Good oral health is a vital part of staying healthy and Medicaid can be a critical component in achieving that goal. States must meet certain requirements to offer dental benefits to children who are covered under the Medicaid program as well as those who are enrolled in the Children’s Health Insurance Program (CHIP). But while children are mandated for care, states can be more selective about providing similar benefits to adults.
Covered Benefits for Children
Medicaid covers dental work for all children in the program under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. Oral screenings are typically included in any physical examination a child may receive, but it should not take the place of a full dental examination by a dental professional. Children can be referred to a dentist under the stipulations set forth within the rules of each state. Any covered dental work provided to a child in Medicaid must meet the program minimums, which include routine preventative care, relief from tooth or oral pain, removal of infection, and restoration of teeth that have been damaged or lost.
Early Periodic Screening, Diagnostic and Testing (EPSDT) Benefit
Under EPSDT, all dental work must be performed on a child that has been deemed as a medical necessity. The guidelines for that determination are established by the states individually. Should there be a condition or malady discovered during a checkup, the state is bound to provide services to treat the problem, regardless of whether or not they are covered under that state’s Medicaid program.
States must also develop a dental maintenance schedule in accordance with established dental associations that have sufficient expertise in providing healthcare for children. Dental services must be offered to children at periodic intervals that follow the prescribed schedule and states must provide dentist referrals to comply with those intervals for care.
Covered Benefits for Children in CHIP
Any state that offers CHIP through the Medicaid expansion must provide the ESPDT benefit. CHIP programs are also required to cover dental services that are essential to prevent disease and promote good dental health, cover emergency procedures, and restore teeth and other oral functions in children.
Covered Benefits for Adults
While Medicaid comes with specific minimum requirements for children in all states, coverage for adults is less stringent. States have more leeway to determine what dental services can be offered to adults in the Medicaid program. Most states maintain a minimum of emergency dental services to all adult enrollees, however, many fail to provide a comprehensive plan.