Understand Your Dental Health Coverage – Florida Dental Access Guide

Understand your dental health coverage.

Oral health is an important part of your child’s overall health.

Oral health is an important part of overall health. Oral health coverage pays for dental services, medication, and special equipment when you are sick and when you are well.

For children specifically, all states are required to provide a comprehensive set of dental benefits to children covered by Medicaid and Children’s Health Insurance Program (CHIP). These benefits are provided as part of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. The EPSDT is designed to ensure that children receive early detection and early care including dental before the problem becomes serious.

EPSDT Dental Benefits

EARLY:

Checking and identifying dental problems early.

PERIODIC:

Examining children’s oral and overall health at regular or periodic, and age-appropriate intervals.

SCREENING:

Providing dental and other screening tests to detect potential problems.

DIAGNOSTIC:

Performing specific tests to follow-up when a risk is identified.

TREATMENT:

Controlling, correcting, or reducing oral health and other health problems found.

Provider Network

For the most part, you must use dental providers that are in the Medicaid provider network. The network can change quite often. Check with your dentist each time you make an appointment and two weeks before your appointment to ensure that the dentist is an active Medicaid dental provider. You may have to pay to see a provider who is not in your network.

If your child has a disability and requires special accommodations, it is important to remember that dental providers are prohibited from denying care to patients because of their disability. In cases where a dentist does not have the equipment or expertise to meet special health care need, they are required to refer the patient to an appropriate dentist.

DID YOU KNOW?

35% of Florida dental providers are enrolled in Medicaid.

Covered Services

A covered service is a service that Medicaid must provide in their program. These services are typically listed in the member handbook provided to you by the dental administrators that are responsible for delivering these services. But just because a service is covered doesn’t mean it is needed. Some services must be proven to be medically necessary.

For persons with special health care needs, the dental administrators (DentaQuest, LIBERTY, MCNA Dental) may offer extra services such as transportation or case management. For additional information, please visit our ‘Special Needs’ page.

Specifically for children, the Medicaid dental care plans must provide all medically necessary dental services, as required by the EPSDT benefit. This is true even if they do not cover a service or the service has a limit. As long as your child’s dental services are medically necessary, dental services have no dollar limit or no time limit. The dentist may have to request special approval before providing your child a service. This is called prior authorization.

Prior Authorization

Prior authorization is a process by which a medical provider (or the patient, in some scenarios) must obtain approval from a patient's health plan before moving ahead with a particular treatment, procedure, or medication. Different health plans have different rules in terms of when prior authorization is required.

Medically Necessary

The medical or allied care, goods, or services furnished or ordered must meet the following conditions:

Be necessary to protect life, prevent significant illness or significant disability, or alleviate severe pain.
Be individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the patient’s needs.
Be consistent with generally accepted professional medical standards as determined by the Medicaid program, and not experimental or investigational.
Be reflective of the level of service that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available statewide.
Be furnished in a manner not primarily intended for the convenience of the recipient, the recipient's caretaker, or the provider.

The fact that a provider has prescribed, recommended, or approved medical or allied care, goods or services does not, in itself, make such care, goods, or services medically necessary or a medical necessity or covered service.