There is one correct answer to whether Medicaid covers dental implants for adults: probably not 100%!
The Medicaid rules for dental care in your state and the reason for replacing teeth affect how much of the costs the program will pay – if anything at all.
Critical Points
Medicaid acts as health insurance uniformly nationwide for care prescribed by a physician.
- It may pay for medically necessary care for all treatment steps.
- Adult recipients rarely qualify under these parameters.
- A Managed Care Organization (MCO) often decides these cases.
Medicaid acts as dental insurance with varying benefits for care prescribed by a dentist.
- It may not pay for all medically necessary treatment steps.
- Each state decides what oral care services to support
- A Dental Benefits Manager (DBM) often decides these cases.
Dental implant treatment often involves up to six separate steps.
Medically Necessary Dental Implants
When medically necessary, Medicaid might pay for some tooth implant services for adults under both elements (health and dental insurance).
However, the definition differs for each component, as does the organization adjudicating claims and the benefits in each state.
Health Insurance
The health insurance component of Medicaid could pay for all dental implant treatment steps or just a handful. Your physician must prescribe the medically necessary treatment.
Health Definition
Medically necessary dental work covered by the health insurance component fits strict criteria applying uniformly nationwide.
- Diagnose or treat a sickness, injury, or symptom
- Suitable for the health problem
- Within usual standards of care by doctors
- Not more expensive than another service
- Part of another covered treatment
Health Claims
In most states, private third-party companies administer Medicaid claims under the health insurance element. File a pre-authorization request with one of these three-lettered entities before starting treatment.
- Managed Care Organization (MCO)
- Accountable Care Organization (ACO)
- Managed Care Enterprises (MCE)
Your Medicaid member ID should have the contact information of your MCO, ACO, or MCE. Below is a sample listing.
Dental Insurance
The dental insurance component of Medicaid might pay for specific tooth implant services, but not all. Your dentist must prescribe each medically necessary treatment.
Of course, your state must support the specific service, and benefits for oral care vary based on where you live.
Dental Definition
Medically necessary dental work prescribed by a dentist has varying benefits for adults in each state. Oral care services covered by the dental insurance component fit lenient criteria.
- Controlling or eliminating infection
- Alleviating pain and disease
- Restoring facial configuration
- Bring back function necessary for speech, swallowing, or chewing
Dental Claims
In most states, private third-party companies known as Dental Benefits Managers (DBM) administer Medicaid claims under the oral care component.
Contact your DBM before beginning any treatment step to verify coverage. Below is a sample listing.
- Liberty Dental Plan
- Managed Care of North America (MCNA)
- DentaQuest (Sun Life Company)
- Delta Dental Insurance
Dental Implant Treatment Steps
Medicaid sometimes covers specific dental implant treatment steps for adults. You do not get permanent artificial teeth in one day. The process takes months and occurs in stages.
At each stage, the care must be medically necessary as defined by the health insurance (covered nationwide) or dental insurance component (varies by state).
Choosing local dental specialists who accept Medicaid is also crucial, as you may need care from an oral surgeon, prosthodontist, or general dentist.
Tooth Removal
Medicaid sometimes covers the first dental implant treatment step (problematic tooth extraction) under both components (health and dental insurance).
The health insurance element pays for tooth removals that are medically necessary nationwide. Examples include the following.
- After a non-biting accidental injury, dislodging, or breaking teeth
- Before radiation treatment for cancer of the neck or jaw
- Before heart surgery to reduce the risk of infection
- When a wisdom tooth is bone-impacted – not soft tissue (gum)
The dental insurance component pays for caries-decayed tooth extraction in roughly twenty-eight states supporting oral surgery benefits. Coverage might expand slightly if a general dentist can remove abscessed or infected molars, bicuspids, or incisors.
Imaging Studies
Medicaid will sometimes pay for dental implant imaging studies under both components (health and dental insurance). Your dentist needs to study the strength of your jawbone and any remaining teeth.
The dental insurance element might cover bitewing or panoramic x-rays in the thirty-nine states supporting benefits for preventive services.
The health insurance component might pay for advanced imaging techniques such as CT scans when medically necessary. For example, patients with osteoporosis or cancer could fit the criteria.
Bone Grafting
Medicaid will sometimes pay for bone grafting needed to support dental implants, but primarily under the health insurance component. You must demonstrate an acceptable reason to rebuild diseased or damaged jaw tissue via surgery.
Medically necessary bone grafting addresses a disease or injury. Have the oral surgeon’s billing office include appropriate ICD-10 diagnosis codes when submitting claims to your MCO.
| Medical Condition | ICD-10 Diagnosis Code |
|---|---|
| Severe atrophy of mandible | K08.23 |
| Jaw pain | R68.84 |
| Oral tumors | C06.9 |
| Accidental trauma to the oral cavity | S09. 93XA |
| Difficulty eating | R63.3 |
Implant Placement
Medicaid rarely pays for implant placement surgery. In this step, an oral and maxillofacial surgeon inserts titanium screws into your jawbone to serve as the roots for missing teeth.
Unlike previous procedure steps, the surgical placement of the titanium screws is not medically necessary by itself. You must establish that the entire treatment protocol is the least expensive treatment alternative for your health problem. Your odds of success are low.
Dental implant payment plans are more affordable than you might think. Your mouth and jaw need months to heal after extractions and this surgery (osteointegration). Spread costs over time.
Abutment Placement
Medicaid rarely covers the additional surgery to place the abutment. In this step, your oral surgeon opens your gums and attaches the abutment to the titanium screw previously embedded in your jaw.
As with the screw insertion, the abutment placement is not medically necessary by itself. You must establish that the complete process is the least costly alternative to correct the diagnosed health condition.
Artificial Tooth
Medicaid is more likely to pay for implant-supported dentures under the dental insurance component. However, the devil is in the details.
Medicaid covers dentures and crowns in thirty-three states through the oral care element. Of course, the least costly treatment rule makes claims approval tricky.
Contact the DBM managing your plan to verify the ADA codes they support for dentures, pontics, crowns, and bridges. You might get lucky!
States Covering Dental Implants
All states might cover dental implants through Medicaid under their health insurance umbrella when deemed medically necessary. However, most recipients will fail this test.
Fewer states pay for specific tooth implant treatment steps through Medicaid under their dental insurance component. Meanwhile, most recipients fall into this category, while oral care benefits vary.
California
Medicaid in California (Medi-Cal) publishes documents verifying that it covers dental implants through the health insurance element when deemed medically necessary for recipients age 21 and older.
Medi-Cal exempts specific services from a $1,800 per year benefits cap for each recipient. You must submit a Treatment Authorization Request (TAR) documenting medical necessity for listed treatments.
“Maxillofacial services, including dental implants and implant-retained prostheses” are included in the list of treatments exempt from the cap. Therefore, file a TAR in advance.
New York
The Medicaid coverage rules for dental implants in New York differ significantly from those in other states. A recent court case (Ciaramella v. McDonald) forced NY to loosen documentation requirements.
New York expanded Medicaid dental benefits (effective 1/31/24), including tooth implants. The new rules make it easier to get all procedure steps covered.
- It is no longer required to provide a letter from a physician
- The dentist must explain why implants are medically necessary
You no longer need to show that implants would alleviate a medical condition - The Prior Authorization Form does not need to be notarized
Indiana
Medicaid in Indiana does not pay for tooth implants for adults through its dental insurance component. Furthermore, the type of Healthy Indiana Plan (HIP) a recipient has determines whether it covers individual treatments.
Dental benefits vary for the various HIP levels.
| HIP Basic | HIP Plus | HIP State | |
|---|---|---|---|
| Extractions | X | X | |
| Panoramic X-rays | X | X | X |
| Oral Surgery | X | ||
| Crowns | X | X | |
| Dentures | X |
Missouri
Medicaid in Missouri does not pay for early-stage dental implant treatment steps under its oral care umbrella unless you count tooth removal. Until very recently, the Show Me State offered no benefits for adults.
Now, Missouri Medicaid covers minimal dental services: examinations, X-rays, cleanings, fillings, and extractions. Recipients must pay for restorative services if they want to replace missing teeth unless they have a medically necessary reason under the health insurance element.
Wisconsin
Wisconsin Medicaid (BadgerCare) provides comprehensive dental benefits for adults while specifically ruling out tooth implants under its health insurance umbrella.
BadgerCare might approve claims for specific treatment steps through the dental insurance element: extractions, imaging studies, oral surgery, and dentures.
BadgerCare excludes dental implant services whether or not a dentist or physician performs the service.
- Tooth implants
- Transplantations
- Surgical repositioning except for reimplantation
- Transseptal fiberotomies
Other States
Other state Medicaid programs might pay for tooth implants. Follow the logic and examples cited above to see if your program will support specific claims.
- Contact the MCO to determine if the health insurance element might cover medically necessary treatment steps after a non-biting accident or cancer recovery.
- Contact the DMO to determine whether the dental insurance component might pay for preliminary treatments such as imaging studies, extractions, and oral surgery.
