Dental Coverage for Medicaid Enrolled Adults (21 years of age and older) Effective July 1, 2021
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The purpose of this memorandum is to inform you of the Department of Medical Assistance Services (DMAS) implementation of dental coverage for adults, age 21 years and over, who are receiving full Medicaid benefits. The coverage includes comprehensive dental services and will begin July 1, 2021.
BACKGROUND
In Governor Ralph Northam’s 2021 budget, funds were allocated to provide oral health care for up to 750,000 adults through Virginia’s Medicaid dental program, Smiles For Children (SFC). Beginning July 1, 2021, Virginia’s nationally recognized SFC program will continue to provide dental benefits to children age 20 and below, and pregnant women but will now add coverage to adults in Medicaid. Dental coverage for adults enrolled in Medicaid will focus on overall oral health, prevention and restoration and will be similar to the coverage currently available to pregnant women.
DENTAL BENEFITS ADMINISTRATOR – DENTAQUEST
DentaQuest is the Medicaid dental benefits administrator (DBA) for the SFC program. They administer the dental coverage and benefits for all Medicaid and FAMIS covered members including those enrolled in both managed care, FFS and members with special needs. Information regarding dental benefits for all members, including how dentists can enroll in the program is posted on DentaQuest’s website located at www.dentaquest.com or can be found on the DMAS website at https://www.dmas.virginia.gov/#/dentalservices. Information may also be obtained by calling the SFC program at 1-888-912-3456.
CONTACT INFORMATION:
How can I help adults enrolled in Medicaid find a dentist?
Option 1: Call the SFC program at 1-888-912-3456. A representative can even help the member make an appointment. The call center is available 8 a.m. – 6 p.m., Monday through Friday.
Option 2: Visit the website at www.DentaQuest.com
SMILES FOR CHILDREN (SFC) SERVICES FOR ADULTS
DMAS is working with its Dental Advisory Committee (DAC) and with its dental benefits administrator, DentaQuest, to design an oral health program for adults enrolled in Medicaid. These new services will include the following:
- Diagnostic (x-rays, exams);
- Preventive (cleanings);
- Restorative (fillings and crowns);
- Endodontics (root canals, Pulpal Debridement);
- Periodontics (gum related treatment);
- Prosthodontics (dentures);
- Oral surgery (extractions, alveoplasty and other oral surgeries), and;
- Adjunctive general services (anesthesia).
- Dental providers’ who wish to treat adults must be credentialed by DentaQuest, and participate in Virginia’s SFC dental provider network.
Adults will be able to access non-emergency transportation services to participate in dental care.
Transportation for adults in fee-for-service (FFS) will be provided by ModivCare, formerly LogistiCare the DMAS FFS transportation broker. Transportation for adults enrolled in managed care will be handled by the Managed Care Organization’s (MCO) Non-Emergency Transportation (NEMT) vendor. FFS and MCO NEMT contact telephone numbers for reservations and ride assist can be found at: https://www.dmas.virginia.gov/#/nemtservices by clicking on Transportation Contacts for Reservation and Ride Assist/Customer Service. Any enhanced dental benefits offered by the Managed Care Plans with end effective June 30, 2021.
Covered Services for Adults Enrolled In Medicaid as of July 1, 2021
|
Specialty Area |
Description |
Services Covered |
Limitations |
|
Diagnostic and Preventive Care |
Services that are used to detect and recognize caries and periodontal disease. Up to three routine cleanings may be permissible |
Exams, routine cleanings, X-rays |
Non routine x-rays such as imaging and cone beam technology would require prior authorization |
|
Restorative Care |
Specialty allows dentists to restore teeth to proper function |
Fillings and crowns |
Crowns are covered when a root canal is done while member is under the adult dental program. Bridges are covered. |
|
Endodontics |
Specialty allows dentists to perform root canals on teeth that have sound below the gum structure (root) yet the above gum structure is compromised (decay or trauma) |
Root canals Pulpal Debridement |
Endodontic retreatment and surgical procedures that have a questionable success rate |
|
Periodontics |
Specialty focuses on keeping gums and the bone below the gums healthy. |
Scaling and Root Planing Gingivectomies Periodontal maintenance procedures |
Periodontal flap procedures, crown lengthening procedures, bone replacement grafts |
|
Dentures and Partials |
Specialty focuses on replacing teeth with removal appliances |
Dentures, Partials, and Repair procedures |
Partials are covered as a part of a definitive treatment plan |
|
Oral Surgery |
Specialty routinely extracts teeth and performs extractions requiring surgical methods such as removing bone |
Extractions Alveoplasty
|
Non-tooth extraction procedures; Surgery necessitated by trauma; and Implants |
|
Adjunctive General Services |
This area while not a specialty is important in that it allows coding for anesthesia services and many other dental procedures not listed elsewhere. |
Anesthesia Services |
Non anesthesia services may require prior authorization |
*DMAS will publish specific CDT codes and benefit limitations prior to 7/1/2021.
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PROVIDER CONTACT INFORMATION & RESOURCES |
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Virginia Medicaid Web Portal Automated Response System (ARS) Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice. |
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Medicall (Audio Response System) Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice. |
1-800-884-9730 or 1-800-772-9996 |
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KEPRO Service authorization information for fee-for-service members.
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Provider Appeals DMAS is launching an appeal portal in late May 2021. You can use this portal to file appeals and track the status of your appeals. Visit the website listed for appeal resources and to register for the portal. |
https://www.dmas.virginia.gov/#/appealsresources
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Managed Care Programs Medallion 4.0, Commonwealth Coordinated Care Plus (CCC Plus), and Program of All-Inclusive Care for the Elderly (PACE). In order to be reimbursed for services provided to a managed care enrolled individual, providers must follow their respective contract with the managed care plan/PACE provider. The managed care plan may utilize different guidelines than those described for Medicaid fee-for-service individuals. |
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Medallion 4.0 |
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CCC Plus |
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PACE |
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Magellan Behavioral Health Behavioral Health Services Administrator, check eligibility, claim status, service limits, and service authorizations for fee-for-service members. |
www.MagellanHealth.com/Provider For credentialing and behavioral health service information, visit: www.magellanofvirginia.com, email: VAProviderQuestions@MagellanHealth.com,or Call: 1-800-424-4046 |
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Provider HELPLINE Monday–Friday 8:00 a.m.-5:00 p.m. For provider use only, have Medicaid Provider ID Number available. |
1-804-786-6273 1-800-552-8627 |
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Aetna Better Health of Virginia |
www.aetnabetterhealth.com/Virginia 1-800-279-1878 |
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Anthem HealthKeepers Plus |
1-800-901-0020 |
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Magellan Complete Care of Virginia |
1-800-424-4518 (TTY 711) or 1-800-643-2273 |
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Optima Family Care |
1-800-881-2166 www.optimahealth.com/medicaid |
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United Healthcare |
and www.myuhc.com/communityplan 1-844-752-9434, TTY 711 |
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Virginia Premier |
1-800-727-7536 (TTY: 711), www.virginiapremier.com |