Missouri’s Medicaid program, known as MO HealthNet, provides coverage for certain medical and health services to eligible residents. Denture coverage for adults exists within MO HealthNet, but access depends on the recipient’s specific category of assistance. Some adult groups receive a comprehensive dental package that includes prosthetics like dentures, while others receive a limited benefit that generally excludes routine restorative services. The ability to receive full or partial dentures is tied directly to the MO HealthNet program a person qualifies for.
Eligibility Requirements for Coverage
MO HealthNet divides recipients into different categories of assistance, which determine the scope of dental benefits received. Comprehensive dental coverage, including full and partial dentures, is provided to children under age 21 and specific adult groups. These groups include pregnant women, individuals qualifying based on blindness, and residents of a vendor nursing facility.
Adults outside these categories receive a limited dental benefit package, generally excluding restorative and prosthetic procedures like dentures. For these individuals, dental care is only covered if it relates to mouth trauma or if the absence of treatment would negatively affect an existing medical condition. Eligibility for comprehensive coverage is confirmed by checking the Medical Eligibility (ME) code, which defines benefits based on factors like income, family size, and qualifying status.
Specific Covered Denture Services
For MO HealthNet participants with comprehensive dental benefits, both full and partial dentures are covered services. Reimbursement for these prosthetics includes the routine visits necessary for the entire fabrication and fitting process. This encompasses initial impressions, try-in appointments, and adjustments for a period of six months following the date the denture is placed.
The program does not require prior authorization for new full or partial dentures. However, replacement dentures are only covered when specific criteria are met. These criteria include when the existing prosthetic no longer fits due to significant weight loss from illness, bone or tissue loss, or deterioration from extended use. The dentist must document the reason for replacement, but no prior authorization request needs to be submitted to MO HealthNet.
Maintenance Limitations
There are specific limitations regarding the maintenance of dentures, particularly relining and rebasing procedures. An initial reline or rebase is allowed within the first 12 months after the placement of immediate dentures. After that, additional relining or rebasing is limited to once every 36 months from the date of the preceding procedure.
Patient Coinsurance
The program also requires a small patient contribution in the form of a coinsurance for each prosthetic device. The denture coinsurance amount is set at five percent of the lesser of the provider’s billed charge or the maximum allowable MO HealthNet amount. Providers are responsible for collecting this coinsurance from the participant. They are prohibited from denying services based solely on a person’s inability to pay the amount immediately. Furthermore, providers are not permitted to hold the completed denture until payment is received from MO HealthNet, ensuring the patient receives the device promptly.
Steps to Receive Denture Services
The process of obtaining covered denture services begins with finding a dental provider who is actively enrolled in the MO HealthNet program. The participant should confirm their eligibility status and specific benefit level with the provider before the initial examination. The dentist will conduct a comprehensive exam to determine the necessity of a denture and formulate a complete treatment plan.
If the patient falls into the limited benefit group, they must first obtain a written referral from their physician. This referral is essential and must explicitly state that the absence of denture placement would negatively impact a specific pre-existing medical condition. This documentation is required for the dental services to be considered medically necessary under the limited coverage rules.
For all eligible recipients, the dentist then proceeds with the necessary steps, such as taking impressions and making adjustments. The provider must dispense the finalized denture to the patient before billing MO HealthNet for the service. The provider is then reimbursed based on the fee schedule, less the small coinsurance amount the patient is responsible for.