About Medicaid Dental Coverage

Medicaid is a federal government and state program that helps provide health care for the impoverished. Medicaid, especially the dental program. has its benefits as well as its demerits. The program helps children, as those insured by Medicaid have better oral health than those who are not insured. To qualify for dental coverage through Medicaid, you must meet certain financial requirements, as well as eligibility and health conditions.

What Is Medicaid?

Medicaid is a voluntary joint program between the federal government and the states. The purpose of the Medicaid program is to provide health insurance coverage to the poor, elderly and disabled. There are eligibility standards and requirements that one must take into consideration when choosing Medicaid. States that participate in the Medicaid program are required to provide care to anyone eligible under the government guidelines.

Anyone on Medicaid who is under the age of 21 may be required to participate in the EPSDT benefit, which stands for Early and Periodic Screening, Diagnostic and Treatment. This is necessary to help prevent and treat medical conditions before they progress.

Those age 21 or older may not qualify for dental coverage. It is up to the state to choose to whom it provides dental care.

EPSDT Benefit Program

Under the EPSDT benefit, all states must provide all Medicaid eligible children under 21 with comprehensive, preventive, restorative and emergency dental procedures. These services are defined by the state.

When on Medicaid, if you or your child are under 21 years old, dental services are required at six-month intervals or standards based on your dentist's office and the EPSDT benefit. The state will determine whether you will need more visits based on a consultation with dental organizations. If a dental procedure is necessary, a consultation will still be needed. The basic services that Medicaid provides include pain relief, treating infections, tooth or teeth restoration and preventive dental care. If you have Medicaid, the state will decide whether specific dental procedures are necessary.

Cons of Medicaid Dental Coverage

One out of every six dentists receive $10,000 or more from Medicaid payments each year. Very few dentists participate in the program. One must do extensive research to find a dentist who accepts Medicaid.

Medicaid does not pay all costs of specific dental services. The reimbursement rates are substantially lower than payments made by other insurance companies.

Because Medicaid requires enrollment fees, billing forms that are not like other standard forms, authorization requirements, slow payment processing and eligibility determination, many dentists will not participate in the Medicaid program.

Sadly, one-third of Medicaid dental appointments that are made end up without the participant showing up to their appointment. This causes dentists many problems, including down time and financial loss. This is another reason why many dentists refuse to get involved with the Medicaid program.

Costs associated with Medicaid are rising, especially prescription drug costs and this is causing a funding problem for the program.

During an economic crisis, many more people begin to apply for Medicaid. As the population rises and the demand increases for government assistance, the funding becomes more scarce.

Several programs in association with Medicaid are actually being eliminated to help with funding. Remimbursements are being frozen, and the eligibility is being adjusted to help provide medical coverage to the impoverished.

Qualifications for Medicaid and Dental Coverage

Medicaid covers individuals who meet certain financial criteria based on the state. Low-income children, the elderly, pregnant women and people with disabilities are categorically eligible which means that in some states although they may not be eligible financially, their situation makes them eligible. This is possible because the federal government allows states to expand coverage beyond these basic standards.

Each state designs their own eligibility rules. This means that there is a wide variation in who is accepted, what financial criteria you must meet, as well as other specifications.

Services Provided

Medicaid provides many different services to meet the needs of participants. Each state decides on which dental services it will provide as well as any other additional services. Medicaid has limited resources, so cost-sharing is limited. This means that children and pregnant women are not entitled to cost-sharing.

Medicaid pays for lab fees, medication, tooth extraction (minimum allowed each year), tooth restoration and other dental services.

If a state chooses to provide additional services, it must apply the services to all political subdivisions, provide financial participation by the state at no less than 40 percent, allow a hearing for any person whose eligibility or claim is denied or not processed in time for an appointment or service, provide administration for the Medicaid plan, designate an agency to administer the plan, provide safeguards for all applicants and meet various other requirements.