Dental and Orthodontic Services to be Included in the Medicaid Managed Care Benefit Package

Know Your Rights: What You Need to Know About the Expansion of Medicaid Dental Coverage in NYS (2024) 

 Dental Services to be Included in the Medicaid Managed Care Benefit Package

Effective July 2, 2012, dental services for Medicaid beneficiaries must be obtained through the member's Medicaid managed care plan, if they are in such a plan. Previously, Medicaid managed care plans had the option of covering dental services for Medicaid enrollees. Medicaid managed care coverage of dental services for Family Health Plus beneficiaries will remain optional to the plans.

• Transition policy - ensuring that treatment not interrupted

If a person enrolled in Medicaid managed care was currently receiving dental care on a fee-for-service basis before July 2012, they may fall under the interrupted treatment policy. According to this policy, certain dental procedures, once authorized under fee-for-service Medicaid, must be completed under fee-for-service Medicaid, even if the enrollee loses Medicaid eligibility or switches to a Medicaid managed care plan. This policy also applies to those enrollees who are receiving dental services through a Medicaid managed care plan and who switch plans, lose Medicaid eligibility, or switch to fee-for-service Medicaid. Click here to see the June 2008 Medicaid Update article, "Policy on Interrupted Treatment for Dental Procedures," for additional information.

• What dentists are "in network?"

In addition to a plan’s network of dental providers,   managed care plan members, as well as those in managed long term care plans, have the right to access dental services at Academic Dental Center clinics licensed under article 28 of the NY Public Health Law. N.Y. Pub. Health Law § 4403-f(7)(b)(vii)(D) (MLTC statute expressly incorporating Medicaid managed care requirements at N.Y. Soc. Serv. § 364-j(4)(a)(iii)(D)).

There are five dental centers in New York State that meet these criteria. They are: 

1. Columbia University College of Dental Medicine;
2. New York University College of Dentistry;
3. Stony Brook University School of Dental Medicine;
4. University of Buffalo School of Dental Medicine (Daniel Squire);
5. University of Rochester Eastman Dental Center.

Under the Model MLTC contract, dental services at these clinics may be accessed without prior approval and without regard to network participation. Plan must reimburse at reimburse the clinic for covered dental services provided to enrollees at approved Medicaid clinic rates.  See Article VII(H)(1) at page 48 of contract.   See also MAP Model Contract, at § 22.12(a); PACE Model Contract, at Art. V(L)(c)(sic).  

See N.Y. Dep’t of Health, Question and Answer Sheet: Transition of Dental and Orthodontia Coverage from Fee for Service to Medicaid Managed Care

Orthodontic Services to be Included in the Medicaid Managed Care Benefit

Effective October 1, 2012, orthodontic services for eligible enrollees under age 21 will also now be carved into the Medicaid managed care benefit package, so must be accessed from in-network providers.

For additional information, click here for a New York State Department of Health question and answer sheet about the dental and orthodontic benefit change.