Paul Sanchez
Dental insurance coverage varies depending on age and location. Dental coverage is an essential health benefit for children, and states are required to provide dental benefits to children covered by Medicaid and the Children's Health Insurance Program (CHIP). However, dental coverage is not considered an essential health benefit for adults, and states have the option to provide dental benefits to their adult Medicaid-eligible population. While most states offer at least emergency dental services for adults, less than half provide comprehensive dental care. Dental insurance can be purchased separately or as part of a health plan in the Marketplace, and there are two categories of Marketplace dental plans: high and low. Medicare typically does not cover dental services, except in cases where dental services are inextricably linked to the clinical success of other Medicare-covered procedures.
| Characteristics | Values |
|---|---|
| Dental coverage for children | Required in all states |
| Dental coverage for adults | Optional in all states |
| Dental services for children | Oral screening, dental examination by a dentist, dental services at intervals that meet reasonable standards of dental practice, emergency services |
| Dental services for adults | Emergency services, comprehensive dental care |
| Dental plan options | High, low |
| Dental plan costs | Premium, deductible, copayments, coinsurance |
| Dental coverage with Medicare | Not covered except for inpatient hospital services connected to dental services when the patient requires hospitalization due to an underlying medical condition |
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What You'll Learn
Dental coverage for children and adults over 18
Medicaid dental coverage differs for children and adults. 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. This is a comprehensive child health program that focuses on prevention, early diagnosis, and treatment of medical conditions. States must provide dental services at intervals that meet reasonable standards of dental practice, as determined by the state in consultation with recognized dental organizations. Oral screening as part of a physical exam does not substitute a dental examination from a dentist after getting a referral.
Dental coverage for children with Medicaid must be available, but it is not mandatory to purchase it. Dental coverage is not considered an essential health benefit for adults, and health plans are not required to offer it. States have the option to provide dental benefits to their adult Medicaid population, and most states provide at least emergency dental services for adults, but less than half provide comprehensive dental care.
The specific dental services provided under Medicaid vary by state, and there are no minimum requirements for adult dental coverage. The Centers for Medicare & Medicaid Services (CMS) is committed to improving access to dental and oral health services for Medicaid and CHIP beneficiaries. Rates of dental service use among adults are relatively low across all states, ranging from under 5% in Alabama and Tennessee to over 30% in Montana, Minnesota, Connecticut, Massachusetts, and New Jersey.
If you have a Marketplace health plan, you can choose a plan with or without dental benefits. If you select a plan without dental benefits, you can purchase a separate dental plan. However, you cannot buy a Marketplace dental plan unless you are also buying a health plan. If your health plan includes dental coverage, the premium covers both health and dental coverage. If you choose a separate dental plan, you will pay a separate premium in addition to your health plan premium.
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Dental services provided by Medicaid
Dental health is an important part of people's overall health. States are required to provide dental benefits to children covered by Medicaid and the Children's Health Insurance Program (CHIP). However, states have the flexibility to determine what dental benefits are provided to adult Medicaid enrollees. There are no minimum requirements for adult dental coverage. While most states provide at least emergency dental services for adults, less than half of the states provide comprehensive dental care.
Medicaid covers dental services for all child enrollees as part of a comprehensive set of benefits, referred to as the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. This is Medicaid's comprehensive child health program, focusing on prevention, early diagnosis, and treatment of medical conditions. The program is mandatory and is 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 in consultation with recognized dental organizations involved in child health. Oral screening may be part of a physical exam but does not substitute a dental examination performed by a dentist. A referral to a dentist is required for every child in accordance with the periodicity schedule set by the state.
Dental services for children must minimally include teeth cleaning, x-rays, cavity fillings, crowns, and other services. The specific dental services provided may vary depending on the state and the child's individual needs. It's important to note that dental coverage for children is considered an essential health benefit, and while it must be available, it is not mandatory to purchase it.
For adults enrolled in Medicaid, the dental services available may vary depending on the state. Some adults enrolled in Medicaid are eligible for surgical procedures and emergency services related to treating symptoms and pain. Other adults may have access to additional dental services, but this is determined by each state's Medicaid program. Adults can visit any dentist that signs up with their MCO and find a dentist through various resources, such as online or by contacting their MCO's member services department.
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The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit
Dental services must be provided at intervals that meet reasonable standards of dental practice, as determined by the state in consultation with recognized dental organizations involved in child health. These services must be provided 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, dental services must include dental care needed for relief from pain and infection, restoration of teeth, maintenance of dental health (provided at as early an age as necessary), and medically necessary orthodontic services. A referral to a dentist is required for every child in accordance with the periodicity schedule set by the state.
The purpose of EPSDT is to ensure that children and adolescents receive appropriate preventive, dental, mental health, and specialty services, and to identify and treat childhood health conditions before they become serious or disabling. States are required to inform all Medicaid-eligible families about the benefit, screen children at reasonable intervals, diagnose and treat any health problems found, and report certain data regarding EPSDT participation annually to the Centers for Medicare & Medicaid Services (CMS).
CMS has developed strategy guides to support states in implementing the EPSDT benefit, offering specific approaches to improve access, utilization, and quality of care for children and adolescents enrolled in Medicaid.
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Dental insurance plans in the Marketplace
Dental insurance is available through the Health Insurance Marketplace, also known as Obamacare or the Affordable Care Act. There are two categories of Marketplace dental plans: high and low. The high coverage level has higher premiums but lower copayments and deductibles, meaning you pay more monthly but less when using dental services. The low coverage level has lower premiums but higher copayments and deductibles, meaning you pay less every month but more when you use dental services.
Dental coverage is treated differently for adults and children under the age of 18. Dental coverage is an essential health benefit for children, meaning that if you are getting health coverage for someone under 18, dental coverage must be available for your child either as part of a health plan or as a separate dental plan. However, you are not required to buy it. Dental coverage is not an essential health benefit for adults, and health plans do not have to offer adult dental coverage.
You can choose a health plan with or without dental benefits in the Marketplace. If you choose a health plan without dental benefits, you can still get a separate dental plan. However, you cannot buy a Marketplace dental plan unless you are buying a health plan at the same time. If your Marketplace health insurance plan comes with dental coverage, you cannot opt out of it, but you can make changes to your plan so that the new one does not cover dental procedures.
You can use the federal Health Insurance Marketplace at HealthCare.gov to find, compare, and enroll in dental plans in your area. You can preview dental plans by answering a few income and household questions. The yearly period when people can enroll in a Marketplace health insurance plan is between November 1 and January 15. Outside of the yearly Open Enrollment Period, you can qualify for a Special Enrollment Period if you have had certain life events, such as losing health coverage, moving, getting married, having a baby, or adopting a child, or if your household income is below a certain amount.
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Submitting a Medicare claim for denial
Medicaid is a health insurance program that provides coverage for dental services to children and adults. States are required to cover dental services for individuals with Medicaid under the age of 21, as part of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. While dental coverage is mandatory for children, states have the option to provide dental benefits to adults.
Now, if you're facing a denial of a Medicare claim, you have the right to file an appeal. Here's a step-by-step guide on submitting a Medicare claim for denial:
- Understand the reason for denial: Before initiating an appeal, it's crucial to understand why your Medicare claim was denied. Common reasons for claim denials include issues with billing, medical necessity, or coverage limitations. Review any documentation or correspondence related to the denial to identify the specific reason.
- Gather supporting documentation: Collect all relevant documents that support your claim. This may include medical records, itemized bills, correspondence with your doctor or provider, and any other evidence that strengthens your case.
- Contact your provider: Before submitting an appeal, consider discussing the denial with your healthcare provider. They may provide additional information or clarification that could be helpful in your appeal. Ask for any supporting documents or explanations they can offer.
- Identify the type of appeal: Medicare appeals typically follow a multi-level process. Familiarize yourself with the different levels of appeals available to you. The specific levels may vary depending on your coverage type, so refer to the decision letters and instructions provided at each stage.
- Submit a written appeal: Initiate the appeal process by submitting a written request. You can use the "Patient Request for Medical Payment" form (CMS-1490S) or follow the instructions provided by your plan. Include a detailed letter explaining why you're submitting the appeal and any supporting documentation you've gathered.
- Follow-up and persistence: Stay engaged in the appeals process. If you disagree with a decision at any level, you usually have the option to proceed to the next level. Continue pursuing your appeal until you reach a satisfactory resolution or exhaust all available levels.
- Seek assistance if needed: If you require guidance or assistance with your appeal, you can contact your local State Health Insurance Assistance Program (SHIP) by visiting shiphelp.org or calling 1-800-MEDICARE (1-800-633-4227). These programs offer free, personalized health insurance counseling to help you navigate the appeals process.
- Judicial review: In certain cases, if your claim amount meets a minimum dollar value (e.g., $1,900 for 2025), you may be able to pursue a judicial review in a federal district court. This option may be considered if lower-level appeals are unsuccessful.
Remember to act promptly when submitting a Medicare claim for denial, as there may be time limits involved in the appeals process. Keep detailed records of all communications, decisions, and submissions related to your appeal.
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Frequently asked questions
Dental coverage is an essential health benefit for children. States are required to provide dental benefits to children covered by Medicaid. This includes dental services and comprehensive oral health programs.
States choose whether to provide dental benefits for adults on Medicaid. While most states provide at least emergency dental services, less than half provide comprehensive dental care.
EPSDT is Medicaid's comprehensive child health program. It is a mandatory service that focuses on prevention, early diagnosis, and treatment of medical conditions. States are required to cover dental services for people with Medicaid under the age of 21 as part of the EPSDT benefit.
Yes, you can get dental insurance through the Health Insurance Marketplace. You can either choose a health plan with dental benefits or a separate dental plan. However, you cannot buy a Marketplace dental plan unless it is purchased alongside a health plan.
