Adult dental benefits for Medicaid adults
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This memorandum establishes that, effective January 1, 2023, Medicaid adult dental benefits are available to adult Medicaid members (age 21 and older) in Hawaii and outlines covered services, limitations, and prior authorization notes.
Adult dental benefits are made available to Medicaid adults effective January 1, 2023.
Coverage Criteria and Limits
Covered services and frequency limits
Covered services include the following categories with stated limitations (some limitations and prior authorization may apply):
These limits may be exceeded based upon prior approval to determine medical necessity.
The memorandum does not enumerate a list of excluded procedures; instead, coverage is determined on a case-by-case basis tied to medical necessity. The document states that coverage limits are specified for each service category and that these limits may be exceeded only with prior approval to determine medical necessity. Providers should treat the listed frequencies and restrictions as enforceable limits unless prior authorization documentation demonstrating medical necessity is obtained.
Services that do not meet the plan’s medical necessity criteria are not covered. The memorandum makes clear that the specified frequency and scope limits will be enforced and that those limits may only be exceeded when prior approval has been obtained to establish medical necessity. Providers should obtain prior authorization when proposing care that exceeds stated limits to avoid denial of coverage.
Service Codes, Categories, and Frequencies
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Prior Authorization, Medical Necessity, and Provider Contacts
Prior authorization may be required
Some coverage limits may be exceeded only with prior approval to determine medical necessity. Providers should obtain prior authorization when services exceed the stated frequency or other limits to ensure coverage.
- Prior authorization may apply to certain services that exceed the listed limits.
- Approval is required to document medical necessity before coverage beyond limits is allowed.
Member and provider referral contacts
Health Plans shall refer members to Community Case Management Corporation (CCMC) for questions about adult dental benefits, finding a dentist, or coordinating transportation; contact numbers are provided. Health Plans shall refer Medicaid Dentists to Hawaii Dental Service for coverage and claims questions.
- CCMC: 808-792-1070 or toll-free 1-888-792-1070 (starting January 2023).
- Hawaii Dental Service (HDS) Medicaid Customer Service: 808-529-9345 or toll-free 855-819-9117.
Medical necessity and prior approval
Coverage is contingent on the medical necessity of each case; services that do not meet medical necessity are not covered. Limits established in the memorandum may only be exceeded with prior approval to determine medical necessity.
- Coverage depends on medical necessity for each case.
- Limits may be exceeded only after prior approval confirms medical necessity.
Member and provider referral contacts and DHS inquiry
For member assistance and dentist support, refer members to CCMC and refer Medicaid Dentists to HDS using the listed phone numbers; contact the DHS policy lead for questions.
- Refer members to CCMC for benefits explanation, dentist finding, and transportation coordination: 808-792-1070 or 1-888-792-1070.
- Refer Medicaid Dentists to HDS for coverage and claims submissions: 808-529-9345 or 855-819-9117.
- DHS contact for questions: Grant Shiira, gshiira@dhs.hawaii.gov.
Background and Scope
Effective January 1, 2023, the Legislature established adult dental benefits for Medicaid members age 21 and older. The benefit package includes a full range of dental care categories: preventive services (comprehensive oral evaluation once every 5 years; periodic screening examinations 2 per year; prophylaxis 2 per year; topical fluoride 2 per year; bitewing x-rays 2 per year), radiology (bitewings, full series 1 every 5 years, periapical x-rays, biopsies), endodontic therapy (root canal therapy on permanent molars), restorative services (amalgams, composites, posts, cores, crowns), periodontal therapy (scaling and root planing once every 24 months), prosthodontic services (complete and partial dentures one every 5 years; denture relines one every 2 years), and emergency/palliative treatment (including gingivectomy for hyperplasia and other medically necessary emergency services). The memorandum reiterates that coverage for any service is contingent on medical necessity and that some limitations require prior authorization to exceed.
Key Definitions
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