Medicare Dental Coverage by STATE. Compiling of Data

[ElCubanito]

Hello all, I was hoping to compile a medicare dental coverage information thread, state by state, in order to benefit those dentists that either new graduates or are looking to go practice in other states. I have worked in CA and NV for past 10 years so I will provide some information about those. Im looking for a few key categories.

1. Coverage for Kids
2. Coverage for Adults
3. Fees for different procedures....whatever you can recall...
4. Pre-Auth, Xrays needed for fillings, extractions, RCT, crowns.

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[ElCubanito]

NV:
Medicare Program is run by Liberty Dental. The States program was previously run by 3 different companies, Scion, HPN and HP (yea, the printer people).
1. All inclusive coverage for Kids <21. Fillings, Sealants, RCT, Crowns.
2. Limited coverage for Adults. Limited Exams and xrays. Extractions. Partials and Complete Dentures. 4+ teeth.
3. Fees are semi-okay. These are estimates. Fillings: 40 , RCT 250-400, Surgical Extractions: around 79, dentures partials 300-500.
4. Pre-Auth needed for Dentures/Partials/RCT. No Pre Auth or xrays for fillings as of yet.


CA:
Medicare program (DENTICAL) is run by notorious/controversial Dental Dental of CA. SoCal also has new "bubble" program called Borrego which is the new "gold rush" down here. Most Dentists in California take Dentical in some way shape or form. Last few years Dentical expanded its coverage to ADULTS.

1. All inclusive coverage for Kids < 21. Fillings, Sealants, RCT, Crowns.
2. All inclusive coverage for Adults > 21. Fillings, RCT anterior and premolar, extractions, crowns, partials and dentures
2a. (Borrego) All inclusive coverage for adults and kids. Fillings, Sealants, RCT all teeth up to 2nd molars, Crowns. NO PREAUTHORIZATION or XRAYS.
NOTE: Apparently they have a federal grant that doesnt go through Dentical, so people are overbilling the crap of it as long as it lasts (10+ RCTs per patient) (Full Mouth Crowns). They no longer take new providers!
3. Fees are semi-ok when bundled with other procedures. Fillings: 40, Extractions 80, Dentures 300-500. RCT 200-400.
4. Pre-Auth: Dentical system is cumbersome, requiring intraoral pictures and xrays for fillings. Aside from fillings pre-auth is required for EVERYTHING: RCT, Crowns, Dentures. Partials. No need to pre-auth or xrays for baby teeth.

 

[pubhealthdent]

Hello all, I was hoping to compile a medicare dental coverage information thread, state by state, in order to benefit those dentists that either new graduates or are looking to go practice in other states. I have worked in CA and NV for past 10 years so I will provide some information about those. Im looking for a few key categories.

1. Coverage for Kids
2. Coverage for Adults
3. Fees for different procedures....whatever you can recall...
4. Pre-Auth, Xrays needed for fillings, extractions, RCT, crowns.

Medicare or Medicaid or both? Big difference

 

[pubhealthdent]

Wisconsin Medicaid programs

1. Coverage for Kids - (Badgercare)
Covers almost all procedures including exams, prophys, sealants, operative, oral surgery, crowns, endo, nitrous
2. Coverage for Adults - (Forward Health)
covers operative (resin or amalgam on any teeth with posterior resin downgrade), SSC, PFM (if special needs), endo (if 50% of crown remains), EXTs, partials (resin or metal base, must be missing 6+ teeth in arch or be missing at least one anterior tooth), full dentures, comp exams, limited exams (2 per year), ER exams, prophy, SC/RP, sedation if special needs
3. Fees for different procedures....whatever you can recall... No idea on the exact fees but I know Wisconsin is in the bottom five for medicaid reimbursement for children and adults
4. Pre-Auth, Xrays needed for fillings, extractions, RCT, crowns.
Pre-auths required for endo (require recent PA+BW, and FMX), crowns (no radiograph required), alveoloplasty (pre-op photos), full and partial dentures (FMX, FMP for partials), relines (nothing required), SC/RP (FMX, FMP), and nitrous

 

[lemoncurry]

Vermont Medicaid.

Kids and pregnant mothers: unlimited
Adults: $510 per year, no Dentures or indirect restorations.
I would assume xrays would be needed for all of the above unless you are physically unable to get them on a patient.

 

[Cold Front]

Ohio Medicaid 2019

1. Kids under 21: All xrays, Exams, prophy, Fluoride, Molar Sealants (once every 2 years), all restorative, SSC (once a year), Pulpotomies, EXT’s, Nitrous, Space Maintainers, and Ortho (prior Authorization needed).

2. All X-rays, Exams, Intraoral pics, Diagnostic casts, Tobacco cessation consults, both amalgam and composite restoratives, EXT’s, Root tips, alveoplasty, RCT’s including molars, posterior teeth SSC’s, Anterior Porcelain crown (prior authorization), Build-ups, Full dentures and partials (every 8 years), SRP’s, and gingivectomies (prior authorization).

3. $22 per sealants, $35 prophy, $50 for pan, $35 for exam, $15 fluoride, $60 simple EXT, $400 Molar RCT, $300 Anterior RCT, $130 Build-up, $150 SSC, $100 alveoplasty per quad, $450 anterior PFM, $100 per quad SRP ($400 full mouth), $550 partial denture per unit, $400 full denture per unit, $25 diagnostic cast, $20 tobacco consult.

4. Pan needed for all removable cases (dentures and partials). PA needed for anterior PFM crowns. Everything else doesn’t need prior authorization.

 

[ElCubanito]

Thank you guys! ColdFront, Lemoncurry, PubhealthDent. Looks like Ohio is pretty good reimbursement rates....Jesus, $22 for a sealant thats pretty good add on!