Searching for coverage for dental implants on Medicaid?
Losing a tooth (or teeth) is not only an aesthetic issue. Dental implants have various benefits. If left untreated, missing teeth affect the ability to chew and bite. You may have also suffered from speech issues as well as loss of self-confidence in your smile. Over time, if left untreated, missing teeth can also lead to jawbone deterioration.
Here’s the problem…
Dental implants are extremely expensive. A single dental implant can cost between $3,000 to $4,500 and up. That’s a big chunk of money for most families to spend on a smile. And if you happen to be a Medicaid recipient? You’re probably asking yourself…
Will Medicaid cover the costs?
In This Guide
- How Does Medicaid Dental Coverage Actually Work?
- What Dental Implants Cost (And Why They’re So Expensive)
- Your Options If Medicaid Denies Your Dental Implant Claim
- Rules on Coverage In Illinois
The Straightforward Truth About Medicaid And Dental Coverage
Okay, here’s the straight truth…
Medicaid dental coverage is a complex mess. The rules about what’s covered and not covered vary drastically from one state to the next. As far as dental implants are concerned, it gets even more confusing.
Why? Medicaid is a federal-state program. This means the federal government sets certain guidelines and regulations. But the state itself gets to pick and choose certain details about dental coverage.
Coverage for children is clear cut. Children who are Medicaid enrollees are provided comprehensive dental benefits through something called EPSDT (Early and Periodic Screening, Diagnostic, and Treatment). This coverage includes things like teeth cleanings, fillings, oral surgery, and orthodontic treatment (braces) if medically necessary.
But what about adults? Here things change significantly.
Recent research shows that only about 1 in 5 adult Medicaid enrollees receive dental services in any given year. Thorough Medicaid coverage for dental services can make all the difference when you are planning a smile makeover and need to figure out if dental implants are covered.
Do Dental Implants Count As “Medically Necessary?”
A few thousand dollars sounds like a lot. A few thousand dollars not covered by Medicaid sounds like even more. But here is the ultimate question.
Will Medicaid cover dental implants? Are they considered medically necessary?
In most cases, the answer to this question is no.
Medicaid views dental implants as cosmetic or elective procedures in most cases. Which means that they do not cover them. Think about it like this — if you want to look better in a selfie then the cost will likely be on you.
Of course, there are exceptions to every rule…
Medicaid in Illinois might cover implants if you have had:
- Facial trauma or some type of accident
- A condition that is causing the jawbone to deteriorate (syphilis, osteomyelitis, etc)
- The implants are needed to restore basic oral functions like chewing
- If alternative treatments such as dentures are not viable for the recipient in their specific case.
The big BUT? You will need extensive documentation from your dentist. That means full medical and dental history, detailed reports and X-rays, a treatment plan, and a letter of explanation why implants are the only solution.
Even with extensive documentation, there are no guarantees on coverage.
Dental Implants Coverage with Illinois Medicaid
On the bright side…
Illinois is one of the better states when it comes to Medicaid coverage for dental work. In Illinois, Medicaid offers extensive dental benefits to adult Medicaid recipients.
About 1.7 million adults are covered under the state’s Medicaid program.
That translates to:
Adults on Illinois Medicaid coverage will receive preventive care, cleaning, fillings, and other restorative services.
The Medicaid program is administered by DentaQuest, which operates the fee-for-service dental program.
As far as dental implants are concerned, even with Illinois Medicaid things are murky at best.
Dental implants are still considered elective treatments in the state and would only be covered if there is clear evidence of medical necessity. The same requirements above apply — you need detailed and comprehensive documentation as to why implants are the only solution for your oral health and function.
How Much Do Dental Implants Cost (And Why So Much)?
Curious as to what all that comes with thousands of dollars?
A single dental implant is made up of three components.
The implant body (the titanium screw that goes into the jawbone)
The abutment (the connector piece)
The crown (the visible “tooth” part)
Each of these has its own associated costs. When you add all three up you get the average of $3,000 to $4,500 per tooth. Need multiple implants? You can do the math for total costs yourself.
Here’s another important factor to consider…
Medicaid reimbursements rates for dental services average just 29.9% of a dentist’s normal fees. That’s why many dental service providers don’t even accept Medicaid — it is not financially viable.
Why does this matter? If most dentists in your area don’t even accept Medicaid that makes finding one who also does implants that much more difficult.
If Medicaid denies your application, you still have several options to explore:
Dental schools are one alternative. Dental school students can perform dental implants under the supervision of experienced professors. While the work may take a bit longer, the reduced costs can be a big help.
There are a number of nonprofit organizations that can provide low-cost or free dental service for those who need them. Mission of Mercy is a good example. While not all locations provide implants, they do offer services.
Talk to your dentist about alternative treatments. Dentures or bridges may not be as permanent or aesthetically pleasing as dental implants. But they are often more affordable, and in many cases, will be covered by Medicaid.
Special Needs for Children and Young Adults
Did you know this little secret?
If you are under the age of 21 and on Medicaid, you may have an easier time getting dental implants approved. Young adults under the age of 21 are still considered to be under EPSDT coverage.
Why the different standard? EPSDT is designed to provide early and thorough diagnosis and treatment of conditions that would otherwise go undiagnosed. If your child has a dental issue uncovered by a routine screening, Medicaid has to pay for the necessary treatment even if it is not something they would normally cover.
This doesn’t mean you automatically qualify for dental implants if your kid has Medicaid. But it does increase the odds in your favor if the need can be medically proven.
What You Need for Proper Documentation
If you really want to give yourself the best odds of getting approved for dental implants on Medicaid, here is the most important thing you can do.
Work with your dentist to build a strong case. This includes having detailed:
- Medical and dental history
- X-rays and diagnostic images of the mouth and jaw
- Explanation as to why implants are medically necessary
- Proof other treatment options will not work (or have not worked)
- Complete treatment plan with cost estimates broken down
- Letters from specialists who may be involved in the treatment.
Pro tip: go to a dental office with experience in Medicaid. These dental practices will be fully aware of the documentation necessary to have a successful approval. They will also be able to guide you through the process.
The Final Word on Medicaid and Dental Implants
So where does that leave you…
Medicaid coverage for dental implants is rare for adults. Implants are considered cosmetic and therefore not medically necessary.
In special circumstances, coverage may be available for dental implants if they are required for trauma, disease, or other medical issues.
Illinois Medicaid coverage provides broad dental benefits. But dental implants are still considered elective and would be denied under Medicaid unless you can provide extensive evidence of medical necessity.
If you do not get approved, consider alternative sources for implants or alternative treatment.
The key thing to do is contact a dentist that has experience in working with Medicaid. They will be able to properly evaluate your specific case, inform you of your options, and guide you through the process, whether that is obtaining Medicaid coverage or finding alternative funding.
