Dental Services through Medi-Cal

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Jan 24, 2023
#8094.01

Dental Services through Medi-Cal

Medi-Cal provides dental services for adults and children. Comprehensive dental services are a mandatory benefit for Medi-Cal beneficiaries under age 21. For adults 21 and over, California has the option of providing Medi-Cal coverage for dental services.

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Disclaimer: This publication is legal information only and is not legal advice about your individual situation. It is current as of the date posted. We try to update our materials regularly. However, laws are regularly changing. If you want to make sure the law has not changed, contact DRC or another legal office.

I. HISTORY OF BENEFITS

Medi-Cal provides dental services for adults and children.

Comprehensive dental services are a mandatory benefit for Medi-Cal beneficiaries under age 21. For adults 21 and over, California has the option of providing Medi-Cal coverage for dental services.1

Medi-Cal dental coverage for adults has varied significantly in recent years. In July 2009, due to budget constraints, California eliminated comprehensive dental coverage for adults. In May 2014, California partially restored Medi-Cal dental coverage for adults. On January 1, 2018, California fully restored Medi-Cal dental coverage for adults.2

II. ACCESSING SERVICES

a. Enrollment

How do I enroll in dental services through Medi-Cal?

Full-scope Medi-Cal beneficiaries are automatically enrolled in Medi-Cal Dental. You do not need to apply separately to get dental services.3 The only exception is for beneficiaries in Sacramento County and for individuals enrolled in the Health Plan of San Mateo. You will need to provide your Medi-Cal Benefits Identification Card to your dental provider to receive dental services.4 Your Benefits Identification Card is issued when you are determined eligible for Medi-Cal. For adults with limited-scope Medi-Cal, see Section III(g) below for information about dental coverage.

How are my dental services covered?

Medi-Cal covers dental services through 3 delivery systems:

  • Medi-Cal Dental: Fee-for-Service (every county except Sacramento)
  • Dental Managed Care: Managed Care (optional in Los Angeles County and mandatory in Sacramento County)
  • Medi-Cal Managed Care Plan (for members of the Health Plan of San Mateo)

What is Medi-Cal Dental?

Medi-Cal Dental is the dental services coverage program in California for all counties, except Sacramento County. Medi-Cal Dental is Fee-for-Service. Under a fee-for-service model, the state pays providers directly for covered services received by you. If you live in a covered county, you can visit any dental provider who accepts Medi-Cal Dental.

What is Dental Managed Care?

Dental Managed Care is a managed care program for dental services available in Sacramento and Los Angeles counties. If you live in Sacramento County, you will have to enroll in a Dental Managed Care plan, and you will be assigned to a dental provider in your network. If you live in Los Angeles County, you can choose to enroll in Dental Managed Care or stay in Fee-for-Service Medi-Cal Dental.5

Under a managed care model, the state pays a fee to a managed care plan. In turn, the managed care plan pays providers for all services you need, that are covered under the plan’s contract with the state. Under Dental Managed Care, you cannot see any covered dentist, you must switch your assigned dental provider if you’d like a new provider. See Section II(b) below for information about enrolling in a Dental Managed Care plan.

b. Finding a Provider

How do I find a Medi-Cal Dental provider?

You can search for a Medi-Cal Dental provider online at https://smilecalifornia.org/find-a-dentist/. You can also call (800) 322-6384 for assistance. Medi-Cal Dental representatives are available to assist callers from 8am – 5pm, Monday through Friday. Language interpreters are available.

For Spanish speakers, the Smile, California website is available at https://sonriecalifornia.org/. You can also find other languages on the globe icon in the upper right corner.

When you contact a dentist, ask if they accept Medi-Cal Dental. You can also request a qualified interpreter, if needed.

How do I find a Dental Managed Care provider?

If you live in Sacramento or Los Angeles counties, you can find information about enrolling in the different Dental Managed Care plans here: https://www.dhcs.ca.gov/services/Pages/ManagedCarePlanDirectory.aspx. Once you are enrolled in Dental Managed Care, your plan will assign you a dental provider.

Currently, there are three Dental Managed Care plans available in Sacramento and Los Angeles counties:

For help enrolling in or changing your Dental Managed Care plan, call Health Care Options at (800) 430-4263. For help with your Dental Managed Care plan, call the Department of Managed Care Help Center at (888) 466-2219.

See Section II(e) below for information about Beneficiary Dental Exceptions, which allows a beneficiary to opt-out of Dental Managed Care and move into Medi-Cal Dental.

How do I find a dental provider if I’m enrolled in the Health Plan of San Mateo?

For individuals enrolled in the Health Plan of San Mateo, dental services are available directly through your Medi-Cal Managed Care plan. Contact the Health Plan of San Mateo to be assigned a dental provider at (800) 750-4776, or visit https://www.hpsm.org/member/hpsm-dental.6

c. First Appointment

What do I need to bring to my first dental appointment?

Bring your Medi-Cal Benefits Identification Card and a Photo Identification Card or Driver’s License to your first dental appointment. Bring your Dental Managed Care plan card, if you’ve joined a Dental Managed Care plan.

Can someone interpret for me at the dental office?

Yes. If your dental provider does not speak your language, you have the right to a language or sign language interpreter at no charge. Your dental provider can call the Telephone Service Center at (800) 322-6384. You and your dentist will be connected with an interpreter who speaks your language and can translate.7

See DRC’s publication Access to Health Care for People with Disabilities under the ADA and other Civil Rights Laws for additional information on your rights when accessing health care: https://www.disabilityrightsca.org/publications/access-to-health-care-for-people-with-disabilities-under-the-ada-and-other-civil

d. Payments

How much are co-payments?

Current Medi-Cal Dental co-payments are below:8

  • Non-emergency services provided in an emergency room: $5
  • Outpatient services: $1
  • Drug prescriptions: $1

What about payments for services not covered by Medi-Cal Dental?

Your provider must tell you which services are and are not covered by Medi-Cal Dental. Your Medi-Cal Dental provider cannot make you get any service that is not covered by Medi-Cal. Your dental provider may charge you for services if you choose to have treatment that is not covered by Medi-Cal Dental.9

e. Beneficiary Dental Exception

What is a Beneficiary Dental Exception?

A Beneficiary Dental Exception allows a member to opt-out of Dental Managed Care and move into Fee-for-Service Medi-Cal Dental. Beneficiary Dental Exceptions are available for individuals enrolled in Dental Managed Care in Sacramento and Los Angeles counties. Beneficiary Dental Exceptions are for beneficiaries who are unable to secure access to services through their Dental Managed Care plan.10

How do I apply for a Beneficiary Dental Exception?

You can apply for Beneficiary Dental Exception via phone, mail, email, or fax. You can apply over the phone by calling (855) 347-3310. You can apply via mail, email, or fax by completing this form: https://www.dental.dhcs.ca.gov/MCD_documents/members/BDE_request_form.pdf

More information on Beneficiary Dental Exceptions is available here: https://dental.dhcs.ca.gov/Members/Dental_Managed_Care/Beneficiary_Dental_Exception/

For beneficiaries who secure a Beneficiary Dental Exception, they shall remain in Fee-for-Service Medi-Cal Dental until the time they choose to opt back in to Dental Managed Care.11

f. Authorized Representatives

What is a Medi-Cal Dental Authorized Representative?

A Medi-Cal Dental Authorized Representative is someone who can act on your behalf to assist with getting you dental care. This can involve helping with billing questions, booking appointments, and getting your dental information.12 You are not required to have an Authorized Representative.

How do I assign an Authorized Representative?

You can assign a Medi-Cal Dental Authorized Representative by completing this form: https://www.dental.dhcs.ca.gov/MCD_documents/members/MCD_appt_auth_rep_form.pdf.

Once the form is filled out and signed, you can submit via email to memberformreturn@delta.org or mail to:

Medi-Cal Dental Program
Attn: Information Security/Privacy Office
P.O. Box 15539 Sacramento, CA 95852-1539

You can add, remove, or change an Authorized Representative at any time.13

g. Accessing Services Without Health Insurance

How can I get dental care without health insurance?

Federally Qualified Health Centers and other community can provide care for you, even if you do not have health insurance. You pay for services based on your income.

You can find a Federally Qualified Health Center near you here: https://findahealthcenter.hrsa.gov/

Dental schools and dental hygiene schools often have clinics that allow dental students to gain experience treating patients while providing care at a reduced cost.

You can find dental care through a local dental or dental hygiene school here: https://www.nidcr.nih.gov/health-info/finding-dental-care.

For more information see: https://www.cdph.ca.gov/Programs/CCDPHP/DCDIC/CDCB/Pages/OralHealthProgram/DentalServices.aspx#

III. ADULT DENTAL COVERAGE

a. Adult Dental Services Coverage

What services are covered under Medi-Cal Dental?

Covered adult dental services include:14

  • Initial Exam
  • Cleanings (prophylaxis)
  • Fluoride Treatment
  • X-Rays
  • Fillings
  • Prefabricated Crowns (Resin & Stainless Steel Only)
  • Extractions
  • Root Canals in Front and Back Teeth
  • Full Dentures
  • Full Denture Adjustments & Repairs
  • Laboratory Processed Crowns
  • Partial Dentures
  • Partial Denture Adjustments, Repairs, and Relines
  • Periodontics (Scaling and Root Planing)
  • Other Medically Necessary Dental Services

b. Cap on Adult Dental Services

Is there a cap on adult dental services?

Dental services for individuals 21 years or older are limited to $1,800 per beneficiary for each calendar year.15 The cap is considered a “soft” cap, because once Medi-Cal has paid $1,800 in claims, all subsequent claims require a Treatment Authorization Request (TAR).

Therefore, services can still be covered beyond $1,800, however, documentation of medical necessity is required for approval. The $1,800 cap resets each calendar year.

What dental services are excluded from the cap?

Certain dental services are exempt from the cap, including:16

  • Emergency dental services
  • Services that are federally mandated, included pregnancy related services
  • Dentures
  • Maxillofacial and complex oral surgery
  • Maxillofacial services, including dental implants and implant-retained prostheses; and
  • Services provided in long-term care facilities

The annual $1,800 per member dental soft cap does not apply to procedures Medi-Cal Dental deems “medically necessary.”17

c. Emergency Dental Services

What qualifies as emergency dental services?

As stated above, emergency dental services are exempt from the annual cap.

Emergency dental services are defined as - a condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in any of the following:18

  • Placing the patient’s health in serious jeopardy
  • Serious impairment to bodily functions
  • Serious dysfunction of any bodily organ or part

Your dental provider will make the determination of what qualifies as an emergency dental service. When applicable, your provider must submit documentation to Medi-Cal Dental to justify the emergency procedure.19

d. Treatment Authorization Requests

Which dental services must be approved by a Treatment Authorization Request?

Certain dental services must be approved by a Treatment Authorization Request (TAR). A TAR is a form used by providers requesting authorization to be paid for providing certain services.20 The TAR must be approved by Medi-Cal Dental before services will be provided. Services requiring the use of a TAR include:21

  • Restorative services
  • Endodontics
  • Periodontics
  • Prosthodontics
  • Implant services
  • Oral and maxillofacial surgery
  • Orthodontics services

Services provided to patients in hospitals, skilled nursing facilities, and other intermediate care facilities also require prior authorization, unless exempted as emergency services.22

What qualifies as “medically necessary?”

As stated above, “medically necessary” services are exempt from the annual cap. For individuals 21 years or older, a service is “medically necessary” when it is:23

  • Reasonable and necessary to protect life
  • To prevent significant illness or significant disability, or
  • To alleviate severe pain

What is required for anesthesia services?

Prior Authorization is required for general anesthesia and intravenous sedation.24 Prior Authorization may be waived when the service is medically necessary to treat an emergency medical condition.25

Only an enrolled Medi-Cal Dental provider may request a Treatment Authorization Request (TAR) for anesthesia services. If an anesthesiologist is not a billing provider, the billing provider rendering the dental services may submit the TAR on behalf of the anesthesiologist rendering the anesthesia.26

e. Tele-dentistry

Is tele-dentistry available?

The Department of Health Care Services permits the use of tele-dentistry as an alternative way to provide dental services. Eligible tele-dentistry services include oral evaluation for new or established patients, periodic oral evaluation for established patients, and examination of radiographic images.27

f. Dental Benefits for Pregnant Medi-Cal beneficiaries

What Medi-Cal Dental services are available for pregnant Medi-Cal beneficiaries?

Pregnant Medi-Cal beneficiaries are covered for dental services no matter what type of Medi-Cal coverage they have. Pregnant Medi-Cal beneficiaries are covered during pregnancy and 12 months past the birth of the baby.28

g. Dental Benefits for Adults with Limited Scope Medi-Cal

What Medi-Cal Dental services are available for adults with limited scope Medi-Cal?

Adults with limited-scope Medi-Cal have restricted coverage with only extractions and emergency services covered.

IV. CHILD DENTAL COVERAGE

a. Coverage

What services are covered under Medi-Cal Dental?

Children ages 0 to 20 with full-scope Medi-Cal benefits and are eligible for the following services:29

  • Oral evaluation (under age 3)
  • Initial Exam (ages 3-20)
  • Periodic Exam (ages 3-20)
  • Prophylaxis
  • Fluoride
  • Restorative Services—Amalgams, Composites, and Pre-fabricated Crowns
  • Laboratory Processed Crowns
  • Scaling and Root planing
  • Anterior Root Canals
  • Posterior Root Canals
  • Partial Dentures
  • Full Dentures
  • Extractions
  • Emergency Services

b. Coverage under EPSDT

What coverage is required under EPSDT?

Under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, children under age 21 must receive benefits and services necessary to “correct or ameliorate defects and physical and mental illnesses and conditions.”30 In addition to periodic and interperiodic assessment of the child’s teeth, EPSDT coverage must, at a minimum, include “relief of pain and infections, restoration of teeth, and maintenance of dental health.”31

V. APPEALS

a. Understanding Denials or Changes in Services

How do I find out if Medi-Cal has denied or changed my dental services?

You will receive a Notice of Action if your dental treatment request is denied or changed. The Notice of Action will tell you whether your dental service is deferred, changed, or denied.32

  • Deferred – returned to the dental provider for correction. The dental provider has 45 days to return the correction(s). If the provider does not respond, you will receive another Notice of Medi-Cal Dental Action to let you know.
  • Changed – the service is approved but different from what the dental provider requested.
  • Denied – the service is not approved.

How do I find the reasons my dental services have been denied or changed?

The Notice of Action should list one or multiple codes explaining the reason your dental services have been denied or changed. There should be a Reason for Action Code insert included with your Notice of Action.33 You can find a sample Notice of Medi-Cal Dental Action form and Reason for Action Code insert here: https://www.dental.dhcs.ca.gov/MCD_documents/members/notice_of_medi-cal_dental_action_english.pdf

What can I do if Medi-Cal denies or limits a service my dental provider has requested?

You have multiple options if Medi-Cal denies or limits a service your dental provider has asked for. First, you can contact your dental provider and request a re-evaluation. You can also request your dental provider submit a new Treatment Authorization Request.34 You can appeal the denial by requesting a hearing. There is more information about requesting a hearing in the section below. Also, your dental provider can appeal the changed or denied treatment through a separate appeal process.

b. Right to a Hearing

What are my rights if my dental treatment request has been denied?

You may request a hearing through the California Department of Social Services (CDSS) State Hearings Division if treatment your dental provider requested has been denied or changed. You may also request a State Hearing if your Conlan refund request was denied.35 You can learn more about Conlan refund requests here: https://www.dhcs.ca.gov/services/medi-cal/Pages/Medi-Cal_Conlan.aspx. State Hearings must be requested within 90 days of receiving the Notice of Action denying or changing benefits.36 A recipient can request a hearing after the 90-day deadline has expires if good cause exists.37

c. Requesting a Hearing

How do I request a State Hearing?

State Hearings can be requested online, over the phone, or in writing. State Hearings can be requested online through the Appeals Case Management System (ACMS): https://acms.dss.ca.gov/acms/login.request.do.

State Hearings can be requested over the phone by calling the State Hearings Division at (800) 952-5253. State Hearings can be requested in writing submitting a written request, by mail to:

California Department of Social Services
State Hearings Division
P.O. Box 944243, Mail Station 9-17-37
Sacramento, California 94244-2430

By Fax to (833) 281-0905.

Additional information on requesting a State Hearing can be found here: https://www.cdss.ca.gov/hearing-requests.

VI. FILING A COMPLAINT

When should I file a complaint?

You should first speak with your dental provider about your concerns. If your dental provider is unable to resolve your concern, or you’d prefer not to speak with them, you can file a complaint with Medi-Cal Dental. Medi-Cal Dental has procedures to resolve complaints about:38

  • Dental Services
  • Quality of care
  • A change to or denial of a Treatment Authorization Request
  • Other types of services provided under Medi-Cal Dental
  • If you believe you’ve been discriminated against or treated unfairly

How do I file a complaint?

To file a complaint over the phone, call the Medi-Cal Dental Telephone Service Center at (800) 322-6384.

To file a written complaint, download the Medi-Cal Dental Complaint Form here: https://www.dental.dhcs.ca.gov/MCD_documents/members/medi-cal_dental_complaint_form_english.pdf. You can email the completed form to MemberFormReturn@delta.org or mail to Medi-Cal Dental at:

Medi-Cal Dental Program
Member Services Group
P.O. Box 15539
Sacramento, CA 95852

The complaint form can be found in different languages on the Smile, California website here: https://smilecalifornia.org/members/

VII. RESOURCES

Denti-Cal Member Website, SmileCalifornia: https://smilecalifornia.org/

DHCS, Medi-Cal Dental Member Handbook 2022: https://www.dental.dhcs.ca.gov/MCD_documents/members/member_handbook_english.pdf

Justice In Aging, Denti-Cal for Adults: https://www.justiceinaging.org/wp-content/uploads/2017/02/Denti-Cal-for-Adults.pdf

CPEHN, Your Dental Services Through Medi-Cal: https://cpehn.org/assets/uploads/archive/denti-cal_restoration_factsheet_english_0.pdf

NHeLP, An Advocate’s Guide to Medi-Cal Services, Ch. 7 Dental Services: https://healthlaw.org/wp-content/uploads/2020/02/NHeLP-MediServicesGuide-Complete-Ch7.pdf

NHeLP, Dental Credit Card Debt: https://healthlaw.org/wp-content/uploads/2018/12/Dental-CC-Debt-CA-Toolkit-12.14.2018-4-Update-3.pdf

DHCS, Medi-Cal Dental Provider Handbook 2022: https://www.dental.dhcs.ca.gov/MCD_documents/providers/provider_handbook/handbook.zip