CurrentVermont Agency of Human Services – Department of Vermont Health AccessPolicy 4.202

Dental Services

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This rule governs coverage, provider qualifications, annual benefit limits, prior authorization, reimbursement, beneficiary billing, and exclusions for dental services provided to Vermont Medicaid beneficiaries. Coverage differs by age, pregnancy or postpartum status, program enrollment, medical necessity, and service type.

Policy Summary

PayerVermont Agency of Human Services – Department of Vermont Health Access

PolicyDental Services

Policy CodePolicy 4.202

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionConsult the Vermont Department of Health Access website to determine which covered dental procedures and services require prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$1,500Annual maximum for covered dental services for most beneficiaries age 21 and older

Under age 21Medically necessary dental services under EPSDT

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CurrentVermont Agency of Human Services – Department of Vermont Health AccessPolicy 4.202

Dental Services

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Sign up for Vermont Agency of Human Services – Department of Vermont Health Access Policy 4.202 alerts

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Policy Summary

PayerVermont Agency of Human Services – Department of Vermont Health Access

PolicyDental Services

Policy CodePolicy 4.202

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionConsult the Vermont Department of Health Access website to determine which covered dental procedures and services require prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$1,500Annual maximum for covered dental services for most beneficiaries age 21 and older

Under age 21Medically necessary dental services under EPSDT

Postpartum eligibility period

NoneEmergency dental services prior authorization requirement

RequiredFinancial-liability acknowledgement before beneficiary billing

Cosmetic proceduresExcluded procedures, including cosmetic orthodontics

Dental Services Coverage Criteria

Under-21 medically necessary dental services

Covered when ALL of the following are met:

Under-21 EPSDT coverage: The beneficiary is under age 21; the dental service is medically necessary; and the service meets EPSDT requirements under Health Care Administrative Rule 4.106.Under age 21

Coverage and service limits do not apply, and published limits may be exceeded when medically necessary.

Beneficiaries age 21 and older

Covered for beneficiaries age 21 and older when ALL of the following are met:

Adult dental coverage: The beneficiary is age 21 or older; the dental service meets the published Vermont Medicaid Dental Supplement criteria; and the service is within the applicable annual maximum unless an exception applies.$1,500 per beneficiary per calendar year

Emergency dental services may continue after the annual maximum is met. The annual maximum does not apply to beneficiaries under age 21; beneficiaries who are pregnant or in the postpartum eligibility period; beneficiaries served through the Community Rehabilitation and Treatment or Developmental Disability Services programs; or medical and surgical services of a dentist, preventive services, prophylaxis, or fluoride treatment.

Emergency dental services

Covered when the emergency service is medically necessary to relieve pain, infection, or bleeding.

Emergency dental services: The service is medically necessary emergency dental treatment to relieve pain, infection, or bleeding.Pain, infection, or bleeding

Covered examples include examinations, diagnostic radiographs of the symptomatic area, sedative fillings, therapeutic pulpotomy, extraction of infected and symptomatic teeth, incision and drainage of abscess, suturing, tooth re-implantation, and minor emergency palliative procedures for dental pain. Emergency coverage does not include replacement of missing teeth or dentures.

Medically necessary orthodontic services

Covered only when ALL of the following are met:

Eligible beneficiary: The beneficiary is under age 21, or is pregnant, or is in the postpartum eligibility period.Postpartum period extends 12 months after pregnancy ends

The postpartum eligibility period begins on the date the pregnancy ends and ends on the last day of the month in which the 12-month period ends.

Medical necessity standard: The orthodontic treatment is medically necessary according to diagnostic criteria adopted by the Department of Vermont Health Access, or the beneficiary has a functional impairment equal to or greater than the severity of a functional impairment meeting those diagnostic criteria.Severe malocclusion or equivalent functional impairment

Orthodontic treatment for cosmetic purposes is not covered.

Medically necessary dentures

Covered only when the denture is medically necessary and the beneficiary meets at least ONE of the following eligibility categories:

Eligible denture beneficiary

Under age 21: The individual is under age 21.Under age 21
Pregnancy or postpartum: The individual is pregnant or in the postpartum eligibility period.Postpartum period extends 12 months after pregnancy ends
Specified program enrollment: The individual is served through the Community Rehabilitation and Treatment or Developmental Disability Services programs.Enrollment in applicable program

Cosmetic procedures, including orthodontic treatment provided for cosmetic purposes, are not covered.

Certain elective procedures are not covered under this policy.

Orthodontic treatment is not covered unless it is medically necessary for an eligible beneficiary and meets the Department of Vermont Health Access diagnostic criteria, or the beneficiary has an equivalent or greater functional impairment. Eligible beneficiaries include individuals under age 21 and individuals who are pregnant or in the 12-month postpartum eligibility period.

Dentures are not covered except when medically necessary for individuals under age 21, individuals who are pregnant or in the postpartum eligibility period, or individuals served through the Community Rehabilitation and Treatment or Developmental Disability Services programs.

Emergency dental services to relieve pain, infection, or bleeding do not include payment for replacing missing teeth or replacing dentures.

Orthodontic treatment provided for cosmetic purposes is not medically necessary for coverage under this policy.

Benefit Limits and Eligibility Rules

Annual dental benefit maximum

Annual maximum$1,500 per beneficiary per calendar year

Applies toBeneficiaries age 21 and older

ExceptionsThe maximum does not apply to emergency dental services and specified exempt beneficiaries and services, including medical and surgical services of a dentist, preventive services, prophylaxis, and fluoride treatment.

Postpartum eligibility period

Start dateThe postpartum eligibility period begins on the date the pregnancy ends.

DurationThe period extends 12 months after the pregnancy ends.

Provider Requirements and Billing Actions

Prior Authorization

Check the Published Prior-Authorization List

Check the Vermont Department of Health Access website for the published list of covered dental procedures and services that require prior authorization. Emergency dental services do not require prior authorization.

Documentation Required

Obtain Written Financial-Liability Acknowledgement

Before performing a procedure that may be billed to the beneficiary, obtain the beneficiary’s written acknowledgement of financial liability.

Applies when billing after the annual maximum has been reached or for services not covered by Vermont Medicaid.

Policy Background

Dental services include diagnostic, preventive, restorative, endodontic, and corrective procedures involving the teeth and associated structures of the oral cavity. The scope also includes services addressing disease, injury, or impairment that may affect a beneficiary’s oral or general health. Emergency dental services are intended to alleviate pain, infection, or bleeding, while orthodontic coverage is limited to medically necessary correction or prevention of severe malocclusions rather than cosmetic treatment.

Key Definitions

Dental services

Procedure typesDiagnostic, preventive, restorative, endodontic, or corrective procedures.

Oral structuresProcedures involving the teeth and associated structures of the oral cavity.

Conditions treatedDisease, injury, or impairment that may affect the oral or general health of the beneficiary.

Dentist

DefinitionAn individual licensed to practice dentistry or dental surgery.

LicensureThe individual must be licensed.

Authorized practice

Policy Summary

PayerVermont Agency of Human Services – Department of Vermont Health Access

PolicyDental Services

Policy CodePolicy 4.202

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionConsult the Vermont Department of Health Access website to determine which covered dental procedures and services require prior authorization.

SourceLink

On This Page

The period ends on the last day of the month in which the 12-month period ends.

Age-based coverage

Age thresholdBeneficiaries under age 21.

Coverage standardAll medically necessary dental services are covered according to EPSDT requirements under Health Care Administrative Rule 4.106.

LimitsCoverage and service limits do not apply, and published limits may be exceeded when medically necessary.

Billing Rule

Apply Medicaid Reimbursement Limits to Beneficiary Billing

When billing a beneficiary for a procedure after the annual maximum has been reached, billed amounts may not exceed the appropriate Medicaid rate for that procedure. This limit does not apply to procedures that are not covered by Vermont Medicaid.

Note

Use a Qualified Enrolled Provider

Ensure dental services are provided by, or under the supervision of, an appropriately licensed provider enrolled in Vermont Medicaid and working within the scope of practice.

Dental services: licensed dentist, dental hygienist, or dental therapist.
Maxillofacial surgery and medical or surgical services of a dentist: licensed medical provider or dentist enrolled in Vermont Medicaid.

Denial Risk

Avoid Cosmetic Orthodontics and Non-Qualifying Dentures

Do not bill Medicaid for cosmetic orthodontic treatment. Dentures are covered only for specified beneficiaries and circumstances; services outside those requirements are not covered.

Medically necessary orthodontic services are covered for beneficiaries under age 21 and for beneficiaries who are pregnant or in the postpartum eligibility period, subject to applicable diagnostic or functional-impairment criteria.
Dentures are limited to individuals under age 21, individuals who are pregnant or in the postpartum eligibility period, and individuals served through the Community Rehabilitation and Treatment and Developmental Disability Services programs.

Denial Risk

Cosmetic and Certain Elective Procedures Are Not Covered

Procedures performed for cosmetic purposes and certain elective procedures are not covered. Orthodontic treatments and dentures are not covered except as specifically provided in the applicable coverage provisions.

Denial Risk

Replacement Teeth and Dentures Are Excluded from Emergency Coverage

Emergency dental coverage for relieving pain, infection, or bleeding does not include payment for replacement teeth or dentures.

Billing Rule

Verify the Annual Maximum and Published Criteria

For beneficiaries age 21 and older, dental services are covered according to published criteria and are subject to a maximum of $1,500 per beneficiary per calendar year. Emergency services may continue after the maximum is met only when consistent with the published criteria.

Review the Vermont Medicaid Dental Supplement, which identifies covered services, procedures excluded from the maximum, and medically necessary emergency procedures that may be covered after the maximum is reached.
The annual maximum does not apply to beneficiaries under age 21, beneficiaries who are pregnant or in the postpartum eligibility period, beneficiaries served through the Community Rehabilitation and Treatment and Developmental Disability Services programs, or specified medical, surgical, preventive, prophylaxis, and fluoride services.

The licensed practice includes dentistry or dental surgery.

Dentures

DefinitionArtificial structures made by or under the direction of a dentist to replace a full or partial set of teeth.

PurposeReplacement of a full or partial set of teeth.

制作Made by or under the direction of a dentist.

Emergency dental services

PurposeServices to alleviate pain, infection, or bleeding.

Covered examplesExamples include examinations, diagnostic radiographs of the symptomatic area, sedative fillings, therapeutic pulpotomy, and extraction of infected and symptomatic teeth.

Additional examplesIncision and drainage of abscess, suturing, tooth re-implantation, and minor procedures for emergency palliative treatment of dental pain.

Medical and surgical services of a dentist

ProviderServices furnished by a licensed doctor of dental medicine or dental surgery enrolled in Vermont Medicaid.

Scope of practiceThe services must be furnished by the dentist working within the dentist’s scope of practice.

Service classificationServices that would be physician services if furnished by a physician or other licensed medical provider, or that may be furnished by such a provider or a dentist.

Orthodontic services

DefinitionUse of one or more devices to medically correct or prevent severe malocclusions.

Medical purposeTreatment must medically correct or prevent a severe malocclusion.

Coverage limitationOrthodontic treatment for cosmetic purposes is not covered.