Does Medicaid Cover Dental Crowns in NC?

Medicaid provides healthcare coverage for eligible low-income individuals and families, and the scope of dental benefits can vary significantly by state and recipient group. Individuals often wonder about coverage for specific procedures, such as dental crowns. This article will clarify the specifics of dental crown coverage under North Carolina Medicaid, outlining who is covered and under what conditions.

North Carolina Medicaid Dental Benefits Overview

North Carolina Medicaid structures its dental benefits differently for children and adults. Children under 21 years old typically receive comprehensive dental care through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. This federal mandate ensures access to services needed to maintain dental health, alleviate pain or infections, and restore damaged teeth. The EPSDT benefit covers a wide range of diagnostic, preventive, and restorative services.

Adults aged 21 and older have more limited dental coverage under North Carolina Medicaid. Adult dental coverage often focuses on emergency care or basic services. North Carolina does offer a relatively comprehensive dental program for adults, which includes preventive services like exams and cleanings, and restorative services such as fillings and extractions. Specific benefit packages and managed care plans may influence the exact scope of services available to adult beneficiaries.

Crown Coverage Details

Dental crown coverage under North Carolina Medicaid is specifically outlined, with distinctions made for age groups and medical necessity. For beneficiaries under 21 years of age, certain types of crowns are covered. Prefabricated resin crowns are limited to primary and permanent anterior teeth, while prefabricated stainless steel crowns, including those with a resin window or esthetic coating, are limited to primary teeth. Coverage for children generally requires medical necessity, meaning the crown is needed to correct or improve a dental condition.

For adults aged 21 and older, crown coverage is substantially more restricted. North Carolina Medicaid generally does not cover cosmetic procedures, and most laboratory-fabricated crowns, such as metal, porcelain, or metal/porcelain combinations, are not covered for adults. Coverage for crowns on adults is typically limited to very specific circumstances where it is deemed medically necessary to prevent severe health complications, and often requires prior authorization. All dental services, including crowns, must be medically necessary and not experimental.

Prior approval is a mandatory requirement for most crown procedures to verify medical necessity. For instance, if a provider believes more than six crowns are warranted for a beneficiary on a single date of service, a prior approval request describing the special circumstances must be submitted.

Finding a Provider and Getting Treatment

Locating a dental provider who accepts North Carolina Medicaid is an important first step. Individuals can use the NC Medicaid website’s provider and health plan lookup tool to find participating dentists. Another resource is the InsureKidsNow.gov Dentist Locator, which helps find dentists who accept Medicaid and CHIP for children. Before scheduling an appointment, it is advisable to call the dental office to verify they are currently accepting new Medicaid patients.

Once a provider is found, the process for obtaining a crown typically begins with an initial consultation. The dentist will assess the need for a crown and determine if it meets Medicaid’s medical necessity criteria. If a crown is deemed necessary and potentially covered, the dentist is responsible for submitting a prior authorization request to Medicaid. This request usually includes a detailed treatment plan, recent X-rays, and clinical notes describing the tooth’s condition.

Prior authorization requests can be submitted electronically through the NCTracks Provider Portal, or via mail or fax. The Medicaid agency reviews these materials to ensure the crown meets coverage criteria, such as structural loss that cannot be fixed with a filling. After submission, a waiting period occurs while the request is reviewed; the dentist and patient will be notified of the approval or denial. Approval of prior authorization is for medical approval only and does not guarantee payment if eligibility or other plan limits are not met at the time of service.