| Is the Benefit Covered? |
Copayment Requirement |
Prior Approval Requirement |
Coverage Limitations |
Reimbursement Methodology |
Populations Covered |
|
|
Alabama
|
|
No
|
|
|
|
|
|
|
Alaska
|
|
Yes
|
|
|
Limited to emergency treatment for relief of pain and infection
|
Fee for service
|
CN
|
|
Arizona
|
|
Yes
|
|
|
Limited to emergency treatment for relief of pain and infection
|
Fee for service
|
CN & MN
|
|
Arkansas
|
|
No
|
|
|
|
|
|
|
California
|
|
Yes
|
$1/visit
|
Specified services including periodontal, crowns and root canals, pre-denture services, services for nursing facility residents
|
Crowns not covered
|
Fee for service
|
CN & MN
|
|
Colorado
|
|
No
|
|
|
|
|
|
|
Connecticut
|
|
Yes
|
|
Specified services
|
Periodontal and fixed bridges not covered, frequency of x-rays limited by type
|
Fee for service
|
CN & MN
|
|
Delaware
|
|
No
|
|
|
|
|
|
|
District of Columbia
|
|
No
|
|
|
|
|
|
|
Florida
|
|
No
|
|
|
|
|
|
|
Georgia
|
|
Yes
|
|
Specified services
|
Limited to emergency treatment for relief of pain and infection, $600/year limit
|
Fee for service
|
CN & MN
|
|
Hawaii
|
|
Yes
|
|
|
Limited to emergency treatment for relief of pain and infection, frequency of x-rays limited by type
|
Fee for service
|
CN & MN
|
|
Idaho
|
|
Yes
|
|
|
Limited to preventative and restorative services
|
Fee for service
|
CN
|
|
Illinois
|
|
Yes
|
|
Specified services
|
Periodontia, posterior root canals and preventive services including exams and cleanings not covered; coverage limited to exams and x-rays necessary to assess oral health, to diagnose oral problems and to develop a treatment plan
|
Fee for service through contracted intermediary
|
CN & MN
|
|
Indiana
|
|
Yes
|
|
Specified services including non-emergency inpatient procedures and oral surgery
|
$600 maximum benefit/year included with denture services, exam and cleaning 1/year (2/year for nursing facility residents), frequency of x-rays limited by type, periodontia limited, second opinions required for specified procedures
|
Fee for service
|
CN
|
|
Iowa
|
|
Yes
|
$3/day
|
Specified services including periodontal
|
Exam and cleaning 2/year, root canals limited to posterior teeth
|
Fee for service
|
CN & MN
|
|
Kansas
|
|
Yes
|
$3/visit
|
Specified services
|
Limited to procedures associated with medically necessary extractions
|
Fee for service
|
CN & MN
|
|
Kentucky
|
|
Yes
|
$2/visit
|
Specified services including periodontal scaling and root planing
|
Exam and cleaning 1/year, frequency of x-rays limited by type, alveoplasty 1/quad/lifetime, coverage of gingevectomy limited by diagnosis
|
Fee for service
|
CN & MN
|
|
Louisiana
|
|
Yes
|
|
Specified services
|
Exams and x-rays only covered in conjunction with denture construction, pregnant women may receive services to care for periodontal needs
|
Fee for service
|
CN & MN - See state-specific FN
|
|
Maine
|
|
Yes
|
|
Oral cancer treatment
|
Limited to trauma care, diagnostic procedures for acute conditions, and emergency treatment for relief of pain and infection
|
Fee for service
|
CN & MN
|
|
Maryland
|
|
Yes
|
|
Specified services including crowns and root canals
|
Services for non-pregnant adults limited to trauma care and emergency treatment for relief of pain and infection
|
Fee for service
|
CN & MN
|
|
Massachusetts
|
|
Yes
|
|
Specified services
|
Limited to emergency care services including x-rays, extractions and oral surgery unless beneficiary meets specified criteria related to severe, chronic disability resulting in inability to maintain oral hygiene or to clinical condition where infection resulting from oral disease would be life threatening
|
Fee for service
|
CN & MN
|
|
Michigan
|
|
Yes
|
$3/visit
|
|
Limited to emergency treatment for relief of pain and infection
|
Fee for service
|
CN & MN
|
|
Minnesota
|
|
Yes
|
B - 50% of payment for non-preventive services applicable to specified adults
|
Specified services
|
Non-emergency and pre-denture services limited to $500/year
|
Fee for service
|
A & B - See state-specific FN
|
|
Mississippi
|
|
Yes
|
$3/visit
|
Specified services
|
Limited to trauma care and emergency treatment for relief of pain and infection, maximum annual payments for specified services
|
Fee for service
|
CN
|
|
Missouri
|
|
Yes
|
$.50-$3/ service depending on payment
|
Specified services
|
Exam and cleaning 2/year
|
Fee for service
|
CN
|
|
Montana
|
|
Yes
|
$3/visit
|
Specified services including prosthetics and oral surgery
|
A - Exam and cleaning 2/year, frequency of x-rays limited by type, bridges limited to anterior teeth and crowns to posterior teeth
B - Services limited to emergency treatment for relief of pain and infection and to services essential for employment
|
Fee for service
|
A & B - See state-specific FN
|
|
Nebraska
|
|
Yes
|
$3/specified services
|
Specified services including periodontia, crowns and root canals
|
Exam and cleaning 1/year
|
Fee for service
|
CN & MN
|
|
Nevada
|
|
Yes
|
|
|
Limited to trauma care and emergency treatment for relief of pain and infection
|
Fee for service
|
CN
|
|
New Hampshire
|
|
Yes
|
|
Specified services
|
Limited to trauma care and emergency treatment for relief of pain and infection
|
Fee for service
|
CN & MN
|
|
New Jersey
|
|
Yes
|
|
|
Exam and cleaning 2/year, frequency of x-rays limited by type
|
Fee for service
|
CN & MN
|
|
New Mexico
|
|
Yes
|
B - $7/visit with annual maximum across all services based on income, see state-specific FN
|
Specified services
|
1 exam and cleaning/year, frequency of x-rays limited by type, specified limits on endodontic, periodontic and restorative services
|
Fee for service
|
CN
|
|
New York
|
|
Yes
|
|
Specified services
|
3 visits/year (limit applicable to dental clinics but not dental offices)
|
Fee for service
|
CN & MN
|
|
North Carolina
|
|
Yes
|
$3/episode of treatment
|
Specified services including periodontia and maxillofacial surgery
|
Frequency of x-rays limited by type, root canals limited to anterior teeth
|
Fee for service
|
CN & MN
|
|
North Dakota
|
|
Yes
|
$2/visit
|
Specified services
|
|
Fee for service
|
CN & MN
|
|
Ohio
|
|
Yes
|
|
Specified services
|
|
Fee for service
|
CN
|
|
Oklahoma
|
|
Yes
|
|
|
Limited to emergency treatment for relief of pain and infection
|
Fee for service
|
CN
|
|
Oregon
|
|
Yes
|
A - $3/visit except diagnostic tests and routine exam/cleaning
|
|
B - limited to emergency treatment for pain and infection
|
Fee for service
|
A & B - See state-specific FN
|
|
Pennsylvania
|
|
Yes
|
|
Prosthetics, crowns, multiple or surgical extractions, periodontia and endodontia
|
CN: exam and cleaning 2/year, MN: preventive care not covered and medically necessary services limited to those provided in a hospital or ambulatory surgery center setting, CN & MN: crowns limited to 1/5 years, services in outpatient hospital or ambulatory surgery center setting limited to $500/procedure unless fee screen higher, services in inpatient hospital setting limited to $1,000/procedure unless fee screen higher
|
Fee for service
|
CN & MN
|
|
Rhode Island
|
|
Yes
|
|
All services except emergency care and palliative treatment
|
Orthodontia not covered
|
Fee for service
|
CN & MN - see state-specific FN
|
|
South Carolina
|
|
Yes
|
$3/visit
|
|
Limited to trauma care and emergency treatment for relief of pain and infection
|
Fee for service
|
CN
|
|
South Dakota
|
|
Yes
|
$1/service unrelated to dentures
|
|
|
Fee for service, or percentage of charge for unlisted services
|
CN
|
|
Tennessee
|
|
Yes
|
B1 - $15/visit, B2 - $25/visit
|
|
Limited to trauma care and emergency treatment for relief of pain and infection
|
|
A & B - See state-specific FN
|
|
Texas
|
|
Yes
|
|
Specified surgical procedures
|
|
Fee for service
|
CN & MN
|
|
Utah
|
|
Yes
|
C - 10% of payment
|
Specified services
|
A - limited to x-rays, fillings, extractions and root canals, B- non-pregnant adults limited to trauma care and emergency treatment for relief of pain and infection, C - limited to diagnostic and preventive services only with fillings and extractions
|
Fee for service
|
A, B & C - See state-specific FN
|
|
Vermont
|
|
Yes
|
A - $3/day, B - $7/day
|
Third molar surgery
|
Exam and cleaning 2/year, endodontia limited to 3 teeth/lifetime, annual payment limit $475 for all services; crowns, bridges, orthodontia and periodontal not covered
|
Fee for service
|
A & B - See state-specific FN
|
|
Virginia
|
|
Yes
|
|
|
Limited to trauma care and oral surgery
|
Fee for service
|
CN & MN
|
|
Washington
|
|
Yes
|
|
Specified services
|
Specified restorative services, including crowns and anterior root canals, not covered for adults
|
Fee for service
|
CN & MN
|
|
West Virginia
|
|
Yes
|
|
Restorative services or item replacement
|
Limited to trauma care including maxillofacial surgery and to emergency treatment for relief of pain and infection
|
Fee for service
|
CN & MN
|
|
Wisconsin
|
|
Yes
|
$.50-$3/service depending on payment
|
Specified services
|
Exam and cleaning 1/year, frequency of x-rays limited by type, orthodontia not covered
|
Fee for service
|
CN & MN
|
|
Wyoming
|
|
Yes
|
|
|
Limited to trauma care and emergency treatment for relief of pain and infection, 2 visits/year
|
Fee for service
|
CN
|
|
American Samoa
|
|
Yes
|
|
|
|
|
See territory-specific FN
|
|
Guam
|
|
Yes
|
|
|
Limited to trauma care, treatment required due to medical conditions, and emergency treatment for relief of pain and infection
|
Fee for service
|
CN
|
|
Northern Mariana Islands
|
|
Yes
|
|
Specified services
|
|
|
CN & MN - See territory-specific FN
|
|
Puerto Rico
|
|
Yes
|
|
|
2 exams and cleanings/year, frequency of x-rays limited by type
|
Fee for service
|
CN & MN
|
|
Virgin Islands
|
|
Yes
|
|
|
Services in public health facilities only
|
Fee for service
|
CN
|
