Does Maryland Medicaid cover dental?

By - January 13, 2021

Medicaid is a program developed to defray some or all health care costs for people with limited income and financial resources. Funding for the program is shared between the federal government and states. The federal government sets the requirements, and the states administer the programs. Beyond the federal requirements, states have a certain amount of flexibility in establishing eligibility and benefits.

All states must adhere to federal mandates that require basic dental coverage for children, but the states are given discretion with regard to dental coverage for adults. Until 2019, Maryland Medicaid excluded dental benefits for adults. Now there is a program in place to cover certain dual-eligibles.

Dual-eligibles 

Individuals who receive Medicare and Medicaid benefits simultaneously are referred to as dual-eligible beneficiaries, or dual-eligibles. When the services in these programs overlap, there is a coordination of benefits to avoid duplicate payments. If the programs cover the same services, Medicare pays first, and Medicaid covers the remaining portion. The cost of health care services not covered under the Medicare program are paid by Medicaid. 

For partial-duals, Medicaid pays some of the costs incurred with Medicare, such as applicable Part A and Part B premiums, deductibles, coinsurance and copayments. Full-duals are entitled to these same benefits plus Medicaid coverage for services not part of the Medicare program. Original Medicare does not cover routine dental care. 

Maryland Medicaid Adult Dental Waiver Program

The Maryland managed care program is called Maryland HealthChoice. The Centers for Medicare & Medicaid Services (CMS) approved an amendment to Maryland HealthChoice that launched a Medicaid adult program for dental benefits, known as the Medicaid Adult Dental Waiver Program. It is a pilot test program that went into effect on June 1, 2019.

Following are the qualifications for eligibility:

  • Fully dual-eligible
  • Disabled
  • Between the ages of 21 and 64
  • Not enrolled in a managed care program, which is a plan with network providers like a Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO)

The dental services included in the Medicaid adult dental pilot program are limited to:

  • Oral exams
  • Cleanings and X-rays
  • Fillings
  • Extractions
  • Anesthesia, if needed for pain

Root canals and dentures are not covered. The maximum total benefit is $800 per calendar year. 

Maryland Healthy Smiles Dental Program (Healthy Smiles)

Healthy Smiles is a dental services Medicaid program that covers the following population:

  • Infants through age 20
  • Women 21 years old or more who are pregnant
  • Adults in the Rare and Expensive Case Management (REM) program, which is a state program for people with highly expensive and rare medical issues
  • Adults age 21 through 25 who were plan members as foster care children

Services include:

  • Checkups and cleanings
  • Fluoride treatments
  • Sealants (children)
  • X-rays
  • Fillings
  • Root canals
  • Crowns
  • Extractions 
  • Anesthesia
  • Denture adjustments (adults)
  • Space maintainers (children)
  • Orthodontia (children)

Resources

Information about Medicaid is available at medicaid.gov., the official U.S. website. The handbook for the adult pilot program for dental services can be accessed at https://mmcp.health.maryland.gov/Documents/Member%20Handbook.pdf. The Maryland Healthy Smiles Dental Program handbook is available at https://mmcp.health.maryland.gov/Documents/3-24-2020%20MD%20Member%20Handbook%202020%20DH%20updates.pdf.

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