Dual-eligible recipients (disabled adults receiving SSDI and retired seniors with few resources) have Medicare and Medicaid coverage.
However, finding a local dentist who accepts both programs is challenging because the overlap area is small.
Medicare Parts A & B do not cover dental work except under rare circumstances, while Part C Advantage Plans often provide oral care benefits with tiny annual limits.
Medicaid covers dental work for adults differently in each state, including minuscule annual maximums restricting benefits.
Therefore, finding nearby dentists accepting Medicaid and Medicare is worth the extra effort because you can double the yearly benefits.
Local Dentists That Accept Medicare
Dual-eligible beneficiaries searching for local dentists who accept Medicare and Medicaid might generate widely divergent lists depending on the type of coverage they have under the former program.
Dentists accept Medicare for adults only when the program might pay for the specific treatment needed and they participate in your plan. Part B has limited oral care benefits, while Part C (Advantage) covers more services.
Parts A & B
The most challenging aspect is finding nearby dentists that take Medicaid and Medicare Parts A & B, which rarely cover oral care. CMS rules explicitly exclude services concerning the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth.
You are unlikely to find a provider who takes Part A or B unless your treatment plan meets narrow parameters.
- Part A might pay for hospitalizations associated with emergency or complicated dental procedures
- Part B might pay for tooth extractions before radiation therapy for cancers of the neck or jaw
Part C
Finding nearby dentists that take Medicaid and Medicare Part C (Advantage) will prove easier because these privately issued insurance programs sometimes include oral care benefits through Preferred Provider Organizations (PPO).
Dentists participating in your PPO network agreed to accept the allowed amount (a discounted fee negotiated by the issuing insurance company – not Medicare) as the total payment for services rendered.
Use the online provider tool to find a dentist who will take your Medicare Advantage Plan. Verify participation before setting up an appointment to avoid unpleasant surprises.
Local Dentists That Accept Medicaid
Dual-eligible beneficiaries searching for local dentists who accept Medicaid and Medicare might generate widely divergent lists depending on where they live because each state establishes different rules for the former program.
Dentists who take adult Medicaid pass a two-part test, and you can readily find them on the online provider directory published by the Dental Benefits Manager selected by your state.
- They agree to accept the meager Medicaid reimbursement as full payment
- They operate in a state that supports the specific dental treatment needed
Family Dentists
Your ability to find nearby family dentists accepting Medicaid and Medicare hinges on whether your state supports adult oral care. If so, the provider directory published by the Dental Benefits Manager is the ideal resource.
State Coverage
Medicaid dental coverage for adults over 21 varies. Although a federal program, each state determines whether to fund oral care benefits.
| Service | Number of States |
|---|---|
| Emergency care only | 16 |
| Restorative | 34 |
| Oral surgery | 31 |
| Preventive | 31 |
| Periodontal | 26 |
Provider Directory
When Medicaid covers dental work for adults in your state, the provider directory published by your Dental Benefits Manager is where you can find dentists who participate in-network with your specific plan.
Prosthodontists
Dual-eligible recipients should set expectations correctly when searching for prosthodontists who accept Medicaid and Medicare. A prosthodontist is a dentist who specializes in designing and fitting replacement teeth.
Dentures for low-income adults are affordable when both programs cover false teeth, and you choose the least expensive treatment alternative recommended by the prosthodontist.
- Medicaid pays for the least expensive dentures in thirty states
- Medicare parts A & B do not cover false teeth
- Medicare Advantage pays for dentures but with annual limits
Oral Surgeons
Dual-eligible recipients will likely find oral surgeons accepting Medicaid and Medicare because they perform medically necessary services. Oral surgeons are dentists with special training in mouth and jaw surgery.
Oral surgeons who take Medicaid for medically necessary treatments might also accept Medicare because both programs act as health insurance in these instances. Coverage is relatively uniform nationwide and across plan types (Parts A, B, & C).
Medically necessary means care arising from non-biting accidents, certain diseases, and treatments considered integral to other services included in the plan. Both programs might cover these services performed by an oral surgeon.
- Reduction of broken jaw or tooth after trauma
- Corrective (Orthognathic) jaw surgery
- Removal of bone-impacted wisdom teeth
- Treatments for diseases affecting the jaw or neck
- Cancer
- Obstructive sleep apnea
- Temporomandibular joint dysfunction
