The dental services covered by Medicaid vary by state and age.
By law, children (and those aged 21 and below) are required to receive comprehensive dental services under the early and periodic screening, diagnosis, and treatment (EPSDT) program.
The dental services include checkups and cleanings, x-rays and diagnosis, root canals and crowns, dentures and bridges, and orthodontic treatment:
The Medicaid website states “At a minimum, dental services include relief of pain and infections, restoration of teeth, and maintenance of dental health.
Dental services may not be limited to emergency services. Each state is required to develop a dental periodicity schedule in consultation with recognized dental organizations involved in child health”
For adults, dental services depend on the state. While some states provide comprehensive dental services (preventive, diagnostic, and restorative), others may provide limited or emergency-only dental care.
Below, we discussed Medicaid dental coverage and the services covered by the program.
What is Medicaid Dental Coverage?
Medicaid is a joint federal and state health insurance program that provides free or low-cost health coverage to low-income families and individuals.
The program is only available to individuals and families (U.S. citizens, legal immigrants, and permanent residents) who meet the eligibility requirements.
These requirements may vary per state, similar to its benefits, which consist of different services. While Medicaid has mandatory services, states are allowed to offer additional services. These services may include dental coverage.
Medicaid dental coverage is mandatory for children enrollees. It provides comprehensive coverage like early screening, diagnosis, and treatment (EPSTD). However, it’s optional for individuals who are 21 and older.
Due to the funding crisis, not all states offer comprehensive Medicaid dental care for adults. While some states offer comprehensive dental care, others offer limited or emergency-only dental care.
Over 25 states, including New York, California, Oregon, and New Jersey, offer comprehensive dental care. Limited coverage is provided in Florida, Indiana, Kentucky, etc. On the other hand, Georgia, Arizona, Utah, and Texas provide coverage for emergency-only dental care for adults on Medicaid.
To enroll in the Medicaid dental program, you must meet the eligibility requirements. We discussed them below.
Eligibility for Medicaid Dental Coverage
To be eligible for Medicaid dental coverage, you need to satisfy the following requirements.
Income Requirements
The income requirement for Medicaid dental coverage differs per state and group (elderly, disabled, pregnant women, etc.). However, most state Medicaid programs cover those earning up to 138% of the federal poverty level (FPL), which is a limit of $20,783 annually for an individual (138% x $15,060).
For a family of 2, the limit is $ 28,207 (138% x $20,440) in 2024. The figure increases per family size.
Age requirements
According to federal law, Medicaid dental benefits are mandatory for children (enrollees) and adolescents under 21. This is part of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) initiative.
For adults over 21, the program isn’t compulsory. It also varies by state, with some states offering comprehensive, limited, or emergency dental services. Emergency services are for critical dental issues like treating infections or acute tooth pain.
Other eligibility criteria
In addition to satisfying age and income requirements, individuals enrolling for Medicaid dental coverage must be U.S. citizens. Permanent residents and legal immigrants are also eligible for the program.
Additionally, the program is available to low-income children and adults, pregnant women (who meet the income guidelines), the elderly, and those with disabilities. It’s also important you live in the state where you are applying for Medicaid.
Covered Dental Services under Medicaid
Routine checkups and cleanings.
Routine checkups and cleaning are included in many states’ Medicaid dental care programs. They are designed to help prevent dental problems.
Routine checkups and cleanings also help dentists identify oral issues like gum disease, tooth wear, etc. The service is mandatory for children, but coverage for adults varies per state.
X-ray and diagnosis.
X-rays and diagnosis are preventive services covered under Medicaid. It helps identify oral health issues early.
While this service is mandatory for children under the ESPDT benefit, coverage for adults differs by state. Ensure you check your state’s Medicaid website to learn about the dental care services that are covered.
Filing and extraction.
Under Medicaid, filling and extraction are mandatory for children in all states. While for adults, states can decide whether to include it or not.
States that offer comprehensive dental services under Medicaid may add filing and extraction for adults. Those that offer limited or only emergency may decide not to include it.
Your state Medicaid may refuse to cover a dental care service if the treatment isn’t medically necessary.
Root canals and crowns.
Root canals and crowns are vital to children’s overall health and are deemed a medical necessity. Thus, they are covered by the state’s Medicaid program.
On the other hand, states may decide to include the procedures or leave them out in their Medicaid plan for adults.
Dentures and bridges.
Denture and bridges are restorative procedures. Thus, children who qualify for Medicaid will get coverage for the treatments.
However, for adults who are 21 and above, it’s left for each state to decide. We recommend buying a dental plan if your state’s Medicaid doesn’t cover your desired dental treatment.
Orthodontic treatment for children.
Federal law requires Medicaid to cover orthodontic treatments for all children (21 and under) if it’s a medical necessity.
Orthodontic treatment includes braces, which help correct misalignments or jawbone problems in children.
Unlike children, states aren’t required by law to cover orthodontic treatments for adults. For detailed info, make sure you visit your State’s Medicaid website.
Note: While Medicaid covers some dental procedures, others may need prior authorization. This is to ensure that the treatment or procedure is of great medical necessity.
Contact your state’s Medicaid office for questions regarding enrollment or the services covered under its Medicaid program.
Accessing Medicaid Dental Services
Finding a Medicaid Dental Provider
Each state provides resources for recipients to find Medicaid dental providers. To find the resources, contact your state Medicaid office or visit their website.
If you are enrolled in a Medicaid-managed care plan, simply log on to your insurance company site to find available dentists. Online directories and local departments can also help you find a dentist that accepts Medicaid.
Dental schools and clinics are another option. They offer dental services for Medicaid enrollees at very affordable costs.
Making appointments and receiving care
Contact the office of your chosen dental provider to schedule an appointment. Discuss your dental health concerns with the dentist.
They’ll carry out examinations and offer treatment recommendations. If further procedures are required, the dentist may seek permission from Medicaid.
Understanding copays and out-of-pocket costs
Medicaid covers dental services for all child recipients; hence, parents aren’t required to make a co-payment. However, adults may be required to pay a co-payment—a fixed out-of-pocket amount paid to cover certain dental services.
In addition to co-payments, adults may be required to pay some out-of-pocket costs, like deductibles and service-specific charges. This varies per state.
Conclusion
Typically, Medicaid dental coverage for children covers preventative, emergency, restorative, and maintenance dental services. For adults, the coverage is optional and varies per state.
We recommend exploring the dental treatment options provided by your state. You can also visit your state’s Medicaid website or contact its Department of Health and Human Services to learn about the specific benefits you are eligible for.
FAQs
What dental services are covered by Medicaid in Texas?
The dental services covered In Texas are dental exams, dental x-rays, and tooth extractions. Each dental treatment are determined medically necessary and should be used by Medicaid recipients.
Does Medicaid cover dental care for adults?
It varies from state to state. However, every state provides some dental benefits for adults enrolled in the program. The benefits may be comprehensive, limited, or emergency-only.
Does Medicaid cover children’s dental care?
Yes. By law, states are required to provide comprehensive dental care coverage to Medicaid-eligible children (below 21). This is part of the Early and Periodic Screening, Diagnostic, and Treatment benefit (EPSDT),
