DraftConnecticut Department of Social ServicesPolicy N/A

Dental Services and Fee Schedule Updates for Adults and Children

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Proposed Connecticut Medicaid State Plan changes governing dental coverage, utilization limits, medical-necessity criteria, prior authorization, documentation, and reimbursement rates for adults and children enrolled in the Connecticut Medical Assistance Program.

Policy Summary

PayerConnecticut Department of Social Services

PolicyDental Services and Fee Schedule Updates for Adults and Children

Policy CodePolicy N/A

Change TypeProposed State Plan Amendment with material coverage and fee schedule updates

Effective DateOctober 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and submit medical-necessity documentation when services exceed applicable limits or orthodontic criteria require authorization.

SourceLink

POLICY UPDATE CHANGES

The proposed SPA updates dental fee schedules for adults and children and revises coverage of selected dental services under the Connecticut Medicaid State Plan.

The proposal adds or clarifies limitations for bitewing films, annual adult dental benefits, long-term-care preventive services, premolar sealants, failed sealants, and replacement of direct restorations.

The proposal specifies orthodontic eligibility and documentation thresholds using the Salzmann Index for beneficiaries age 20 and under.

$1,000

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DraftConnecticut Department of Social ServicesPolicy N/A

Dental Services and Fee Schedule Updates for Adults and Children

Customize your policy alerts

Sign up for all Connecticut Department of Social Services policy alerts

Know when Connecticut Department of Social Services releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerConnecticut Department of Social Services

PolicyDental Services and Fee Schedule Updates for Adults and Children

Policy CodePolicy N/A

Change TypeProposed State Plan Amendment with material coverage and fee schedule updates

Effective DateOctober 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and submit medical-necessity documentation when services exceed applicable limits or orthodontic criteria require authorization.

SourceLink

POLICY UPDATE CHANGES

The proposed SPA updates dental fee schedules for adults and children and revises coverage of selected dental services under the Connecticut Medicaid State Plan.

The proposal specifies orthodontic eligibility and documentation thresholds using the Salzmann Index for beneficiaries age 20 and under.

$1,000

Adult annual dental benefit maximum

1 set/yearStandard annual bitewing limit

26Orthodontic treatment threshold

24Orthodontic imaging threshold

3 yearsSealant failure period

2 yearsRestoration replacement period

Covered Dental Services and Limitations

General dental coverage

Covered when medically necessary, clinically appropriate, and applicable regulatory criteria are met.

General covered dental services: The service is a covered dental category, treatment is medically necessary and clinically appropriate, and any applicable regulatory criteria, prior authorization, documentation, frequency, age, and post-procedure review requirements are satisfied.

Covered categories include diagnostic, preventive, restorative, endodontic, periodontal, prosthodontic, oral and maxillofacial surgical, anesthesia and sedation, orthodontic, adjunctive, and other Department-recognized dental services.

Pediatric EPSDT coverage

For beneficiaries age 20 and under, medically necessary dental services are covered pursuant to EPSDT.

EPSDT dental coverage: The beneficiary is age 20 or under and the dental service is medically necessary within the applicable service category.Age 20 years old and under

Quantitative, frequency, or service limitations may be exceeded when medically necessary and authorized under applicable state and federal requirements.

Adult annual benefit

For beneficiaries age 21 and older, coverage is subject to the annual maximum and applicable authorization rules.

Adult dental benefit: The beneficiary is age 21 or older, the service is otherwise medically necessary and covered, and annual benefits do not exceed $1,000 unless the excess is prior authorized based on medical necessity.$1,000 per calendar year

The benefit year runs from January 1 through December 31 and resets each calendar year.

Periodontal services

Periodontal services are covered for the specified beneficiary populations when medically necessary.

Periodontal eligibility: The beneficiary is age 20 or under; or the beneficiary is age 21 or older and has a qualifying medical condition specified by applicable regulation.

Periodontal flap surgery is covered for beneficiaries age 20 and under when medically necessary.

Orthodontic coverage

Orthodontic services are covered for beneficiaries age 20 and under when the applicable Salzmann Index and documentation criteria are met.

Orthodontic standard pathway: The beneficiary is age 20 or under, the Salzmann Index is at least 26, and prior authorization based on medical necessity is obtained.Salzmann Index >= 26

Orthodontic exception pathway: The beneficiary is age 20 or under, the Salzmann Index is below 26, treatment is medically necessary, a licensed behavioral health professional documents that treatment will significantly ameliorate psychological conditions caused by malocclusion, and the beneficiary has been in continuous therapy with that professional for at least 6 months.Salzmann Index < 26; continuous therapy >= 6 months

Prior authorization based on medical necessity remains required.

Orthodontic imaging pathway: The Salzmann Index is at least 24; or, if below 24, panoramic radiographs and diagnostic casts are supported by prior authorization based on medical necessity.

Medical-necessity exceptions to limits

Specified utilization limits may be exceeded only when medically necessary and properly authorized.

Limit exception: The service exceeds an applicable quantitative, frequency, replacement-period, or annual benefit limit, the service remains medically necessary, and required prior authorization is obtained.Varies by service

Applicable limits are assigned to the Medicaid beneficiary rather than to an individual provider.

Cosmetic, experimental, investigational, educational, or otherwise not medically necessary dental services are not covered. Covered dental treatment must meet applicable medical-necessity and clinical-appropriateness requirements.

Procedures or services of an unproven, experimental, or research nature are not covered under the dental benefit.

Premolar sealants are not covered unless they are medically necessary and receive prior authorization.

Sealants that fail within three years of placement are not covered unless medically necessary with prior authorization. The provider that placed the original sealant must return the reimbursement, or may replace the failed sealant at no cost.

Direct restorations requiring replacement within two years of initial placement are not covered unless medically necessary with prior authorization. Replacement may result in recoupment of the initial restoration fee paid to the provider.

Services determined to be otherwise not medically necessary are not covered. Dental services must also satisfy applicable clinical-appropriateness, regulatory, documentation, authorization, and treatment requirements.

Frequency, Benefit, and Treatment Limits

Bitewing films

Standard limitNo more than 1 set of bitewing films during any 1 calendar year.

Medical-necessity exceptionThe limit may be exceeded based on medical necessity.

Beneficiaries age 20 and underUnder EPSDT, beneficiaries age 20 and under receive all medically necessary services within this category.

Adult annual dental benefit

Annual maximumNot more than $1,000 per calendar year for beneficiaries age 21 and older.

Benefit yearThe calendar year runs from January 1 through December 31 and resets each new calendar year.

Authorization, Documentation, and Denial Prevention

Prior Authorization

General Dental Prior Authorization

Covered dental services require medical necessity and clinical appropriateness, and prior authorization and post-procedure review requirements apply. Providers must submit required authorization, clinical, and supporting documentation in accordance with Sections 17b-262-1006 through 17b-262-1017 of the Regulations of Connecticut State Agencies.

Confirm that the service is covered, medically necessary, and clinically appropriate before treatment.
Obtain prior authorization when required and retain documentation for post-procedure review.
Administer services and claims in accordance with applicable authorization, participation, billing, reimbursement, and documentation requirements.

Prior Authorization

Override the Adult Annual Maximum

For Medicaid beneficiaries age 21 and older, dental services are subject to a $1,000 annual benefit maximum for each calendar year, January 1 through December 31. Services above the maximum may be covered only with prior authorization based on medical necessity.

Policy Scope

The dental benefit includes a broad range of care, including diagnostic, preventive, restorative, endodontic, periodontal, prosthodontic, oral and maxillofacial surgical, anesthesia and sedation, orthodontic, and adjunctive services. Coverage is subject to medical necessity, clinical appropriateness, and applicable utilization-management requirements, including prior authorization, documentation, frequency, age, treatment, and post-procedure review requirements.

Key Terms

Salzmann Index

PurposeThe Salzmann Index is used to determine the level of misalignment of a Medicaid beneficiary’s teeth.

Coverage applicationThe index is used in determining eligibility for orthodontic coverage.

Key thresholdsOrthodontic treatment generally uses a threshold of 26 points; panoramic radiographs and diagnostic casts generally use a threshold of 24 points.

EPSDT

MeaningEPSDT means Early and Periodic Screening, Diagnostic and Treatment.

Eligible beneficiariesThe provisions apply to Medicaid beneficiaries age 20 and under.

Coverage requirement

Policy Summary

PayerConnecticut Department of Social Services

PolicyDental Services and Fee Schedule Updates for Adults and Children

Policy CodePolicy N/A

Change TypeProposed State Plan Amendment with material coverage and fee schedule updates

Effective DateOctober 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and submit medical-necessity documentation when services exceed applicable limits or orthodontic criteria require authorization.

SourceLink

On This Page

Salzmann Index >= 24, or authorized exception below 24

Prior authorization of panoramic radiographs and diagnostic casts is part of the orthodontic treatment-request submission.

The maximum may be exceeded with prior authorization based on medical necessity.

Long-term-care preventive services

Covered populationMedicaid beneficiaries residing in long-term-care facilities.

Annual limitUp to 2 oral examinations, prophylaxis services, and fluoride treatments per calendar year.

ExceptionThe limit may be exceeded based on medical necessity.

Sealant failure

Failure periodSealants that fail within 3 years from the date of placement are not covered.

Coverage exceptionCoverage may be available when the replacement is medically necessary with prior authorization.

Provider remedyThe original provider must return reimbursement, or may replace the failed sealant at no cost.

Direct restoration replacement

Replacement periodDirect-placed restorations requiring replacement within 2 years of initial placement are not covered.

Coverage exceptionCoverage may be available when replacement is medically necessary with prior authorization.

Financial consequenceReplacement may result in recoupment of the initial restoration fee paid to the provider.

Orthodontic treatment Salzmann Index

Standard thresholdThe minimum scoring limit is a Salzmann Index score of 26 points or higher.

AuthorizationOrthodontic treatment at the standard threshold requires prior authorization based on medical necessity.

Exception below 26A score below 26 may qualify when treatment is medically necessary and a licensed behavioral health professional attests that treatment will significantly ameliorate psychological conditions caused by malocclusion; the beneficiary must be in continuous therapy for at least 6 months.

Orthodontic panoramic radiographs and diagnostic casts

Standard thresholdPanoramic radiographs and diagnostic casts are covered for beneficiaries with a Salzmann Index of 24 points or higher.

Case submissionPrior authorization of panoramic radiographs and diagnostic casts is part of the orthodontic treatment-request case submission.

Exception below 24For a score below 24, coverage requires prior authorization based on medical necessity.

Document medical necessity and submit the required prior authorization request before providing services that exceed $1,000.
The benefit maximum resets at the beginning of each calendar year.
Apply the limit to the Medicaid beneficiary’s benefit assignment, not to the provider.

Unsupported block type: prior_auth אצלinternal?

Unsupported block type: prior_auth

Denial Risk

Noncovered Service Types

Cosmetic, experimental, investigational, educational, unproven, research-oriented, or otherwise not medically necessary services are not covered. Claims for these services may be denied and are not payable under the dental benefit.

Confirm that the service has a covered, medically necessary purpose before treatment and billing.
Do not bill services determined to be cosmetic, experimental, investigational, educational, unproven, research-oriented, or otherwise not medically necessary.

Unsupported block type: documentation

Unsupported block type: prior_auth

Unsupported block type: documentation

Denial Risk

Unmet Utilization Limits

Services that exceed frequency, age, benefit-maximum, treatment, sealant-failure, or restoration-replacement limits may be denied when the applicable requirements are not met. Providers should verify each beneficiary-based limitation before treatment and billing.

Confirm that the service is within the applicable frequency and age limits or obtain authorization for a medically necessary exception.
Verify annual benefit maximums and treatment-specific criteria before submitting the claim.
Apply sealant-failure and restoration-replacement rules based on the beneficiary’s benefit assignment, not the provider’s history.

Unsupported block type: documentation

Denial Risk

Orthodontic Criteria Not Met

Orthodontic coverage may be denied when the applicable Salzmann Index threshold, prior authorization, medical-necessity documentation, radiograph requirements, or diagnostic-cast requirements are not met.

Treatment generally requires a Salzmann Index score of at least 26 with prior authorization based on medical necessity.
A score below 26 requires qualifying medical-necessity documentation and behavioral-health attestation.
Panoramic radiographs and diagnostic casts require inclusion in the case submission and are subject to the score- and authorization-based coverage rules.

Beneficiaries age 20 and under receive all medically necessary dental services within the applicable category.