Determining whether Medicaid covers a specific dental procedure for adults requires some 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 choose to 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, pregnant women, the medically needy, and those dually eligible for Medicare have extra considerations.
Medicaid Adult Dental Coverage by State
Medicaid differs from state to state, particularly regarding the various types of specialized dental procedures their plans might cover for adults.
- Finding a local dentist that accepts Medicaid often proves challenging due to the low reimbursement rates and the complex web of rules
- Financial assistance programs might prove a more viable option for adults who live in a region that does not cover the specific treatment needed
- Expect benefits only for the least costly treatment alternative for any oral care problem
Medicaid uniformly pays for medically necessary and emergency dental work for adults across the country. However, these nine state limit benefits for select vital treatments that you need right away.
Emergency oral care might include the following.
- 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
- Treatment of injuries to the teeth or supporting structures
Medicaid frequently covers preventive dental treatments for adults. Preventive services might include regular oral exams, cleanings, and X-rays.
These four states combine preventive care with emergency services but do not cover any additional restorative or major treatments – except Florida which also covers dentures.
Medicaid also varies from region-to-region for coverage of major restorative dental work for adults. Restorative treatments repair or replace decayed, damaged, or missing teeth.
Your plan will likely honor claims for many of the least expensive restorative options if you reside in one of many states with this benefit.
|New Mexico||New York||North Carolina|
|Pennsylvania||Rhode Island||South Carolina|
Medicaid rarely covers dental implants anywhere (except when medically necessary) due to the least costly alternative rule. Low-income adults who enjoy major restorative care benefits should expect their plan to include dentures (see below) rather than implants to replace missing choppers.
Furthermore, private companies often administer plans in select regions. They will follow the same guidelines and reject claims for dental implants.
Likewise, government agencies develop creative brand names for their programs, which follow the same rules. Therefore, expect any of these brands to deny dental implant claims.
Medicaid could pay for root canals and other endodontic procedures in the twenty-six states that include restorative care benefits. 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 and could cap the reimbursement level for each treatment. Here are some of the root canal exclusions you might encounter.
- One per tooth per lifetime
- Front incisors only
- 2nd molars excluded
- 3rd molars excluded
- Have a monetary limit
Medicaid might cover dental crowns in the twenty-six states with major restorative benefits. A crown is a cap placed over the tooth to reinstate its shape and size, strength and improve its appearance.
Your prosthodontist may recommend four different types of crowns, and your plan might pay for only the cheapest of the four options and could place time limits for replacement caps.
- Ceramic crowns for front incisors
- Porcelain-fused to metal
- Gold alloys crowns
- Base metal alloys
Medicaid also varies from region-to-region as to whether plans cover dentures for adults. A denture is a removable plate or frame holding one or more artificial teeth.
As you will quickly learn, the least expensive treatment alternative rule plays a massive role in determining out-of-pocket costs for better appliances – as does the benefit in your region.
The cost of dentures with Medicaid can range widely and offers an opportunity to illustrate how dental coverage varies regionally and how the least costly alternative rule might come into play in a second context.
The cost of dentures rises with the quality of materials used. The chart below estimates costs based on average price points and state-level benefits for a replacement plate.
|Quality||Price||State Yes||State No|
Your Medicaid plan is likely to pay for partial dentures with metal clasps rather than the pricier alternatives for missing teeth such as bridges, implants, and precision attachments. Of course, this holds only in areas that include the benefits.
Removable partial dentures are typically replacement teeth attached to a gum-colored plastic base. The metal clasp connects the appliance to your natural teeth.
Your Medicaid plan is less likely to pay for immediate dentures because of the extra costs associated with creating the temporary false teeth.
The dentist fabricates temporary dentures on the same day as the extraction to avoid a gap in your smile while your gum and jaw heal, and the lab fabricates the permanent appliance.
Medicaid might pay for dentures in twenty-six states that have this benefit. If you live elsewhere, you will have to self-pay to replace missing choppers.
Take the chart of restorative care coverage and add or subtract these names from the list.
Medicaid also differs regionally as to whether plans cover periodontal procedures for adults. A periodontist specializes in the prevention, diagnosis, and treatment of gum diseases leading to tooth loss.
Medicaid might include deep cleaning (root planing and scaling) in the eighteen states with periodontal benefits. Deep cleaning removes plaque and tartar below the gum line to treat early-stage gingivitis.
Medicaid could also include several gum surgeries in eighteen states with periodontal coverage for patients with advanced gingivitis and other soft tissue diseases of the mouth.
- Gingival flap surgery to treat late-stage disease
- Gum grafting to address receding gum lines
Your plan is less likely to honor claims for pricier alternatives such as laser gum surgery and experimental treatments such as pinhole rejuvenation.
Medicaid pays for periodontal services in only nineteen states. If you reside in one of the thirty-two other regions, you will have to self-pay for these services.
Take the baseline chart of restorative benefits and add or subtract these names from the list.
|Add Periodontal||Subtract Periodontal|
Medicaid is both uniform and variable regarding oral maxillofacial surgery payments for adults because of its dual nature as both health and dental insurance. An oral surgeon treats diseases, injuries, and defects of the mouth, teeth, jaws, face, head, and neck.
- The coverage is uniform across the country when the oral surgeon treats diseases and injuries medically necessary. In these instances, Medicaid acts like health insurance and often pays for the service.
- The coverage is variable by area when the oral surgeon performs regular dental work. Then, only twenty-five states include a benefit.
For example, Medicaid might pay for impacted wisdom teeth surgical extractions across the country. In this case, the health insurance component includes the benefit because the procedure is medically necessary.
Impacted wisdom teeth can cause pain, infection, and lead to the development of cysts. The third molars could be impacted in the gums or jaw bone.
However, erupted third molars teeth do not meet these parameters and fall into the dental category.
Likewise, Medicaid could include corrective jaw surgery when performed for a medically necessary reason across the country. Orthognathic operations to address sleep apnea or temporomandibular joint disorders (TMJ) might qualify under the health insurance component of your plan.
Conversely, Medicaid might pay for non-urgent tooth extractions only in the twenty-five states with oral surgery benefits. Having a tooth pulled because of decay or pulp death falls squarely in the dental category.
Oral Surgery States
As mentioned, Medicaid includes oral surgery benefits for dental care (deemed not medically necessary per health insurance rules) in only twenty-five states. If you reside elsewhere, you will have to self-pay for these services.
Take the chart of restorative coverage (above) and add or subtract these names from the list.
|Add Oral Surgery||Subtract Oral Surgery|
Medicaid is both uniform and variable regarding payments for adults’ orthodontic braces because of its dual nature as both health and dental insurance. An orthodontist specializes in correcting crooked teeth and jaws and misaligned bite patterns.
- The coverage is uniform when the orthodontist treats a medically necessary condition (accidental injury, TMJ, or sleep apnea). In this case, your plan acts like health insurance and might honor claims everywhere.
- The coverage is variable when the orthodontist addresses a malocclusion (misaligned teeth or bite). In this case, your plan acts like dental insurance and honors claims only in two regions: Oregon and the District of Columbia.
Medicaid is unlikely to pay the full cost of Invisalign clear braces because of the least expensive alternative rule. Invisalign is a premium option with a much higher price-point than metal appliances.
Medicaid is more likely to include Smile Direct and other direct-to-consumer options because these alternatives have much lower prices than metal appliances installed by orthodontists.
Medicaid will often include retainers when the plan honors claims for the preceding orthodontia as it is critical for maintaining the position of teeth after removing the braces.
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. Therefore, expect to pay out of pocket for any of these expenses.
Types of Medicaid Plans Including Dental
The type of Medicaid that you have could impact whether it pays for dental work for adults. Each state offers a variety of plans designed for different groups of low-income individuals.
In addition to the straight or regular program, you could enroll in unique plans for pregnant women, dual-eligible Medicare recipients, and individuals deemed medically needy.
Pregnancy Medicaid covers dental work for women more extensively. The hormones can make some pregnant women more susceptible to gum disorders such as gingivitis. Therefore, proper oral care is critical.
- Women under the age of 21 automatically enjoy 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) program.
- 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
- Virginia – Comprehensive care including braces to age 21
Adult Medicaid recipients who are dually eligible for Medicare could lose whatever dental benefits they might have. Parts A and B do not cover oral care unless medically necessary and some discount programs include these elements.
The QMB program pays Medicare Part A and Part B premiums plus any deductibles and coinsurance for Medicare-covered services. Your local Medicaid office supports the funding.
- QMB Only loses any dental benefits
- QMB Plus keeps any dental coverage – if applicable
The Specified Low-Income Medicare Beneficiary (SLMB) Program pays Part B premiums only. Your local Medicaid office supports the funding.
- SLMB Only loses any dental benefits
- SLMB Plus keep any dental coverage – if applicable
Adults enrolled in the Medically Needy Medicaid plan have a reduced chance of enjoying dental coverage. People who earn too much money to qualify could meet eligibility requirements if their medical expenses spend down income enough to satisfy the threshold.
Only thirty-three states offer the Medically Needy program, and of this group, nine do not pay for regular dental work, leaving twenty-four that include at least one specialty area.
There is no single correct response to whether Medicaid will cover specific dental procedures for adults, as many variables go into the answer.
First, each state makes unique rules about which oral care services to support, and these decisions often change over time as budgets grow or shrink due to economic reasons and shifting political winds.
Second, some dental treatments are medically necessary, which means that Medicaid acts like health insurance and is more likely to honor claims. The extraction of bony-impacted wisdom teeth is a classic example.
Third, there are many different plans designed for unique populations. Pregnant women, the medically needy, and those dually enrolled in Medicare could gain or lose oral care benefits – assuming they had any in the beginning.