States are required to cover dental services for people with Medicaid under the age of 21, as part of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit.
People under age 21
EPSDT is Medicaid's comprehensive child health program. The program focuses on prevention, early diagnosis, and treatment of medical conditions. EPSDT is a mandatory service required 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. Dental services may not be limited to emergency services for EPSDT recipients. At a minimum, services must include:
- Relief of pain and infections
- Restoration of teeth
- Maintenance of dental health
Oral screening may be part of a physical exam but doesn’t substitute for a dental examination from a dentist after getting a referral. 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 doesn’t 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 such services are included in the state's Medicaid plan.
People age 21 and older
States may choose whether or not to provide dental benefits to their adult Medicaid-eligible population 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.