Surgery--Again

Overview

Currently, Medicare will pay for dental services that are an integral part either of a covered procedure (e.g., reconstruction of the jaw following accidental injury), or for extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw. Medicare will also make payment for oral examinations, but not treatment, preceding kidney transplantation or heart valve replacement, under certain circumstances. Such examination would be covered under Part A if performed by a dentist on the hospital's staff or under Part B if performed by a physician.

Statutory Dental Exclusion

Section 1862 (a)(12) of the Social Security Act states, "where such expenses are for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth, except that payment may be made under part A in the case of inpatient hospital services in connection with the provision of such dental services if the individual, because of his underlying medical condition and clinical status or because of the severity of the dental procedure, requires hospitalization in connection with the provision of such services."

Background

The dental exclusion was included as part of the initial Medicare program. In establishing the dental exclusion, Congress did not limit the exclusion to routine dental services, as it did for routine physical checkups or routine foot care, but instead it included a blanket exclusion of dental services.

The Congress has not amended the dental exclusion since 1980 when it made an exception for inpatient hospital services when the dental procedure itself made hospitalization necessary.

Coverage Principle

Coverage is not determined by the value or the necessity of the dental care but by the type of service provided and the anatomical structure on which the procedure is performed.

Services Excluded under Part B

The following two categories of services are excluded from coverage:

A primary service (regardless of cause or complexity) provided for the care, treatment, removal, or replacement of teeth or structures directly supporting teeth, e.g., preparation of the mouth for dentures, removal of diseased teeth in an infected jaw.

A secondary service that is related to the teeth or structures directly supporting the teeth unless it is incident to and an integral part of a covered primary service that is necessary to treat a non-dental condition (e.g., tumor removal) and it is performed at the same time as the covered primary service and by the same physician/dentist. In those cases in which these requirements are met and the secondary services are covered, Medicare does not make payment for the cost of dental appliances, such as dentures, even though the covered service resulted in the need for the teeth to be replaced, the cost of preparing the mouth for dentures, or the cost of directly repairing teeth or structures directly supporting teeth (e.g., alveolar process).

Exceptions to Services Excluded

The extraction of teeth to prepare the jaw for radiation treatment of neoplastic disease.

An oral or dental examination performed on an inpatient basis as part of comprehensive workup prior to renal transplant surgery or performed in a RHC/FQHC prior to a heart valve replacement.

Definition

Structures directly supporting the teeth means the periodontium, which includes the gingivae, periodontal membrane, cementum of the teeth, and the alveolar bone (i.e. alveolar process and tooth sockets).

Overview

Dental services under Title XIX of the Social Security Act, the Medicaid program, are an optional service for the adult population, individuals age 21 and older. However, dental services are a required service for most Medicaid-eligible individuals under the age of 21, as a required component of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit.

Individuals under Age 21

EPSDT is Medicaid's comprehensive child health program. The program's focus is on prevention, early diagnosis, and treatment of medical conditions. EPSDT is a mandatory service required to be provided under a state's Medicaid program.

Dental services must be provided at intervals that meet reasonable standards of dental practice, as determined by the state after consultation with recognized dental organizations involved in child health, and at such other intervals, as indicated by medical necessity, to determine the existence of a suspected illness or condition. Services must include at a minimum, relief of pain and infections, restoration of teeth and maintenance of dental health. Dental services may not be limited to emergency services for EPSDT recipients.

Oral screening may be part of a physical exam, but does not substitute for a dental examination performed by a dentist as a result of a direct referral to a dentist. A direct dental referral is required for every child in accordance with the periodicity schedule set by the state. The Centers for Medicare & Medicaid Services does not further define what specific dental services must be provided, however, EPSDT requires that all services coverable under the Medicaid program must be provided to EPSDT recipients if determined to be medically necessary. Under the Medicaid program, the state determines medical necessity.



If a condition requiring treatment is discovered during a screening, the state must provide the necessary services to treat that condition, whether or not such services are included in the state's Medicaid plan.



Individuals Age 21 and older



States may elect to provide dental services to their adult Medicaid-eligible population or elect not to provide dental services at all as part of its Medicaid program. While most states provide at least emergency dental services for adults, less than half of the states provide comprehensive dental care. There are no minimum requirements for adult dental coverage.


Downloads
Guide to Children's Dental Care in Medicaid [PDF, 624KB]

Dental Contacts [PDF, 199KB]

Policy Issues in the Delivery of Dental Services to Medicaid Children and Their Families [PDF, 55 KB]

National Dental Summary Report 2008 [PDF, 346 KB]

2010 Dental Fact Sheet [PDF, 50KB]

2010 Eight-State Medicaid Dental Review Summary Report [PDF, 133 KB]

Individual State Reports (October 2010) [ZIP, 672 KB]

State Reports 2008 [ZIP, 1630 KB]

CMS Dental Strategy [PDF, 184 KB]

Adult Medicaid Dental Benefits
Dental benefits are an optional benefit for the adult Medicaid population (age 21 and over). The extent of benefits varies across the states from no benefit to comprehensive benefits in a few states.

Adult Medicaid Dental Benefits Offered to the Largest Percent of the State’s Adults

What population of adult beneficiaries is described in this section?

Adults age 21 and older

What is the name of the program?

Medicaid

Does your state cover any dental benefits for adults?

Yes

Does your state cover only emergency dental services for adults?

No

Cap or Maximum Payment Limits on Adult Medicaid Dental Services

For the population described above, is there a maximum dollar limit or cap on the amount that may be expended per individual for dental benefits during a defined time period?

No

Comments:
none


Exclusions or Other Limits on Adult Medicaid Dental Services

States may limit receipt of specific dental services by employing strategies other than maximum payment limits. Referring to the benefits described for the population in Adult Medicaid Dental Benefits above, are there any exclusions other than dollar maximums?

Yes

Please describe the specific services and, respectively, the exclusions or other limits that apply:

In addition to specific age and other limits, many dental services (in the FFS program) require prior authorization by surface, tooth, quadrant or arch. Limits and exclusions may be found in the fee schedule containing "general information and instructions" that is available from the NYSDOH. Similar requirements are used in managed care plans.

Comments:
none


Pregnancy-Related Dental Services

Does your state Medicaid program offer pregnancy-related dental benefits to women over age 21 with income up to 133% FPL, or to a higher percentage of FPL?

Yes

Please specify the % FPL.

200% FPL

Comments:
Pregnant women over the age of 21 may receive the same dental benefits as other adults.


Dental Benefits for Other Groups of Adults

Excluding the population whose dental benefits are described in the Adult Medicaid Dental Benefits section and excluding pregnant women whose dental benefits are described in the Pregnancy-Related Dental Services section, are there any other adult populations groups in your state who receive dental benefits?

Yes

Please describe the specific group, the name of the program providing services and the dental services available to each group:

Certain populations that are not eligible for full Medicaid, such as undocumented immigrants and temporary non-immigrants, may be eligible for treatment of an emergency medical condition, including emergency dental services only.