Health First Colorado, Colorado’s Medicaid program, provides comprehensive dental benefits for eligible adults aged 21 and over. Maintaining good oral health is connected to overall physical well-being. Understanding the specifics of this coverage, particularly for high-cost restorative treatments, is important for members. This guide clarifies the program’s policy on dental implants and details the process for accessing covered care.
Coverage Status for Dental Implants
Colorado Medicaid covers dental implants, but only in cases deemed medically necessary, not for routine cosmetic or elective procedures. Coverage includes the surgical placement of titanium posts into the jawbone and the attachment of the prosthetic crown or bridge. This benefit helps patients restore functional dental capacity when less invasive alternatives, such as dentures or bridges, are insufficient.
To qualify, a member must undergo a thorough evaluation by their dental provider to assess oral health and bone structure. Detailed documentation is required to show sufficient jawbone support and management of chronic issues, like persistent infections. DentaQuest, the program administrator, individually reviews each case to confirm the procedure meets medical necessity criteria. Procedures aimed solely at improving aesthetic appearance are generally excluded.
Scope of Covered Adult Dental Services
While implants require specific medical circumstances, the adult dental benefit includes a broad array of standard services. Adult members have access to preventative care, including two annual dental exams and two routine cleanings per year. Diagnostic procedures, such as X-rays and comprehensive oral evaluations, are also covered.
The program covers extensive restorative services intended to preserve natural teeth. These services include amalgam and composite fillings to treat cavities. More complex restorative treatments, such as root canals and crowns, are also available, but they require specific administrative approval. Coverage also extends to periodontics, including periodontal scaling for managing gum disease.
For replacing missing teeth, the program covers extractions and prosthetic options, including both partial and complete dentures. Importantly, the state removed its annual financial cap on adult dental benefits as of July 1, 2023. Eligible members no longer have a maximum dollar limit on covered services each state fiscal year.
Prior Authorization and Medical Necessity
For extensive or complex dental services, Health First Colorado requires Prior Authorization (PA) before the procedure can be performed. PA is a pre-approval process where the program reviews the proposed treatment plan to confirm it meets the program’s requirements and is truly medically necessary. Procedures requiring PA include crowns, root canals, dentures, and dental implant surgery.
The dental provider, not the member, is responsible for submitting the PA request. The provider must submit detailed documentation, including the patient’s medical history, X-rays, and justification for why the proposed treatment is the appropriate and least costly option to resolve the patient’s condition. This documentation proves the medical necessity of the service. DentaQuest reviews these submissions for compliance and clinical appropriateness.
If a PA request is denied, the member has the right to appeal the decision through a formal process. Understanding that the PA process can be lengthy is important, and members should discuss the timeline with their provider before starting any high-cost treatment plan.
Finding Providers and Accessing Benefits
Accessing the Health First Colorado dental benefit requires finding a provider enrolled in the network. The state partnered with DentaQuest to manage adult dental benefits and maintain the network of participating dentists. Members must confirm a dentist’s participation before scheduling an appointment, as not all dental offices accept Health First Colorado.
Members can use the official provider search tool on the Health First Colorado website or the DentaQuest website to locate a nearby participating dentist. DentaQuest also operates a dedicated Member Services line (1-855-225-1729) to assist with finding a provider, verifying benefits, and answering coverage questions.
The dental office is responsible for confirming the member’s eligibility on the date of service. Members must receive care from an enrolled provider, as the program does not typically cover services rendered by out-of-network dentists. For those who have trouble locating a provider, contacting DentaQuest directly is the most direct way to access the dental network and begin care.