West Virginia’s Medicaid program, known as Mountain Health Trust, includes dental coverage for eligible residents. The range of services available varies significantly based on the age of the recipient, with different levels of benefits provided for children and adults.
Comprehensive Dental Coverage for Children
Dental care for children and young adults under the age of 21 is mandated to be comprehensive under federal law through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. EPSDT requires states to cover any medically necessary service to treat a condition discovered during a screening, meaning virtually all types of dental care are covered for this age group.
The benefits include diagnostic services (routine examinations and X-rays) and preventive care (cleanings and fluoride treatments). Restorative procedures are also covered, including fillings, root canals, and extractions. Orthodontia, or braces, can be covered if a dentist determines the condition is medically necessary, such as for severe malocclusion that impacts chewing or speech. This comprehensive coverage is not subject to the financial limitations applied to adult coverage.
Scope of Adult Dental Benefits
For adults aged 21 and older, West Virginia Medicaid recently expanded its dental benefits beyond emergency procedures. Effective July 1, 2024, the program provides coverage for a wide range of diagnostic, preventive, and restorative services. This expansion allows adult recipients to seek necessary routine and non-emergency dental treatment.
The services covered include routine diagnostic and preventive care, typically meaning two check-ups and cleanings per year, along with necessary X-rays. Restorative services are included, such as fillings and extractions. The coverage also extends to prosthodontic services, which involves replacing missing teeth with appliances like dentures, partials, crowns, and implants under certain conditions.
This adult benefit is subject to a specific financial limit: a $2,000 allowance per recipient over a two-year budget period. The total cost of all covered diagnostic, preventive, and restorative services cannot exceed $2,000 within that 24-month timeframe. The two-year period helps recipients manage the cost of larger restorative treatments, such as dentures.
Recipients are responsible for the full cost of any dental services that exceed the $2,000 limit within the two-year period. The benefit specifically excludes services classified as cosmetic in nature. Procedures like teeth whitening, cosmetic bonding, and braces for purely aesthetic reasons are not covered.
Finding Participating Dentists and Utilizing the Benefit
Accessing the benefit begins with confirming eligibility for the Mountain Health Trust program. Individuals can check their status and update personal information through the state’s online portal, WV PATH, or by contacting the West Virginia Department of Health and Human Services. Eligibility must be verified periodically, so maintaining up-to-date contact information is important.
West Virginia Medicaid manages dental benefits through various Managed Care Organizations (MCOs). These MCOs include:
- Aetna Better Health
- Highmark Health Options
- The Health Plan
- Wellpoint
Recipients must locate a dentist who is actively participating in their specific plan’s network. To find a participating dentist, contact the member services line listed on the Medicaid ID card or use the provider search tool on the MCO’s website.
Before scheduling an appointment, confirm with the dental office staff that they accept the specific Mountain Health Trust plan. If a procedure is anticipated to be costly, such as extensive restorative work, the dentist may need to submit a prior authorization request to the MCO to confirm coverage and medical necessity. Understanding the $2,000 two-year limit is crucial, and members should ask their provider to help track the remaining benefit allowance.