Does Virginia Medicaid Cover Dental for Adults and Children?

Medicaid provides healthcare coverage to individuals and families meeting income and resource requirements. While often focused on general medical care, dental health is an integral component of overall well-being. Dental coverage under Medicaid can vary significantly by state, depending on regulations and budgetary decisions.

Understanding Virginia Medicaid Dental Coverage

Virginia’s Medicaid dental program, known as CardinalCare Smiles, offers comprehensive dental benefits for eligible residents. This program is administered by DentaQuest, which manages dental services for both children and adults enrolled in Virginia Medicaid and the Family Access to Medical Insurance Security (FAMIS) program.

Dental coverage in Virginia Medicaid distinguishes between different age groups. For individuals under the age of 21, comprehensive dental services are provided through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. This federal mandate ensures that children and adolescents receive all medically necessary dental care.

Adults aged 21 and older enrolled in Virginia Medicaid also have access to dental coverage, which was expanded starting July 1, 2021. This expansion provides a comprehensive dental benefit focusing on prevention and restoration. Additionally, pregnant individuals enrolled in Medicaid and FAMIS MOMS receive comprehensive dental services.

Specific Covered Dental Services

Virginia Medicaid’s CardinalCare Smiles program covers a wide range of dental services, with distinct differences for children and adults. For children and adolescents under 21, the EPSDT benefit ensures coverage for all medically necessary dental procedures. This includes preventive care such as regular check-ups, cleanings, fluoride treatments, and dental sealants. Restorative services like fillings, crowns, and root canals are also covered. Extractions, space maintainers, and medically necessary orthodontics (braces) are included for this age group.

For adults aged 21 and over, the expanded dental benefit provides coverage for a variety of services essential for maintaining oral health. These services typically include diagnostic procedures like X-rays and comprehensive exams. Preventive care, such as routine cleanings, is also covered. Restorative treatments, including fillings and root canals, are available. Gum-related treatments, dentures, and oral surgeries, including extractions, are generally covered. Certain services, such as braces and bridges, are typically not covered for adults.

Accessing Dental Care

To access Virginia Medicaid dental benefits, locate a dental provider who accepts Virginia Medicaid. This can be done through the DentaQuest website or by calling DentaQuest directly at 1-888-912-3456. Confirm with the dental office that they accept your specific Medicaid coverage before scheduling an appointment.

When attending a dental appointment, individuals should bring their Virginia Medicaid identification card and their Managed Care Organization (MCO) ID card, if enrolled in a health plan. Some dental services may require prior authorization from DentaQuest or the MCO before treatment can begin. The dental provider typically handles the prior authorization process.

If a claim for a dental service is denied, or a service request is not approved, individuals have the right to appeal. An appeal should be filed with the MCO within 60 days of receiving the adverse benefit determination. If the MCO upholds the denial, a further appeal can be made to the Department of Medical Assistance Services (DMAS) through a State Fair Hearing process within 120 days. Non-emergency transportation services are available for Medicaid members to attend dental appointments, arranged through CardinalCare Smiles or the MCO’s transportation vendor.