| 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
|
$1,800 cap on services/year but cap doesn't apply to emergency services, maxillofacial surgery or to residents of nursing facilities; 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
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
Florida
|
|
Yes
|
5% of payment for denture-related services
|
|
Limited to services to alleviate pain or infection or preparatory or related to dentures
|
Fee for service
|
CN & MN
|
|
Georgia
|
|
Yes
|
|
Specified services
|
Limited to emergency treatment for relief of pain and infection, limit does not apply to pregnant women
|
Fee for service
|
CN & MN
|
|
Hawaii
|
|
Yes
|
|
|
Limited to emergency treatment for relief of pain, infection and bleeding
|
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 crowns
|
Exam and cleaning 2/year, frequency of x-rays vary by type, orthodontia and periodontia not covered, endodontia limited to root canals for anterior teeth with crowns if necessary
|
Fee for service
|
CN & MN
|
|
Kansas
|
|
Yes
|
$3/date of service
|
Specified services
|
Limited to procedures associated with medically necessary extractions
|
Fee for service
|
CN & MN
|
|
Kentucky
|
|
Yes
|
A - $2/visit
|
Specified services including periodontal scaling and root planing
|
Adult 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
|
A, B, C & D - See state-specific FN
|
|
Louisiana
|
|
Yes
|
|
Specified services
|
Exams and x-rays only covered in conjunction with denture construction; pregnant women may also receive specified preventive, restorative and periodontal services
|
Fee for service
|
CN & MN - See state-specific FN
|
|
Maine
|
|
Yes
|
|
Specified procedures
|
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
|
|
|
Services for non-pregnant adults limited to trauma care and emergency treatment rendered in a hospital emergency department
|
Fee for service
|
CN & MN
|
|
Massachusetts
|
|
Yes
|
|
Specified services
|
Adult exam and cleaning 2/year, root canals limited to anterior teeth
|
Fee for service
|
CN & MN
|
|
Michigan
|
|
Yes
|
$3/visit
|
|
Adult exam and cleaning 2/year, frequency of x-rays limited by type
|
Fee for service, Public Dental Clinics paid average commercial rate
|
CN & MN
|
|
Minnesota
|
|
Yes
|
B1 - 50% of payment for restorative services - See state-specific FN
|
Specified services
|
A - includes limited orthodontia coverage
|
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 except adults who are not pregnant, blind or residing in nursing facilities are limited to trauma care related to facial injury or treatment of health-impacting disease or medical condition
|
Fee for service
|
CN & MN
|
|
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
|
|
Specified services
|
Exam and cleaning 2/year, frequency of x-rays limited by type
|
Fee for service
|
CN & MN
|
|
New Mexico
|
|
Yes
|
A - $5/visit, B - $7/visit non-preventive services - see state-specific FN
|
Specified services
|
Exam and cleaning 1/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 periodontal and orthodontic services and maxillofacial surgery
|
Exam and cleaning 2/year, frequency of x-rays limited by type, root canals limited to anterior teeth, prefabricated crowns and pulpotomies limited to 6/day, pulp caps and recement inlays and crowns not covered
|
Fee for service
|
CN & MN
|
|
North Dakota
|
|
Yes
|
$2/visit
|
Specified services
|
|
Fee for service
|
CN & MN
|
|
Ohio
|
|
Yes
|
$3/day
|
Specified services
|
Exam and cleaning 1/year; frequency of x-rays limited by type; crowns, posts and related services not covered
|
Fee for service
|
CN
|
|
Oklahoma
|
|
Yes
|
|
|
Limited to emergency extractions and smoking cessation counseling
|
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
|
$.50-$3/service, depending on payment
|
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
|
$3/procedure
|
Specified services
|
|
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
|
Adult coverage limited to ICF/MR residents
|
Fee for service
|
CN & MN
|
|
Utah
|
|
Yes
|
C - 10% of payment
|
Specified services
|
A - limited to x-rays, fillings, extractions and root canals, C - limited to diagnostic and preventive services only with fillings and extractions
|
Fee for service
|
A & C - See state-specific FN
|
|
Vermont
|
|
Yes
|
$3/visit
|
|
Exam and cleaning 2/year, endodontia limited to 3 teeth/lifetime, annual payment limit $495 for all services; crowns, bridges, orthodontia and periodontal not covered
|
Fee for service
|
A - 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
|
|
|
Exam and cleaning 1/year, 2 emergency treatments/year, frequency of x-rays limited by type, crowns not covered
|
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
|
|
|
1 exam and cleaning/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
|
