Does Medicaid Cover Dental in Virginia?

Virginia’s Medicaid program, known as Cardinal Care, extends dental coverage to eligible individuals, including children and adults. The scope of these dental benefits can differ based on a person’s age and specific program enrollment. Understanding the details of this coverage is important for accessing necessary oral healthcare services within the state.

Virginia Medicaid Eligibility Requirements

Virginia Medicaid provides healthcare coverage for individuals and families with limited incomes. Eligibility depends on specific financial and non-financial requirements. Various groups can qualify, including pregnant individuals, children, parents or caretaker relatives, adults aged 19-64, individuals with disabilities, and seniors.

Income limits are tied to the Federal Poverty Level (FPL) and vary by household size and eligibility group. Non-financial criteria include Virginia residency and U.S. citizenship or qualified immigrant status. Individuals must meet these requirements to enroll in Medicaid, as dental coverage is contingent upon active Medicaid enrollment.

Adult Dental Benefits

Adult Medicaid members in Virginia, aged 21 and older, receive comprehensive dental benefits. This coverage, managed under the Cardinal Care Smiles program by DentaQuest, focuses on maintaining overall oral health, prevention, and restoration. Covered services for adults include diagnostic procedures like X-rays and exams, and preventive care such as cleanings.

Restorative treatments are also included, encompassing fillings, root canals, and crowns. Gum-related treatments, dentures, and oral surgeries like extractions are covered. Adjunctive general services, such as anesthesia, are part of the benefits. However, certain services, like braces and bridges, are not covered for adult members. There are no copayments for these covered adult dental services.

Dental Benefits for Children and Adolescents

Children and adolescents under the age of 21 enrolled in Virginia Medicaid, including FAMIS, receive extensive dental benefits through the Cardinal Care Smiles program. This comprehensive coverage is mandated by the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program, which emphasizes preventive care and supports healthy development through early assessment, diagnosis, and treatment of health conditions.

Covered services for this age group are broad and include regular oral exams and cleanings every six months. Fluoride treatments and sealants are also covered to help prevent tooth decay. When necessary, X-rays are provided.

Restorative services like fillings, crowns, and root canals are included, as are space maintainers and extractions. Medically necessary orthodontics (braces) are covered, though they may require prior approval. These services are provided without copayments for children.

Finding a Dentist and Using Your Benefits

Once enrolled in Virginia Medicaid, members can find a dental provider who accepts their benefits through several avenues. DentaQuest is the dental benefits administrator for Virginia’s Cardinal Care Smiles program, which encompasses both Medicaid and FAMIS. Individuals can use the DentaQuest website to search for participating dentists within their zip code. Alternatively, members can call the Cardinal Care Smiles program directly at 1-888-912-3456, where representatives can assist with finding providers and even help schedule appointments.

If a member is part of a Managed Care Organization (MCO), they can contact their MCO for assistance in locating network dental providers. When visiting a dental office, it is important for members to present their Medicaid ID number and any relevant MCO information. Some dental services may require prior authorization before treatment can proceed; the dental provider typically handles this process by submitting a request to DentaQuest or the relevant MCO. Non-emergency transportation services for dental care appointments are also available for adults.