Four sets of dual natures determine whether your Medicaid plan will cover wisdom teeth removal for adults.
First, Medicaid is primarily health insurance with uniform rules nationwide and dental insurance with uneven benefits in each state.
Second, oral and maxillofacial surgeons are medical doctors and dentists performing procedures billed to health and or dental insurance.
Third, the extraction of bony-impacted third molars fits under the health insurance component, and removing their gum-impacted counterparts falls into the dental insurance element.
Finally, the Managed Care Organization (bone-impacted) or Dental Benefits Manager (gum-impacted) adjudicates claims and is the final authority.
Gum-Impacted Wisdom Teeth Removal
Depending on the oral surgery benefits in your state, Medicaid might cover soft-tissue-impacted wisdom teeth removal for adults under the dental insurance element. These procedures are not medically necessary, so the coverage is hit or miss.
State Benefits
Two critical qualifiers determine whether your Medicaid plan will pay for removing gum-impacted wisdom teeth: the age of adulthood and the oral surgery benefits supported by your state.
Age Of Adulthood
Medicaid covers dental work for children nationwide with probable support for soft-tissue-impacted wisdom teeth extraction. However, each state determines the age cutoff. Some stop at 18, while others continue until your child’s 21st birthday.
You can find oral surgeons accepting your Medicaid plan by referencing the provider directory published by the Dental Benefits Manager (see below). Due to the age rules, you should be able to locate more pediatric dentists.
Most people have their wisdom teeth removed between the ages of 18 and 24, so a significant portion of low-income families can sneak by before their teenager becomes an adult as defined by their state.
Oral Surgery
Medicaid pays for gum-impacted wisdom teeth removal for adults over 21 when their state offers oral surgery benefits. Since most people need this service at some point, it makes sense to be proactive.
Medicaid covers adult oral surgery in only twenty-five states, so act before age eighteen to be safe.[1]
| Support Oral Surgery | Exclude Oral Surgery |
|---|---|
| Arkansas | Alabama |
| California | Alaska |
| Colorado | Arizona |
| Connecticut | Florida |
| Delaware | Georgia |
| Illinois | Hawaii |
| Iowa | Idaho |
| Massachusetts | Indiana |
| Minnesota | Kansas |
| Nebraska | Kentucky |
| New Jersey | Louisiana |
| New Mexico | Maine |
| New York | Maryland |
| North Carolina | Michigan |
| Ohio | Mississippi |
| Oregon | Missouri |
| Pennsylvania | Montana |
| Rhode Island | Nevada |
| South Carolina | New Hampshire |
| South Dakota | North Dakota |
| Vermont | Oklahoma |
| Virginia | Tennessee |
| Washington | Texas |
| Wisconsin | Utah |
| Wyoming | West Virginia |
Dental Benefits Manager
The Dental Benefits Manager (DBM) chosen by your state is the final authority determining whether your Medicaid plan will cover soft-tissue-impacted wisdom teeth.
A DBM is a third-party private company specializing in claims administration for the dental insurance element (if available). Find the DBM name from your member ID card and have the provider submit correspondence and claims information to them.
- DentaQuest
- Liberty
- MCNA
- Delta Dental
Bony-Impacted Wisdom Teeth Removal
The health insurance component of Medicaid should cover bony-impacted wisdom teeth removal, regardless of the state where you live. The rules apply nationwide when treating an illness, injury, disease, disability, or developmental condition.
Medically Necessary
Medicaid pays for extracting bony-impacted wisdom teeth under the health insurance component when medically necessary. Jawbone-impacted third molars fit this definition because they can cause pain and infection and develop cysts.
Oral and maxillofacial surgeons perform these complicated extractions, and your plan should pay for all costs associated with these medically necessary services.
- Extraction of partially or entirely bony third molars
- Therapeutic drug injection (Dexamethasone)
- Deep sedation (general anesthesia)
- Panoramic radiographic image
Finding a local oral surgeon who accepts Medicaid for bone-impacted wisdom teeth removal should prove relatively easy. They are licensed physicians whose offices regularly bill health insurance plans for services rendered.
Managed Care Organization
The Managed Care Organization (MCO) chosen by your state is the final authority determining whether your Medicaid plan will pay for removing bony-impacted wisdom teeth.
An MCO is a private third-party company that administers claims processing for the health insurance component. Submit your oral surgeon’s letter of medical necessity to the MCO printed in bold letters on your member ID card.
- 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
Branded Names
Branded names concocted by each state sow confusion for low-income adults wondering whether their Medicaid plan pays for wisdom teeth removal. Do not feel bad if you fall into this trap. You have plenty of company.
Just scroll back to the top if you found this article by searching for any brand names that confound many people.
| State | Brand 1 | Brand 2 |
| Arizona | Care 1st | AHCCCS |
| California | Medi-Cal | |
| Colorado | Health First Colorado |
|
| Connecticut | Husky | Connecticare |
| Georgia | Peach State Health Plans |
|
| Hawaii | Quest Integration |
|
| Illinois | Medical Card | County Care |
| Indiana | Hoosier Care | HIP Plus |
| Kentucky | Passport | KY Health Choices |
| Louisiana | Healthy Lousiana |
|
| Maryland | Medical Assistance |
|
| Massachusetts | MassHealth |
|
| Michigan | Medical Assistance | Healthy Michigan Plan |
| Minnesota | Medical Assistance |
|
| Missouri | Missouri Care |
|
| New Jersey | NJ Family Care |
|
| New York | Healthy Choice |
|
| North Carolina | Health Choice |
|
| Ohio | Buckeye Insurance |
|
| Oklahoma | SoonerCare |
|
| Oregon | Oregon Health Plan |
|
| Pennsylvania | Medical Assistance |
|
| South Carolina | Healthy Connections |
|
| Tennessee | TennCare |
|
| Texas | STAR |
|
| Virginia | Cover Virginia | Family Access to Medical Insurance Security |
| Washington | Apple Health |
|
| Wisconsin | BadgerCare |
Article Citations:
[1] The Medicaid and CHIP Payment and Access Commission
