The Virginia Medicaid program, known as Cardinal Care, offers health coverage to eligible residents, including adults who require dental services like dentures. Historically, adult dental benefits were limited, but a legislative change effective July 1, 2021, significantly expanded comprehensive dental coverage for adults aged 21 and older who receive full Medicaid benefits. This expansion ensures that services focusing on overall oral health, prevention, and restoration are available to a much larger population in the state. This article provides a clear understanding of the current coverage for dentures, qualification pathways, and specific rules for accessing this benefit.
Current Status of Adult Dental Coverage in Virginia Medicaid
Yes, Virginia Medicaid, through the Cardinal Care Smiles program, covers dentures for eligible adults. This coverage falls under prosthodontics, which includes services for replacing missing teeth with removable appliances. The expanded adult dental benefit includes full dentures for individuals who have lost all teeth in an arch, as well as partial dentures for those missing only some teeth.
The benefit also covers necessary preparatory procedures, such as extractions, to prepare the mouth for the denture fitting. Initial fittings and adjustments are included to ensure the patient achieves proper comfort and function with the new appliance. The Department of Medical Assistance Services (DMAS) manages this benefit, with DentaQuest administering the Cardinal Care Smiles program for all Medicaid and Family Access to Medical Insurance Security (FAMIS) members.
Eligibility Requirements for Virginia Medicaid
Accessing the denture benefit requires an individual to be enrolled in the full Virginia Medicaid program. Eligibility for adults falls under two main pathways: the Aged, Blind, and Disabled (ABD) category or the Affordable Care Act (ACA) Adult Expansion Group. The Adult Expansion Group includes non-disabled adults aged 19 to 64 whose household income is at or below 138% of the Federal Poverty Level (FPL).
The FPL limits change annually, so applicants must check the current figures to determine if their income qualifies. For the ABD group, individuals must be 65 or older, blind, or disabled, and they must meet specific income and resource limits. Individuals may apply for coverage online through Cover Virginia or by submitting a paper application to their local Department of Social Services office.
The eligibility determination process also considers other factors beyond income, such as Virginia residency and citizenship or eligible immigration status. Certain groups, like former foster care individuals up to age 26, may qualify for Medicaid with no income limit. Enrollment in the full Medicaid benefit is the prerequisite for receiving the comprehensive dental coverage that includes dentures.
Accessing the Denture Benefit and Limitations
Once an adult is enrolled in full Virginia Medicaid, the denture benefit is accessed through a network of participating providers in the Cardinal Care Smiles program. Recipients must use a dental provider who is credentialed by DentaQuest and enrolled in the state’s Medicaid network. Individuals can locate a list of these providers by calling the Cardinal Care Smiles program or searching the DentaQuest website.
Denture services are subject to specific utilization rules and frequency limits. While full and partial dentures are covered, replacements are authorized only once within a defined time frame, often five years, unless medically necessary due to irreparable damage or loss. Additionally, repairs to an existing denture, such as adding teeth or fixing a broken base, are covered, as are relines and rebases, though these services also have their own frequency limitations, such as once every 36 months for a reline.
Many higher-cost procedures, including the provision of new dentures, require the dental provider to submit a prior authorization request to DMAS before treatment can begin. The prior authorization process ensures that the requested service is medically appropriate and meets the program’s coverage guidelines. The program covers simple prosthetics but does not cover complex or cosmetic procedures like dental implants or bridges for adult members.