Determining whether Medicaid covers a specific dental procedure for adults in 2023 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.
What Dental Services Does Medicaid Cover?
The dual nature of Medicaid determines what dental services your Medicaid plan will cover in 2023 for adult patients. There is no single correct answer, and the private company processing claims is the final authority.
Finding a local dentist that accepts Medicaid hinges on these two key concepts.
- The health insurance component of Medicaid pays for medically necessary oral care uniformly across the country, and a Managed Care Organization (MCO) administers claims
- The dental insurance element of Medicaid pays for oral care that is not medically necessary unevenly in each state, and a Dental Benefits Manager (DBM) makes claims determinations
Dental grants for low-income adults can offer a more viable avenue to fix your teeth if you live in one of the many states with limited or no benefits.
Medicaid sometimes covers restorative dental services for adults under both program modules. Restorative care repairs or replaces decayed, damaged, or missing teeth.
Medicaid pays for dental implants under the health insurance component when medically necessary: to prevent further bone atrophy caused by diseases such as diabetes, digestive disorders, or osteoporosis, or to strengthen the jawbone after accidental fractures or surgery to remove cancerous lesions
Medicaid pays for other restorative treatment under the dental insurance element when a state supports the benefit, subject to other possible limitations.
- Dentures when the recommended false teeth are the least costly treatment alternative
- Root canals that do not trip state-specific exclusions
- One root canal per tooth per lifetime
- Root canal of front incisors only
- 2nd & 3rd molar root canals excluded
- Crowns, when the recommended cap placed over the damaged tooth, does not violate the least expensive treatment option
- Ceramic crowns for front incisors
- Porcelain fused to metal crowns for molars
States Supporting Restorative Care 2023
|New Mexico||New York||North Carolina|
|Pennsylvania||Rhode Island||South Carolina|
Medicaid sometimes covers oral surgery services for adults under both program modules. An oral and maxillofacial surgeon treats diseases, injuries, and defects of the mouth, teeth, jaws, face, head, and neck.
Medicaid pays for oral surgery under the health insurance component when medically necessary.
- Wisdom tooth removal of bone-impacted third molars that cause pain, infection, and develop cysts
- Corrective jaw operations that reconstruct facial and body defects caused by congenital deformities, accidents, or illnesses
Medicaid pays for other oral surgery services under the dental insurance element in the states that provide the benefit.
States Supporting Oral Surgery 2023
|New Jersey||New Mexico||New York|
|Pennsylvania||Rhode Island||South Carolina|
Medicaid covers emergency dental services for adults across the country. However, the two components work differently with urgent care.
Paying for emergency dental work without insurance should not be an issue for recipients learning about these distinctions.
The health insurance component should consistently pay for medically necessary emergency dental work (arising from non-biting accidents, certain diseases, and treatments considered integral to other services included in the plan) across the country.
- Extractions of broken teeth after an accident
- Root canals after non-biting trauma
The dental insurance element pays for differing layers of emergency dental care associated with tooth decay and gum disease based on residence state.
Sixteen states provide limited emergency oral care services only.
- Procedures necessary to control bleeding, relieve pain or eliminate acute infections
- Services that are required to prevent “pulpal death” and the imminent loss of teeth
States Supporting Emergency Care Only 2023
If you live in one of the thirty-four remaining states, see below to determine the other emergency dental services your coverage might include. For instance, those with oral surgery benefits might have benefits for urgent extractions of painful teeth.
Medicaid rarely covers orthodontic dental services for adults under either program module. However, every rule has exceptions.
Medicaid pays for braces for adults under the health insurance component when medically necessary: the orthodontia prevents, diagnoses, or treats an injury, disease, or its symptoms. Examples include repositioning teeth after a non-biting accident or treating sleep apnea or Temporomandibular Joint Disorders (TMJ or TMD).
Medicaid does not appear to cover orthodontic braces under the dental insurance element in any state. The time to address a handicapping malocclusion is before reaching your 21st birthday.
Medicaid sometimes covers preventive dental treatments for adults. Preventive services might include regular oral exams, cleanings, fluoride application, sealants, and X-rays that help patients avoid decay, gum inflammation, and tooth loss.
Thirty-one states pay for preventive dental services under the oral care element.
States Supporting Preventive Care 2023
|Nebraska||New Jersey||New Mexico|
|New York||North Carolina||North Dakota|
|Rhode Island||South Carolina||South Dakota|
Medicaid covers periodontal dental services for adults less frequently, as fewer states provide benefits for preventing, diagnosing, and treating gum diseases such as gingivitis.
If you live in one of the nineteen states with relevant benefits under the oral care element, your plan could pay the periodontal treatment costs of these common procedures.
- Deep cleaning (root planing and scaling)
- Gingival flap surgery to treat late-stage disease
- Gum grafting to address receding gum lines
States Supporting Periodontal Care 2023
|New Mexico||New York||North Carolina|
|North Dakota||Pennsylvania||Rhode Island|
Medicaid does not cover cosmetic dental services for adults under either program module in any state. Cosmetic procedures change healthy tissue to enhance appearance and symmetry rather than improve the function of a patient’s teeth, gums, or bite.
In other words, Medicaid will not pay to alter the shape, color, position, and alignment of your teeth or gums, including these procedures and others.
- Teeth whitening or bleaching
- Lumineers or labial veneers
- White Fillings
Filing Claims with Medicaid Dental Plans
Filing a claim with the correct Medicaid dental plan is the only way to know if you have coverage for a specific oral care procedure. This article and others are not the final authority; the organization adjudicating claims determines that.
Managed Care Organizations
Each state chooses at least one (often more) Managed Care Organizations (MCO) to process dental claims for the health insurance component of the program. An MCO is a private third-party company specializing in healthcare administration.
Find the MCO name on your member ID card. File your claim with this Medicaid dental plan when you have a medically necessary reason prompting the need for oral care.
As you can see, many MCOs operate in many states.
- 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 nationwide
- UPMC Health Plan: MD, OH, PA, WV
- Sunshine Health: FL
- Staywell: FL
- Wellcare: AZ, FL, GA, HI, KY, MO, NE, NJ, NY, SC
Dental Benefits Managers
Many MCOs outsource the processing of claims to Dental Benefits Managers (DBM) under the dental insurance element of the program. A DBM is a private third-party company specializing in oral health administration.
Find the DBM name on your member ID card or MCO website. File your claim with this Medicaid dental plan when you do not have a medically necessary reason prompting the need for oral care.
Once again, many DBMs operate in multiple states.
- Liberty Dental
- Managed Care of North America (MCNA)
- Delta Dental
Branded State Names
Branded names concocted by each state sow confusion about the correct Medicaid dental plan. Do not feel bad if you fall into this trap and do not know where to file your claim. You have plenty of company.
Just scroll back to the top and read back down to the bottom if you found this article by searching for any of these brand names that confound many people.
|State||Brand 1||Brand 2|
|Colorado||Health First Colorado|
|Georgia||Peach State Health Plans|
|Illinois||Medical Card||County Care|
|Indiana||Hoosier Care||HIP Plus|
|Kentucky||Passport||KY Health Choices|
|Michigan||Medical Assistance||Healthy Michigan Plan|
|New Jersey||NJ Family Care|
|New York||Healthy Choice|
|North Carolina||Health Choice|
|Oregon||Oregon Health Plan|
|South Carolina||Healthy Connections|
|Virginia||Cover Virginia||Family Access to Medical Insurance Security|