People with Disabilities

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Dental services covered by Program HH

  • Diagnostic
    • Bitewing x-rays once a year, unless already covered by Medicaid
    • Comprehensive exam once every three years, but not within three years of a comprehensive exam covered by Medicaid
    • Full mouth series once every four years
    • Panoramic x-ray once every three years but not within three years of a panoramic x-ray covered by Medicaid, except if provided in conjunction with a scheduled outpatient facility procedure or as medically necessary for the diagnosis and follow-up of oral and maxillofacial pathology and trauma.
    • Panoramic x-ray once every two years for patients who cannot cooperate for intra-oral film due to a developmental disability or medical condition that does not allow for intra-oral film placement
    • Periapical x-rays
    • Periodic exam once every six months, but not within six months of a periodic exam covered by Medicaid.
  • Endodontics
    • Anterior and premolars only
    • Molars with prior authorization
  • Oral surgery
    • Biopsies
    • Extractions
    • Incise and drain
    • Splinting for repositioning a traumatized tooth or stabilizing an alveolar fracture

    Limited to children through age 20

    Prior authorization is required for all of the following:

    • Bone replacement graft for ridge preservation per site
    • Placement of device to facilitate eruption of impacted tooth
    • Radical resection of maxilla or mandible
    • Surgical repositioning of teeth
    • Tooth transplantation
    • Transseptal fiberotomy
  • Orthodontic limited to children through age 20
    • Treatment that meets the specifications of utilization criteria
  • Periodontics
    • Full mouth debridement once every five years
    • Periodontal maintenance once per six months, but not within three months of a prophylaxis covered by Medical Assistance or Program HH
    • Scaling and root planing once every 3 years
  • Preventive

    Prophylaxis

    • MA coverage – once every six months
    • Program HH coverage only - once every six months
    • Previous history of documented periodontal therapy
      • May be alternated with a periodontal maintenance appointment
    • Fluoride varnish
      • Once a year
    • Sealants - recipients through age 18
      • Only first and second permanent molars
  • Prosthodontics
    • Removable appliances - once per arch every three years but not within three years of a removable appliance provided by MA. Partial dentures must meet utilization criteria and be prior authorized
    • Reline, rebase and repair of removable appliance - may not exceed the cost of new appliance.

    Limited to children through age 20

    Must meet utilization criteria and be prior authorized:

    • Fixed partial denture (crowns and pontics)
  • Relief of pain
    • Palliative treatment
    • Sedative fillings
  • Restorative
    • Anterior fillings
    • Crowns - made of prefabricated stainless steel, prefabricated resin or laboratory resin
    • Posterior fillings - paid at the amalgam rate regardless of the material used
  • Temporomandibular joint (TMJ) disorder

    The following must meet utilization criteria and be prior authorized:

    • All TMJ splints
    • Occlusal orthotic appliance
    • Unspecified TMD therapy, by report

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