Oral Health

The Medicaid benefit for children and adolescents includes comprehensive dental benefits, including screening, prevention, and treatment services. Treatment services for oral health conditions identified through a screen are also covered for Medicaid-enrolled children. This section contains information on how oral health services are delivered; state practices and approaches to screenings, referrals, and diagnoses for oral health for children; strategies for oral health service delivery to Medicaid-enrolled children; and other innovations and strategies to help states improve access to and delivery of oral health services.

 

Alabama
1st Look
In partnership with the Alabama Chapter of the American Academy of Pediatrics, the Alabama Academy of Pediatric Dentistry, and the Alabama Dental Association, the Alabama Medicaid Agency operates the 1st Look Program. The collaborative program is designed to reduce early childhood caries by “encouraging primary care physicians to perform dental risk assessments, provide anticipatory guidance, apply fluoride varnish when indicated, and refer children to a dental home by age one.” Children who have already seen by a dentist do not qualify for this program.
Alaska Alaska Medicaid covers all dental services for children on a fee-for-service basis. This includes exams, X-rays, scaling, polishing, sealants, and fluoride varnish (physicians may apply fluoride varnish in Alaska). Alaska also covers dentures, crowns, caps, root canals and oral surgery, though some may require prior authorization. Alaska also covers orthodontia services, including braces, if deemed medically necessary and prior authorization is obtained.
Arizona Primary care providers are required to conduct an oral health screening as part of an EPSDT screening, and make referrals to dentists as needed.
Arkansas
As noted in the Arkansas Medicaid Handbook, dental care is covered for children with ARKids First A and Medicaid. This includes orthodontic care such as braces, if medically necessary. Arkansas Medicaid must approve all orthodontic care before treatment. Children with ARKids First B can get some dental care, but not orthodontic care.
California California has a “Denti-Cal” website dedicated to the Medicaid oral health benefit. The site contains a section on the EPSDT benefit as it pertains to oral health services for children; this section offers examples of supplemental oral health services not covered under the Medicaid state plan but required to be made available for children. Dental provider bulletins offer updates on Medicaid policy for oral health and a dental Medicaid provider manual details available services.
Colorado
Colorado Medicaid’s Dental Manual contains information on covered services for children under the EPSDT benefit. The state allows physicians, nurse practitioners, and physician assistants to bill for administering fluoride varnish to children under age 5 during a well-child visit. Dental providers may also provide the service.
Medical personnel offering oral health services to young children enrolled in Medicaid must either receive on-site training from a Colorado initiative that trains health care providers on providing oral health services to children (“Cavity Free at Three”) or they must complete modules of the national Smiles for Life curriculum.
Connecticut
The Connecticut Dental Health Partnership, an administrative services organization, manages Medicaid oral health care services on behalf of the Connecticut Department of Social Services. The Partnership’s website contains various informing materials for enrollees and dental providers, including summaries of dental benefits and provider newsletters/communications.
The Partnership has a statewide Care Coordination and Outreach unit consisting of seven Dental Health Care Specialists. Dental providers refer patients to the Care Coordination unit when the patient has significant barriers to receiving dental services, such as medical, behavioral, logistical or cultural barriers (including language and transportation difficulties). Dental Health Care Specialists also:
  • Work with dental providers to develop treatment plans in conjunction with medical providers for enrollees who need intensive case management
  • Provide focused outreach to specific client populations (e.g. prenatal clients, children with special health care needs, clients who use the emergency room for dental care and non-utilizers of dental services)
  • Perform community outreach, visiting dental providers’ officers to assist them in becoming dental homes and visiting community agencies to increase awareness of the program and to encourage referrals of their clients to the Partnership
A July 2013 report on utilization of dental services for Medicaid-enrolled children and their parents in Connecticut examined changes to utilization since dental benefits were carved out in 2008.  The report found that the number of very young children under 3 who received any care in 2011 was nearly 42 percent (up from 21 percent in 2008) and the percent with preventive care was 37 percent,  up from under 14 percent in 2008. It also found that the number and percent of children 3 to 19 with preventive care increased in Medicaid and the Children’s Health Insurance Program, to 69% and 73% respectively.
Delaware No information at this time.
District of Columbia
In 2004, the District developed a dental periodicity schedule and a plan to improve provider participation, training, coordination of dental services and outreach. The schedule follows the American Academy of Pediatric Dentistry’s Periodicity Schedule oral health recommendations in consultation with the local dental community.
The Department of Health Care Finance works closely with the District’s Pediatric Oral Health Coalition to improve pediatric dental services for children in Medicaid. As of FY 2014, the District implemented payment for fluoride varnish services by primary care providers  in an effort to increase the number of young children receiving oral health services. The District’s HealthCheck provider training portal began offering a training on fluoride varnish as well.
Florida
In Florida, DentaQuest administers the Children’s Medicaid Statewide Prepaid Dental Plan (a Prepaid Ambulatory Health Plan) and provides oral health services to Medicaid-enrolled children. The organization provides a statewide directory of participating dentists and offers a “find a dentist” tool to help families identify Medicaid-participating dentists.
A dental office reference manual offers providers guidance on covered oral health benefits and Medicaid procedures.
Georgia Primary care providers can bill (using code D1206) for applying fluoride varnish to a Medicaid-enrolled child.
Hawaii Hawaii’s Medicaid Provider Manual contains a detailed description of the dental services available to children eligible for EPSDT, including applicable billing codes, and whether prior approval is needed for each service. The state also operates a dental page for providers, which contains dental fee schedules and contact information for dental coordinators employed by Community Case Management Corporation (CCMC). Hawaii Medicaid contracts with CCMC to help beneficiaries find dentists and other dental providers.
All children in Idaho Medicaid are eligible to be enrolled in Idaho Smiles, a managed care program administered by BlueCross of Idaho and DentaQuest.
Illinois has had a school-based dental program in place since 2006 in an effort to increase the number of EPSDT children receiving preventive dental services and oral health screens. The state has a separate enrollment procedure for providers to work in the schools. DentaQuest administers this process on behalf of the state.
Providers are required to list the dates and times of scheduled school visits on a Google Calendar. The Department of Healthcare and Families Services’ (HFS) has an interagency agreement with the Illinois Department of Public Health for their oral health consultants (dental hygienists) to provide quality assurance assessments and monitor the school-based dental program on behalf of HFS.
Indiana Indiana EPSDT provider manual provides information on dental observation and screening as part of well-child visits, as well as guidelines on providing dental anticipatory guidance to parents.
Dental hygienists at Title V agencies in Iowa can be reimbursed by Medicaid for providing oral screenings and fluoride varnish applications to Medicaid-enrolled children.
The state’s I-Smile dental home initiative began as a result of legislation passed in 2005 which stated:
“… every recipient of medical assistance who is a child 12 years of age or younger shall have a designated dental home and shall be provided with the dental screenings and preventive services, diagnostic services, treatment services, and emergency services as defined under the Early and Periodic Screening Diagnosis and Treatment (EPSDT) program.”
The I-Smile initiative seeks to connect children to dental services, and to promote the delivery of dental care in alternative settings as well as dentists’ offices.  It relies on dental hygienists employed by regional Title V agencies who serve as care coordinators. The I-Smile Oral Health Coordinators work in communities and establish relationships with local dentists and physicians. I-Smile coordinators also assist EPSDT beneficiaries with making appointments, keeping appointments, arranging transportation, and understanding the importance of good oral health.
Kansas Dental Screens are part of a KAN Be Healthy visit. The Health Plans, or their subcontractors, provide dental services to all children eligible for KAN Be Healthy, including more advanced dental services as deemed medically necessary.
Kentucky The Kentucky Medical Dental Program provides oral health services to Medicaid-enrolled children. The state provides information on participating dental providers, billing of oral health services under the EPSDT benefit, and Kentucky’s regulations for oral health service delivery to children on the Dental Services webpage.
The Louisiana Department of Health and Hospitals recently completed a competitive procurement process to select Managed Care of North America Dental (MCNA) to provide dental services to Medicaid and Louisiana Children’s Health Insurance Program (LaCHIP) enrollees. The anticipated start date for this program is July 1, 2014.
Phase III of the First STEPS (Strengthening Together Early Prevention Services) Learning Initiative, which ran from April-November 2013, is entitled “Encourage Healthy Habits by Improving Oral Health and Healthy Weight Screening, Treatment, and Referral.” Participating practices were provided with training on prevention of early childhood caries, including strategies such as completing an oral health risk assessment, an oral health screening, and fluoride varnish application.
Since 2009, all dental-related customer services for Maryland Medicaid beneficiaries have been coordinated by DentaQuest. DentaQuest is contracted to assist Medicaid enrollees in the “Maryland Healthy Smiles” Program locate dental care within a reasonable distance from the enrollees’ residence to ensure adequate access to oral health care services. Additionally, DentaQuest provides verification of dental benefits and eligibility verification.
The Maryland Healthy Smiles Dental Program is available for all Maryland Medicaid enrollees under 21 years of age as well as pregnant women. The program covers a variety of dental benefits for children, including fluoride treatment, cleanings, and fillings.
Through the Maryland’s Mouths Matter Fluoride Varnish and Oral Health Screening Program for Kids program, Maryland Medicaid reimburses for the application of fluoride varnish to Medicaid-enrolled children ages 9 months – 36 months old in primary care provider offices. Reimbursement by Medicaid is limited to EPSDT certified primary care providers who have successfully completed a state approved oral health screening and fluoride varnish program training program.
No information at this time.
Oral health services for children are provided by a Prepaid Ambulatory Health Plan (PAHP), Delta Dental. The PAHP provides beneficiaries with information on eligibility and covered services, as well as a Member Handbook.
The state also lists Medicaid professionals who have received fluoride varnish certificates.
The Minnesota Department of Health website hosts an Oral Health Screening Online Module that offers primary care providers information on their role in providing oral health screenings for Medicaid-enrolled children.
Mississippi
Mississippi Cool Kids (EPSDT) providers are encouraged to perform an oral health assessment and apply fluoride varnish at the same time as the child’s regularly scheduled Mississippi Cool Kids Screening.
Medicaid also reimburses dental providers for an oral evaluation and counseling with each child’s primary caregiver for children under the age of three.
No information at this time.
Montana
Montana’s Department of Public Health and Human Services provides resources on oral health services in the state. This includes a list of providers treating Medicaid-enrolled children, a Medicaid dental fact sheet on How to Find and Keep a Dentist, and rules and fees for orthodontia services for Medicaid beneficiaries under age 21. The state also provides a list of federally funded health center dental clinics.
Montana also has several brochures on Medicaid dental services for families and children on its oral health program website, as well as resources on school-based oral health screenings.
The state’s Medicaid dental provider handbook contains information on covered services for children, as well as the dental periodicity schedule for children.
Nevada
Nevada delivers most oral health services through MCOs to children enrolled in these plans; the remainder receive the services through fee-for-service.  Orthodontia is carved out of the MCO contract and all children receive those services through fee-for-service—all orthodontia services require prior authorization (see 1003.9 of the dental handbook.)
Nevada Medicaid reimburses for fluoride varnish provided by physicians and other providers who administer Healthy Kids screens (e.g., Federally Qualified Health Centers).
New Hampshire The New Hampshire Department of Health and Human Services’ “New Hampshire Smiles” program helps connect Medicaid-enrolled children to dentists. A detailed Dental Provider Manual offers more information on Medicaid-covered services, including under the EPSDT benefit.
Managed care organizations must develop dental provider networks that include safety net dental providers, including:
  • Dental education institutions,
  • Hospital-based dental programs, and
  • “Dental clinics sponsored by governmental agencies as well as dental clinics sponsored by private organizations in urban/under-served areas.”
Managed care organization performance measures under Centennial Care include a measure of the percentage of enrolled members ages 2-21 who have at least one dental visit during the year.
New York Medicaid’s dental delivery system relies on nearly 180 freestanding dental clinics throughout the state; over 90% of dentists in the state are practicing in private settings.
Dental services such as dental screenings and fluoride treatments are also provided to children through school-based health centers (SBHCs), including comprehensive SBHCs as well as Dental SBHCs dedicated specifically to providing dental services. Dental hygienists, dental assistants, and supervising dentists are all examples of staff that SBHCs are permitted to add to provide expanded services according to local need.
Dental care, including preventive and restorative care, is on a list of services that can be covered by EPSDT if needed to correct or ameliorate a child’s health problem. As of April 1, 2014, a new contractor (CSC) is assuming responsibility from the Division of Medical Assistance for prior approval requests of certain EPSDT services including dental and orthodontic services.
North Dakota Health Tracks provides dental services including relief of pain and infections, restoration of teeth and maintenance of dental health. Health Tracks also covers orthodontia services (braces) and additional dental services as deemed medically necessary.
Ohio Dental benefits for children are covered by managed care organizations. The state maintains a web page explaining covered dental benefits under Medicaid.
No information at this time.
Several of the Coordinated Care Organizations (CCOs) provide dental services. For Oregon Health Plan enrollees belonging to a CCO that does not provide dental services, the state has a web site to help beneficiaries find a dentist.  The Oregon Health Plan maintains a Prioritized List of Dental Health Services that details covered services for adults and children. Oregon’s services for children include:

  • Preventive care and cleanings, twice per 12 months.
  • Fluoride varnish
  • Oral health risk assessment
  • Sealants
  • Other services as deemed medically appropriate

The Oregon Health Plan also is participating in initiatives related to Oral Health including the Early Childhood Cavities Prevention campaign, which launched the First Tooth Project, designed to help providers implement preventive oral health services for infants and toddlers under the age of 3 into their current practice.

No information at this time.
No information at this time.
South Carolina South Carolina Medicaid covers application of topical fluoride varnish by primary care providers during well-child visits for children up to age 3. Physician applying fluoride varnish must also offer relevant oral health anticipatory guidance. The state also offers a Medicaid dental provider manual that includes information on dental benefits for children.
South Dakota
Support to Families
The South Dakota Department of Social Services prepared a set of Dental Frequently Asked Questions (FAQs) for Medicaid beneficiaries. The FAQ contains information on dental shortages and makes recommendations for beneficiaries who are having trouble finding a dentist who accepts Medicaid. The Department of Social Service’s website also contains a link to the federal InsureKidsNow.gov website to help beneficiaries find a Medicaid-participating dentist in their area.
Bright Futures Curriculum
The American Academy of Pediatrics’ Bright Futures periodicity schedule is explicitly referenced in South Dakota’s administrative rules. These rules specify that dental screenings under the EPSDT benefit must be completed according to the following schedule:
“(3)  For dental healthcare, a dental screening by a dentist when the child is one year old. After the age of one, the dental screenings follow the schedule established under subdivision (1) of this section.”
Tennessee Tennessee provides dental services to children through its TENNderCare (EPSDT) program. The state contracts with DentaQuest to serve as the Dental Benefits Manager Prepaid Ambulatory Health Plan. Services provided to TENNderCare beneficiaries include: six-month appointments, screens and diagnostic tests, topical fluoride treatment, pit and fissure sealants, and substance abuse counseling. Tennessee does not provide orthodontic treatment (braces) unless the child is diagnosed with severe handicapping malocclusion.
Texas
Pediatric and general dentists participating in Texas Health Steps are being trained to provide children aged 6-35 months with a First Dental Home. Dentists can bill an all inclusive bundled code for a First Dental Home visit, which has the following components:
  • Caries risk assessment.
  • Dental prophylaxis.
  • Oral hygiene instructions with primary caregiver.
  • Application of topical fluoride varnish.
  • Dental anticipatory guidance.
  • Establishment of recall schedule.
No information at this time.
No information at this time.
Virginia Virginia covers the comprehensive set of pediatric dental services as recommended by the American Academy of Pediatric Dentistry (AAPD).
Washington’s Medicaid program reimburses dentists, physicians, physician assistant, advanced registered nurse practitioners for fluoride varnish applications.
Children’s oral health services are provided through Medicaid managed care organizations (MCOs). Each MCO must have a Dental Director and each is required to educate its provider network about the state’s Infant and Child Oral Health Fluoride Varnish Program for Primary Care Practitioners program, which reimburses Medicaid primary care providers for applying fluoride varnish to young children. The MCOs are also responsible for ensuring continuity of dental and orthodontic care for Medicaid beneficiaries.
Wisconsin
Children are given mouth exams as part of a HealthCheck preventive care exam. Children who need additional dental care are referred to a dental provider and these services are covered by HealthCheck.
HealthCheck nursing agencies are reimbursed by Medicaid for providing dental sealants to Medicaid beneficiaries under age 21.
Wyoming All children in Wyoming Health Check receive dental services on a fee-for-service basis. The Health Check brochure details which services are covered by age group. Other dental services are provided as deemed medically necessary.