Determining whether Medicaid covers a specific dental procedure for adults requires detective work. This post provides helpful clues for you to follow.
Treatments covered differ based on the state, why needed, plan type, and other option prices.
Each state has unique rules for the dental specialty areas it will pay for. Medicaid is health insurance nationwide, meaning all recipients might enjoy benefits for medically necessary services.
The least expensive alternative rule affects what your plan might pay for implants, dentures, orthodontia, and other services. The organization responsible for handling claims has the last say, not this or any other article.
Adult Medicaid Coverage
Medicaid has a split personality. It operates uniformly as health insurance nationwide while varying as adult dental insurance. Each state determines the oral care benefits to support.
Most recipients pay no premiums, meaning low-income families get dental insurance at no cost if their state supports the type of care needed.
Health Insurance
The health insurance component of Medicaid pays for medically necessary dental work uniformly nationwide. However, qualifying conditions are rare, meaning this avenue will help fewer recipients.
Dental services that health insurance might cover are medically necessary. They treat non-biting injuries and diseases affecting the head, neck, and jaw.
Private insurance companies called Managed Care Organizations (MCOs) administer these claims. Your member ID card should include the MCO contact information.
Dental Insurance
The dental insurance element of Medicaid pays for oral care that is not medically necessary unevenly nationwide. While qualifying conditions occur frequently, each state supports dental benefits differently.
Private insurance companies called Dental Benefit Managers (DBM) administer these claims. Your member ID card should include the DBM contact information, and their online portal is the authority on covered treatments.
- Liberty Dental Plan
- Managed Care of North America (MCNA)
- DentaQuest (Sun Life Company)
- Delta Dental Insurance
Annual Limits
The dental insurance component of Medicaid typically includes an annual benefit maximum that limits the plan’s payout each year. Each state sets different thresholds.
For instance, Nebraska and South Carolina have a $750 annual limit, while South Dakota’s reaches $2,000. You will have to pay out-of-pocket for expenses exceeding this amount.
Special Groups
Medicaid covers comprehensive dental care for children nationwide up to age 18 or 21 under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program.
However, benefits often diminish for adults while continuing for special groups such as pregnant women, elders needing long-term care, people with developmental disabilities, or those with acquired brain disorders.
Research the rules in your state by following the links below for each numbered service.
- Emergency (Pain, Infection)
- Preventive (Exams, X-Rays)
- Restorative (Fillings, Crowns)
- Prosthodontic (Dentures, Implants)
- Periodontal (Deep Cleaning, Gum Graft)
- Endodontic (Root Canals, Abscesses)
- Oral Surgery (Extractions, Jaw Procedures)
| State | 1 | 2 | 3 | 4 | 5 | 6 | 7 |
|---|---|---|---|---|---|---|---|
| AL | X | X | |||||
| AK | X | X | X | X | X | ||
| AZ | X | ||||||
| AR | X | X | X | X | |||
| CA | X | X | X | X | X | X | X |
| CO | X | X | X | X | X | X | X |
| CT | X | X | X | X | X | X | |
| DE | X | X | X | X | X | X | |
| FL | X | X | X | X | X | ||
| GA | X | ||||||
| HI | X | X | X | X | X | X | X |
| ID | X | X | X | X | X | X | X |
| IL | X | X | |||||
| IN | X | X | X | X | |||
| IA | X | X | X | X | X | X | X |
| KS | X | X | X | X | |||
| KY | X | X | X | ||||
| LA | X | X | |||||
| ME | X | X | X | X | X | X | |
| MD | X | X | X | X | |||
| MA | X | X | X | X | X | X | |
| MI | X | X | X | X | X | X | X |
| MN | X | X | X | X | X | X | X |
| MS | X | ||||||
| MO | X | X | X | ||||
| MT | X | X | X | X | |||
| NE | X | X | X | X | X | X | X |
| NV | X | X | X | X | X | ||
| NH | X | X | X | X | X | ||
| NJ | X | X | X | X | X | X | |
| NM | X | ||||||
| NY | X | X | X | X | X | ||
| NC | X | X | X | X | X | X | X |
| ND | X | X | |||||
| OH | X | X | X | X | X | X | |
| OK | X | X | X | X | |||
| OR | X | X | X | X | X | X | |
| PA | X | X | |||||
| RI | X | X | X | X | X | X | X |
| SC | X | X | X | X | |||
| SD | X | X | X | X | X | ||
| TN | X | X | X | X | X | ||
| TX | X | ||||||
| UT | X | X | X | X | X | X | |
| VT | X | X | X | X | X | X | X |
| VA | X | X | X | X | X | X | |
| WA | X | X | X | X | X | X | X |
| WV | X | X | X | ||||
| WI | X | X | X | X | X | ||
| WY | X | X | X | X |
Major Prosthodontic Services
Medicaid covers prosthodontic services under the dental insurance umbrella in states that support major restorative care. A prosthodontist is a dentist who specializes in replacing missing teeth.
Dentures
Medicaid pays for dentures in approximately thirty-one states and counting. Expect the government benefits to grow over time rather than shrink for the least expensive treatment alternative a prosthodontist might recommend.
However, expect limits on how often you can replace dentures, varying by state from once every six to ten years. Meanwhile, less costly repairs, adjustments, and relines of existing appliances can happen more frequently.
Implants
Medicaid rarely pays for tooth implants under the dental insurance umbrella. These permanent replacement appliances installed by a prosthodontist are not the least expensive treatment option.
However, Medicaid might pay for early-stage treatment steps to prepare your mouth for implant steps under the health insurance component. Medically necessary treatments might include one of the following.
- Prevent further bone atrophy caused by diseases such as diabetes, digestive disorders, or osteoporosis.
- Strengthen the jawbone after accidental fractures or surgery to remove cancerous lesions.
Extractions and Oral Surgery
Medicaid sometimes covers adult oral surgery services under both modules (dental and health insurance). An oral and maxillofacial surgeon treats diseases, injuries, and defects of the mouth, teeth, jaws, face, head, and neck.
Wisdom Teeth
Medicaid oral surgery coverage for wisdom tooth extraction perfectly illustrates the dual nature of the program (health and dental insurance). The removal of third molars is sometimes medically necessary and sometimes not.
When the third molars are bone-impacted, Medicaid covers wisdom tooth removal under the health insurance component. In these medically necessary cases, recipients in all fifty states should expect their MCO to approve claims.
Medicaid possibly pays for wisdom teeth removal under the dental insurance element when the third molars are gum-impacted. However, your state must support oral surgery benefits; otherwise, your DBM will deny any claims.
Jaw Surgeries
Likewise, Medicaid might cover oral surgery that corrects jaw abnormalities under health insurance nationwide and dental insurance per rules established in each state.
Health insurance covers jaw surgery when medically necessary. Possible claims your MCO might approve include congenital deformities, temporomandibular (TMJ) syndrome, obstructive sleep apnea, and restoration of function following treatment for substantial accidental injury, infection, or tumor.
The dental insurance element pays for jaw surgery less frequently. For instance, some states exclude Tori removal from oral surgery benefits.
Periodontal Gum Treatments
Medicaid covers periodontal services for adults less frequently. Preventing, diagnosing, and treating gum diseases such as gingivitis falls outside the scope of health insurance.
Therefore, only the dental insurance component will honor claims for periodontal treatments. Benefits vary by state and have limits.
Gum Grafting
Medicaid rarely pays for gum grafting, even in the states supporting periodontal benefits, because the surgical procedure is more expensive than first-line treatments.
The cost of gum grafting without insurance can reach $2,500. A publicly funded program such as Medicaid must have spending limits, which you can expect to find here.
Deep Cleaning
Medicaid more frequently pays for periodontal deep cleaning as this first-line treatment is less expensive and fits under the annual benefit limits. We have seen examples of these procedure codes covered.
| ADA Code | Description |
|---|---|
| D4341 | Root Planing & Scaling |
| D4355 | Full-Mouth Debridement |
| D4910 | Periodontal Maintenance |
Endodontic Treatment Benefits
Medicaid covers endodontic services for adults less frequently. Treating infected tissue inside your teeth falls outside the scope of health insurance unless the dentist prescribes antibiotics.
Therefore, only the dental insurance component will honor claims for the expensive part of endodontic treatments, and benefits vary by state and have limits.
Root Canals
In most states with endodontic benefits, Medicaid pays for root canals to remove inflamed or infected pulp inside a tooth. However, many states limit the coverage to front teeth while excluding molars.
Root canal payment plans might help recipients in states without endodontic benefits. The pain can be excruciating, leaving you no choice if you want to save the tooth.
Tooth Abscesses
Medicaid probably pays to address tooth abscesses in the states with endodontic benefits because this first-line treatment is less expensive than a root canal.
However, we could not find any specific references verifying benefits for abscesses. Contact your DMO to confirm coverage.
Basic Restorative Services
Medicaid covers restorative oral care in the states supporting this service under the dental insurance component. The health insurance element rarely factors in this treatment category.
Fillings
Medicaid pays for fillings in all states, supporting basic restorative dental services, as this is the least expensive and most frequently needed treatment.
Tooth decay (caries) falls neatly inside the dental insurance category. Your plan might pay for white fillings only in the front teeth (central and lateral incisors).
Crowns
Medicaid might cover crowns under both coverage elements (dental and health insurance), depending on why your tooth needs the treatment.
Expect your plan to pay for crowns when your state supports basic restorative care and you need the treatment to protect a tooth weakened from decay or cracks. File the claim with your DMO.
Your plan might pay for crowns through the health insurance element if you broke the teeth in a non-biting accident. Request a pre-certification from your MCO in these cases.
Orthodontic Braces Services
Medicaid rarely covers adult orthodontic dental services under either program module (health and dental insurance). However, every rule has exceptions.
Necessary Braces
Medicaid might cover orthodontic braces for adults under the health insurance umbrella when the recipient can establish a medically necessary reason. However, these qualifying conditions are rare.
Learn how to get braces covered by medical insurance, and apply these lessons when filing pre-certification documents with your MCO. Some of these conditions might qualify.
- Reposition teeth after a non-biting accident such as a broken jaw
- Temporomandibular Joint Disorders (TMJ or TMD) bite adjustments
- Sleep apnea (when crooked teeth restrict or block airflow)
- Removal of braces to treat disease of the head, neck, or jaw
- Before radiation therapy
- Before highly stomatotic chemotherapy
- Complications of IV bisphosphonates
Correcting Malocclusions
In any state, Medicaid does not cover orthodontic braces for adults to straighten crooked teeth. The time to correct a handicapping malocclusion is before reaching your 21st birthday.
No credit check financing for braces might be a way to work around this limitation. Consumer-direct clear aligner trays offer payment plans and more affordable price points, a key consideration for low-income families.
Cosmetic Dentistry Procedures
Medicaid does not cover cosmetic dental procedures under the health or dental insurance component, and no state makes extra provisions to include services to improve appearance.
Tooth Whitening
In most instances, Medicaid does not cover tooth whitening as this procedure is cosmetic. You will probably have to pay out-of-pocket to brighten your smile.
However, in rare cases, Medicaid might pay for tooth whitening under the health insurance umbrella. The procedure could be medically necessary when removing stains caused by prescription medications.
- Bacterial Infections: Antibiotics
- High Blood Pressure: Anti-hypertension
- Severe Allergies: Antihistamines
Submit a letter of medical necessity to your MCO describing how these prescription drugs yellowed your teeth.
Dental Bonding
In most cases, Medicaid does not cover dental bonding as this procedure is typically performed for cosmetic reasons. You will probably have to pay out-of-pocket to enhance your teeth’ shape, size, and color.
However, in rare cases, Medicaid might pay for bonding under the dental insurance umbrella. Your dentist must use the composite resin material for structural, restorative, or protective reasons.
Emergency Pain Treatment
Medicaid covers emergency dental services for adults across the country. However, health and oral care rules are different for urgent needs.
How emergency dentist bills are paid can differ depending on the treatment needed and the rules in each state.
Medical Emergencies
The health insurance component of Medicaid should pay for emergency dental work after a non-biting accident that dislodges, chips, or breaks teeth or jaws.
These services are medically necessary. Therefore, recipients nationwide should expect coverage because the rules are uniform in all states.
Dental Emergencies
The dental insurance element of Medicaid pays for limited emergency oral care nationwide. Recipients should expect their plan to cover two basics at minimum.
- 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
Rules for other dental emergencies like tooth pulling and root canals are different in each state.
Preventive Care Services
Medicaid sometimes covers adult preventive oral care treatments under the dental insurance umbrella. Preventive services might include regular oral exams, cleanings, fluoride application, sealants, and X-rays that help patients avoid decay, gum inflammation, and tooth loss.
The health insurance component never pays for preventive services as they are not medically necessary. The only possible exception might be X-rays after a non-biting accident or when used as a cancer screening tool.
