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Medicaid Reimbursement for Adult Dental Services


Medicaid reimburses for adult dental services rendered by  licensed, Medicaid-participating dentists.  Medicaid reimbursable adult dental services are provided to recipients age 21 and older.  Services include:

•  Diagnostic examination for the denture services;

•  Radiographs necessary for dentures;

•  Extractions and other surgical procedures essential to the preparation of the mouth for dentures if the recipient is to receive dentures; 

•  Provision of complete dentures; 

•  Repairs and relines of the dentures, if warranted;

•  Oral prophylaxis; and

•  Emergency extractions and abscess treatment to alleviate pain or infection.

LIMITATIONS:

Medicaid reimbursement is limited to one set of complete dentures, upper or lower or both, for the life of the recipient.  Relines are limited to one per denture, per 12-month period.  Oral prophylaxis is limited to one per 12-month period.

Recipients who reside in a nursing facility, intermediate care facility for the developmental disabled or state mental hospital must have the oral examination requested by their attending physician and the Director of Nurses.

EXCEPTIONS:

The provider may request authorization for reimbursement for services in excess of the service limitations.  

ELIGIBILITY:

Medicaid reimburses for adult dental services for all Medicaid recipients 21 years of age and older.

REIMBURSEMENT:

Medicaid reimbursement for adult dental services is the maximum Medicaid fee or the provider’s customary fee, whichever is lower.

Recipients are required to pay the provider a five-percent coinsurance on adult dental services.  The coinsurance is five percent of the Medicaid fee or the provider’s charge, whichever is lower.  Recipients who reside in nursing facilities, intermediate care facilities for the developmentally disabled, or state mental hospitals are exempt from the coinsurance.
 
 

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