Does Medicaid Cover Dentures in South Carolina?

Medicaid, known as Healthy Connections in South Carolina, is a joint federal and state program providing healthcare assistance to eligible low-income individuals. For adults, Healthy Connections Medicaid generally does not cover dentures as part of its standard dental benefit. However, those enrolled in the Intellectual Disability and Related Disabilities (ID/RD) Waiver may have denture coverage under certain conditions.

Medicaid Adult Dental Benefits in South Carolina

South Carolina’s Healthy Connections Medicaid offers dental benefits for children and adults, with differing scopes. Children and young adults under 21 receive comprehensive dental coverage through the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, including exams, cleanings, fillings, root canals, and dentures.

For adults aged 21 and older, dental benefits are more limited. Covered services typically include annual exams, X-rays, cleanings, fillings, and extractions. There is an annual benefit limit, generally around $1,000, for these procedures each fiscal year, from July 1 to June 30. Procedures like crowns, root canals, periodontal scaling, and dentures are explicitly excluded from the standard adult dental benefit.

Denture Coverage Details and Limitations

While standard adult Medicaid in South Carolina typically excludes denture coverage, an exception exists for individuals enrolled in the Intellectual Disability and Related Disabilities (ID/RD) Waiver program. For these beneficiaries, dental services, including dentures, are covered, mirroring the comprehensive benefits provided to children. This coverage is based on medical necessity, ensuring dentures address conditions impacting overall health, such as the ability to eat or speak.

Denture types, whether complete or partial, are covered if medically necessary for eligible ID/RD Waiver participants. Obtaining dentures under this waiver requires prior authorization. The dental provider must submit documentation to DentaQuest or the managed care organization (MCO) for approval. This documentation typically includes a treatment plan and justification for medical necessity.

ID/RD Waiver funding for adult dental services, including dentures, is utilized only after any available State Plan dental funding for adults has been exhausted. Services requiring prior authorization follow the standard Medicaid review process for children’s benefits for ID/RD waiver beneficiaries.

How to Obtain Dentures Through Medicaid

To obtain dentures through South Carolina Medicaid, the first step involves verifying eligibility for the ID/RD Waiver program, as this is the primary pathway for adult denture coverage. Individuals should contact the South Carolina Department of Health and Human Services (SCDHHS) or their waiver case manager to confirm enrollment and understand their specific dental benefits.

Once eligibility for denture coverage is confirmed, the next step is to find a dental provider who accepts Healthy Connections Medicaid. Individuals can search for participating dentists through DentaQuest’s website or by calling their member services line. The chosen dentist will conduct an initial consultation, assess health needs, and develop a treatment plan.

The dentist will then be responsible for submitting the prior authorization request, if required, to DentaQuest or the relevant managed care organization. This submission typically includes clinical documentation and the proposed treatment plan to justify the medical necessity of the dentures. After approval, appointments will be scheduled for impressions, fittings, and the eventual delivery of the dentures. If a request for coverage is denied, members have the right to appeal the decision by following the instructions provided in the denial notice, usually within 60 calendar days.