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.

The excerpt on dental coverage from the 2011 Report of the Secretary on the Quality of Health Care Delivered to Children Under Medicaid and CHIP (see link below) provides the most recent available data.

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] Dental Services Excerpt from the 2011 Secretary's Report [PDF, 203 KB]
Related Links Inside CMS
Medicaid and CHIP Promising Practices
Related Links Outside CMS
American Dental Association Guide to Medicaid Dental Innovations American Academy of Pediatric Dentistry's compilation of State EPSDT Dental Periodicity Schedules

Page Last Modified: 11/16/2011 12:11:17 PM
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