The limits below apply to categorically needy and State Blind Pension adults age 21 and over. The following individuals are not eligible for dental services except when the patient's medical condition requires the dental service be provided in an inpatient hospital or surgical center:
GA cash and GA-related MA recipients whose MA benefits are state funded only
MNO recipients age 21 and over
See Appendix A for a list of covered services.
Oral examinations are limited to one each year.
Prophylaxis (cleaning) is limited to one each year.
Full dentures are limited to one in each arch every seven years, no matter what procedure code is used.
Partial dentures to replace two anterior (front) teeth or four posterior (back) teeth, excluding third molars, are limited to one in each arch every seven years, no matter what procedure code is used.
Relining of dentures is limited to one in each arch every two years, no matter what procedure code is used.
Payment for root canals requires post-op review and pre-op and post-op radiographs, with the following conditions:
A periapical film must be taken that shows the root and crown of the natural tooth (pre-op and post-op).
The tooth must be filled within two millimeters of the radiological apex (unless there is a curvature or calcification of the canal that limits the ability to fill to the radiological apex).
The root canal filling material cannot be filled beyond the radiological apex.
The root canal filling must be properly condensed or obturated.
Root canals are not covered for:
Intentional (elective) endodontics.
Third molar (unless it is an abutment tooth).
Teeth with advanced periodontal disease.
Teeth with sub osseous or furcation carious involvement.
Teeth that can be restored with simpler methods (for example, amalgam, composite, or crowns).
Teeth that have had endodontic treatment at an earlier time.
Crowns must be approved in advance.
Radiological films for proposed crowns of abutment teeth must have acceptable views of adjacent and opposing teeth.
Teeth must have pathological destruction by caries or trauma and must involve:
Four or more surfaces and two or more cusps for molars.
Four or more surfaces and at least 50 percent of the incisal edge for anterior teeth.
Three or more surfaces and one cusp for bicuspids.
A request for a crown following a root canal must meet the following conditions:
There must be a month go by between the date the root canal is completed and the date that the request for a crown is submitted.
A periapical film must be taken that shows the root and crown of the natural tooth.
The tooth must be filled within two millimeters of the radiological apex, unless there is curvature or calcification of the canal that limits the ability to fill to the radiological apex.
The root canal filling material cannot be filled beyond the radiological apex.
The root canal filling must be properly condensed or obturated.
To be approved, a crown must be opposed by a tooth or denture in the opposite arch or be an abutment for a partial denture.
Crowns will not be covered for:
Teeth that can be restored with simpler methods.
Teeth with sub osseous or furcation carious involvement.
Teeth with advanced periodontal disease.
A third molar (unless it is an abutment tooth).
A primary tooth if the radiograph indicates imminent exfoliation.
Crown coverage is limited to one crown for each tooth every six years.
Crown coverage is limited to four each calendar year for each recipient, up to two crowns in each arch.
The dentist should tell the patient how important it is to take care of a crown. MA does not cover replacement of crowns that are dislodged, broken, or lost.
MA does not cover restorations, procedures, or applications done to change vertical dimension. The patient must pay for those. Such procedures include, but are not limited to, those done primarily for replacement of tooth structure lost by attrition, realignment of teeth, splinting, equilibration, full mouth rehabilitation, and treatment of temporomandibular joint (TMJ) syndrome.
New benefit limits have been implemented for those under Fee for Service. For more information, see OPS Memo 110804.
Updated February 14, 2012, Replacing April 12, 2007