the provided road map to find your answer. Just be prepared for a plan B – given the many obstacles.