Does Medicaid Cover Children’s Dental?
Good oral health is important and also plays a critical role in a patient’s overall health. It is a requirement for states to provide dental benefits for children who are covered by Medicaid and the Children's Health Insurance Program (CHIP). For adults, states are able to select if dental benefits are provided. Visit the Medicaid website (www.medicaid.gov) for additional information regarding how children dental care provided through Medicaid.
Medicaid Dental Benefits
Dental services are covered through Medicaid for all children who are enrolled. These dental benefits are one portion of the comprehensive benefits included in the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. While doctors may complete oral screening as part of a physical exam, it is not an adequate substitution for the dentist completing a thorough dental examination. Dentist referrals are required for children in accordance with the periodicity schedule which is established by the state.
At a minimum, dental services for children need to include the following:
1. Dental health routine maintenance
2. Providing relief for pain or infection
3. Tooth restoration
According to the EPSDT benefit, if a service is determined to be medically necessary, it must be provided. States determine what is medically necessary. If a condition which requires treatment is identified during a screening, the state needs to provide necessary services to treat that condition. This is required regardless of whether or not the service is included in the state's Medicaid plan.
It is a requirement for each state to develop a dental periodicity schedule. This is created along with consultation from recognized dental organizations who are involved with child health care. For children entitled to EPSDT, dental services cannot be limited or restricted to emergency services.
It is required for dental services to be provided at intervals that meet reasonable standards of dental practice. In addition, the services should be provided at intervals which are medically necessary, in order to determine if a suspected illness or condition exists. To establish these intervals, states are expected to consult with recognized dental organizations who are involved in children’s health care. In accordance with each State's periodicity schedule and at other intervals as deemed medically necessary, it is required to provide every child with a referral to a dentist. The periodicity schedule which is established for other types of EPSDT services, is not allowed to dictate the schedule for dental services.
CHIP Dental Benefits
States which provide CHIP coverage to children via a Medicaid expansion program, are also required to provide the EPSDT benefit. Separate CHIP programs are required to include coverage for dental services described as necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions.
When a state has a separate CHIP program, they are allowed to select from two different dental coverage options. This includes dental benefits which meet the CHIP requirements or a benchmark dental benefit package. A benchmark dental package is required to be substantially equal to one of the following:
1. the most popular federal employee dental plan for dependents
2. the most popular plan selected for dependents in the state's employee dental plan
3. dental coverage offered through the most popular commercial insurer in the state