As 10,000 baby boomers retire on a daily basis, healthcare worries emerge. Medicaid is the primary coverage for low-income individuals. While 30 percent of retirees do have some form of extra care coverage,toothless individuals are likely to have little to no dental coverage. Relying solely on state care puts their oral care in jeopardy. And premature aging and problems associated with lack of dental care contribute to the continuation of substandard living. So will Medicaid make a move to cover cosmetic dental procedures?
What dental services are currently covered by Medicaid?
Medicaid covers specific dental needs for about half of the country. Benefits are currently limited and specified to essential services only. Children’s benefits are for individuals under the age of 21. Part of Medicaid’s Early Periodic Screening, the EPSDT program offers dental evaluations, emergency, preventative, and restoration care on a per need basis. Bi-annual visits are covered, but all other visits are per dentist request. Medicaid Orthodontic Benefit is available for severe malocclusion. This specific benefit covers up to three years of treatment and one year of follow-up retention care.
Medicaid covers a variety of dental procedures, regardless of age:
- most routine dental services: include cleanings, exams, sealants, fillings, x-rays every 5 years
- dentures – either partial or complete sets, once per decade
- limited individual periodontal services: 4 quadrants of scaling or root planning per year (periodontal surgery is covered if it’s due to an underlying condition)
craniofacial reconstruction is covered for those with post-traumatic or genetic abnormalities
- endodontic treatment and stainless steel caps for individuals under 21
Routine visits do not count toward annual limits, and visits through specialty programs such as MPW (Medicaid for Pregnant Women) are only covered for the allotted or specified time period, such as during the pregnancy.
Medicaid covers children under 21 nationwide, but there are still no mandatory coverage specifications for adult care. Therefore, this is a tricky solution based on state laws and mandates. As of early 2015:
- 2 states covered orthodontic requirements
- 9 states placed monetary limits on adult-based Medicaid covered dental care
- 19 states covered periodontal care and emergency dental care for non-disabled or non-pregnant adults
- 25 states covered oral surgery and dentures
- 26 states covered restorative issues
- 27 states covered dental prevention services
What dental care Is excluded in Medicaid coverage?
Surgical elective procedures such as dental implant are not covered. The same holds true for adult root canals outside of specific pre-conditions, crown lengthening, and replacement dentures within specific time periods. Basic bridgework, crowns, bonding, whitening, veneers, and all experimental procedures must be self-paid or covered by personal insurance. Medicaid also refuses to pay for retainers, TMJ splints, mouthpieces, or night guards.
Medicaid does not currently cover cosmetic dental procedures in any form, and there are no firm indications that this will change anytime in the near future. The Medicaid program requires states to pay 50 percent of the funding needed to cover the costs of the statewide benefits. When state economies struggle to stay afloat, Medicaid benefits drop. As the budgets improve, Medicaid kicks back in and expands coverage. Medicaid acts as a skeletal catch-all that covers only the basic dental care requirements. But since the program evolves based on monetary allowance, that may feasibly change.