Determining whether Medicaid covers a specific dental procedure for adults requires some detective work. The included treatments vary by state and reason.

Finding a local dentist that accepts Medicaid patients adds an additional twist. Many providers do not participate due to low reimbursement levels, and heavy administration costs.

Follow the outline for guidance on possible dental coverage and providers for each service.

Medicaid Dental Coverage for Adults by Service

Medicaid dental coverage for adults varies by the type of service that you need and where you live. It is a federal program for low-income families administered locally. The federal government sets a minimum standard and gives each state the latitude to extend benefits – and many do for oral care – each in its own unique way.

Begin by exploring each dental procedure type and reason to see if you might have coverage. It is a 50/50 proposition at best. You could be lucky – or not.

Major Restorative Services

Medicaid dental coverage of major restorative services for adults exists in 26 different states. A prosthodontist specializes in this area: treating and handling oral and facial problems that involve restoring missing tooth and jaw structures.

A prosthodontist is highly trained in implants, crowns, bridges, dentures, temporomandibular disorders (TMJ/TMD), and more.

Dentures

Medicaid covers dentures for adults in 25 states following the least costly alternative rule. This rule means that many longer-lasting higher-end treatment options are not included.

A denture is a removable plate or frame holding one or more artificial teeth.

  • More likely to pay for less expensive removable dentures
    • Full devices consist of upper and lower sets when all natural teeth are missing
    • Partials replace one or more natural teeth
  • Less likely to pay for fixed dentures due to the higher costs
    • Fixed bridge cement to remaining natural teeth
    • Implant supported fixed devices screw into the abutment

Most Medicaid plans offer replacement choppers every 5 to 10 years. However, some pay for only one set per lifetime.

Implants

Medicaid rarely covers dental implant costs in full. Implants are the more expensive tooth replacement option. Therefore, the implant body, abutment, and implant-supported dentures are elective (not included).

The dental implant treatment process has multiple stages. It is not a single treatment. Therefore, Medicaid may pay for certain early stages in the process.

  • CAT scans to measure bone density and structural anomalies
  • Tooth extractions due to an accident or disease-related condition
  • Bone grafting after an accident or related to a medical disease
  • Surgical placement of the implant body into the jaw

Crowns

Medicaid covers dental crowns in 26 states. A crown is a cap placed over the tooth to restore its shape and size, strength, and improve its appearance.

Your prosthodontist may recommend four different types of crowns. Medicaid might pay for only the least expensive of the four options.

  1. Ceramic crowns for front teeth
  2. Porcelain-fused to metal
  3. Gold alloys crowns
  4. Base metal alloys

Your plan could also place limits on what it pays for crowns such as once per tooth every five years.

Orthodontic Braces

Medicaid covers orthodontic braces for adults when medically necessary across the country. In this case, it means the procedure treats an injury, disease, or symptoms. Therefore, the plan may pay if you suffer an accidental injury, TMJ, or sleep apnea.

Medicaid covers elective orthodontic braces for adults in Oregon and the District of Columbia. This 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 26-point system determines medical necessity for children under the age of 21. The point system does not apply to adults. The qualifying criteria are stricter.

Basic Care

Medicaid dental coverage of basic oral care for adults is more accessible across the country. This means that your plan is more likely to pay for the service. In addition, patients with otherwise healthy smiles utilize basic services most frequently.

Preventive Care

Medicaid pays for preventive dental work in 27 states. Preventive or wellness care helps you avoid cavities, periodontal disease, enamel wear, and other conditions that can lead to tooth loss. If you live in a region paying for preventive care, your plan should support some of these procedures.

  • Regular visits to the dentist, checkups, or exams
  • Cleaning (prophylaxis)
  • Bitewing X-rays
  • Sealants

Dental plans have no waiting periods for preventive oral care.

Periodontal

Medicaid pays for periodontal work in 18 different states. A periodontist specializes in the prevention, diagnosis, and treatment of gum diseases, which can lead to tooth loss. If you live in a region paying for periodontal procedures, your plan may pay for some of these expenses.

  • Gingivectomy or gingivoplasty
  • Osseous surgery
  • Scaling & root planing (deep cleaning below the gum line)
  • Bone and soft tissue grafts

Root Canal

Medicaid pays for root canals and other endodontic procedures in 26 different states. An endodontist specializes in treating the soft inner tissue of the teeth called the pulp.

Beware that your policy may place limits on the number of root canal therapies. It can also cap the reimbursement level for each treatment. Here are some of the root canal exclusions you might encounter.

  • One per tooth per lifetime
  • Front teeth only
  • 2nd molars excluded
  • 3rd molars excluded
  • Have a monetary limit

Oral Surgery

Medicaid pays for oral surgery in 24 different states. Oral surgeons typically perform non-urgent extractions under anesthesia, as well as other operative procedures. If you live in a region paying for oral surgery, your plan may help with some of these expenses.

  • Wisdom tooth extraction
  • Underbite surgery
  • Orthognathic surgery
  • Corrective jaw surgery for TMJ

Pregnancy Medicaid

Pregnancy Medicaid covers dental work more extensively. The hormones can make some pregnant women more susceptible to gum disorders such as gingivitis. Therefore, proper oral care is very important.

  1. Women under the age of 21 automatically enjoy some level of comprehensive dental care while pregnant as a minimum requirement. The federal government requires this across the country under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit.
  2. Women over the age of 21 sometimes qualify for additional dental benefits while pregnant. Four states that otherwise restrict support for adults, extend specified categories of comprehensive care to expectant women.
    • Louisiana – Preventive, restorative, periodontal, and oral surgery
    • Missouri – all categories
    • Nevada – Preventive and periodontal
    • Oklahoma – Preventive and restorative only

Pregnancy Medicaid will not cover every dental procedure in every location. Here are some probabilities to use as a benchmark for the most common treatments.

  • Fillings: (more likely) stops the spread of infections
  • Teeth cleaning: (most likely) prevents gum disease
  • Wisdom teeth removal: (less likely) except in emergencies
  • Root canal: (more likely) stops the spread of infection
  • Orthodontic braces: (highly unlikely) for any cosmetic reason

Cosmetic Procedures

Medicaid does not cover cosmetic dentistry for adults under any circumstances. Cosmetic dentistry improves appearance rather than the function of a patient’s teeth, gums, or bite. The goal is to improve aesthetics such as the shape, color, position, and alignment of your teeth. Cosmetic procedures are always elective. Expect to pay out of pocket for any of these expenses.

  • Bleaching and Whitening
  • Bonding
  • Lumineers
  • White Fillings
  • Veneers

Supplemental dental insurance pays for cosmetic procedures via an optional rider.

Medically Necessary

Medicaid covers dental work for adults when medically necessary across the country. The definition of medically necessary may include oral care arising from non-biting accidents, certain diseases, and treatments deemed integral to other services included in the plan.

The private insurance company adjudicating the claim is the final arbiter – contact the carrier for a pre-authorization. Work with your dentist to develop a narrative documenting why the treatment relates to an accident or disease.

Emergency Treatment

Medicaid covers emergency dental services for adults across the country. The federal government provides a definition for children that we can safely extrapolate to those over the age of 18.

  • Procedures necessary to control bleeding, relieve pain or eliminate acute infection
    • Starting root canal treatment on infected teeth
    • Draining abscesses and infected areas
    • Treating soft tissue swellings associated with erupting teeth
    • Palliative care for oral soft tissue infections such as herpes
  • Procedures that are required to prevent “pulpal death” and the imminent loss of teeth
    • Decay removal
    • Application of medications
    • Temporary fillings
  • Treatment of injuries to the teeth or supporting structures
    • Temporary fillings for fractured teeth
    • Stabilizing loose teeth and supporting bone
    • Cleaning and suturing traumatic wounds
    • Palliative therapy for Pericoronitis
      • Irrigation of swellings
      • Removing debris from infected areas
      • Relieving trauma caused by opposing teeth

Finding Dentists That Accept Medicaid for Adults

Finding local dentists that accept Medicaid for a specific adult service requires a two-pronged approach. Many practices do not participate because of low reimbursement levels, high appointment cancellation rates, poor compliance with recommended treatments, and heavy administrative demands.

  1. Each state determines which treatments to include or exclude. Scroll to the bottom of the page to see which oral care procedures apply where you live.
  2. Private companies administer most plans. Identify the carrier and utilize their “Provider Directory” to find a participating practice in your area.

Cosmetic

Finding a local cosmetic dentistry practice that takes Medicaid is nearly impossible. As discussed above, cosmetic procedures are always elective (not medically necessary) and therefore always uncovered – regardless of where you live.

We say nearly impossible because many procedures that fall into the cosmetic category have multiple treatment phases. Sometimes the beginning stages are medically necessary and therefore covered. For example, dental implants are considered cosmetic and involve many treatment stages (see above).

Dentures

Finding a local dentist that accepts Medicaid for adult dentures is somewhat easier. As noted above, about half the states will pay for dentures. Scroll to the last section to determine if you live in the lucky half of the country.

If you live in the lucky half, surf online to the website of the private company administering your plan. Pull up their provider finder directory and select the corresponding insurance program. It should provide a list of dentists near your zip code that accepts Medicaid for dentures.

Oral Surgeons

Finding a local oral surgeon that takes Medicaid for adults requires an additional step drawn from the elements addressed above. Twenty-five states include this benefit. Therefore, these residents can go straight to their online provider directory to find a participating practice.

Patients residing in other regions may find oral surgeons accepting Medicaid for emergency and medically necessary procedures. Remember that coverage is nationwide for these two reasons.

  1. Emergency oral surgery after an accident or prevent pulpal death or loss of teeth
  2. Medically necessary oral surgery connected to disease or accident

Coverage by State

Take all the lessons learned in each section above to narrow down the list of local dentists accepting Medicaid for a specific treatment. Follow this key to read the chart of state-by-state dental coverage for non-pregnant, non-disabled adults as of July 2018. Expect it to remain the same in 2019 and later.

  • Preventive – V
  • Restorative – R
  • Periodontal – P
  • Dentures – D
  • Oral Surgery – S
  • Orthodontia – O
StateVRPDSO
Alabama
AlaskaXXX
Arizona
ArkansasXXXXX
CaliforniaXXXXX
ColoradoXXXXX
ConnecticutXXXXX
Delaware
DCXXXXXX
FloridaX
Georgia
Hawaii
Idaho
IllinoisXXX
IndianaX
IowaXXXX
Kansas
KentuckyXX
LouisianaX
Maine
Maryland
MassachusettsXXXX
MichiganX
MinnesotaXXXXX
Mississippi
Missouri
Montana
NebraskaXXXXX
NevadaX
New Hampshire
New JerseyXXXXX
New MexicoXXXX
New YorkXXXXX
North CarolinaXXXXX
North DakotaXXXX
OhioXXX
Oklahoma
OregonXXXX
PennsylvaniaXXXXX
Rhode IslandXXXXX
South CarolinaXXX
South DakotaXXXX
Tennessee
Texas
Utah
VermontXXXX
VirginiaX
WashingtonXXXXX
West Virginia
WisconsinXXXXX
WyomingXXXX

Sources:

  1. Medicaid.gov
  2. National Academy for State Health Policy
  3. Emergency Conditions
  4. Report to Congress
Posted