May 2019 Volume LIV Number 3


Coding Corner

September 2018 Volume LIII Number 5

What to Do When You Realize that Medicaid Doesn’t Cover a Service Your Patient Needs

By Dr. Jessica Meeske

North Central Trustee and board liaison to the AAPD Pediatric Dental Medicaid and CHIP Advisory Committee

As an advocate for our patients with Medicaid and having success- ful Medicaid programs in our states, the two most common questions I’m asked by my colleagues are, "Why doesn’t Medicaid cover this?" and "What am I to do if this is the best treatment option for my pa- tient?" Here’s what you can do about it.

First, you can talk to parents about a needed procedure. I have found when I take the time to explain what the child needs and how it will benefit them, more often than not, the parents will figure out away to try to pay for it. You need to be sure you document this conver- sation in the chart and have the parent sign a "non-covered services" form. These forms are available from your state dental Medicaid office or the Medicaid contractor or you can create your own. It basically says that you informed the parent that the service was not a covered benefit and they would be responsible for paying it out of pocket.

Because Medicaid by law covers the majority of preventive, restorative, and emergency services, we are really only talking about a handful of codes that aren’t covered. The first time I had this conver- sation, it was uncomfortable. However, because SDF is currently not a covered service in Nebraska, I have this conversation with my parents at least once per day. I have found that less than 10 percent choose not to pursue the needed treatment, which means 90 percent do! While I am encouraging my Medicaid contractor to accept this code in the future, for the time being, my patients are getting the best service recommended and I’m enjoying being paid my full fee.

I have also found this to be true with recommended orthodontic care. Currently, I have no orthodontist in my community that is ac- cepting patients with Medicaid. That puts me in the difficult position of watching the occlusion, growth, and crowding get worse when I know I can make the patient better. It is not uncommon to see canines starting to get impacted and realize if I don’t intercept the problem soon, the patient will have a much greater problem down the road.
While I still submit to Medicaid for the orthodontic treatment plan, more often than not, it gets denied because the case doesn’t meet  the very narrow criteria. Sometimes, it’s as simple as recommending primary extractions to facilitate a pathway for the permanent tooth to change course and erupt in the most favorable position I can make happen.

I approach the ortho consultant with the parent the same as all parents. I present the diagnosis, treatment plan, risks, benefits, and al- ternatives (including seeing an orthodontist and paying out of pocket).

Then I let them know the case is not severe enough to be covered  by Medicaid. You can expect a sigh, but typically, the parent already received the denial letter from the state/contractor. If the parent and child are motivated to pursue the treatment, we bring in the business team member in to talk through paying for it out of pocket. While about half of my families with Medicaid will not be able to afford orthodontic treatment at that time, the good news is HALF WILL! Even if we offer a discount, the fee is far higher than what Medicaid would have paid me.

The silver lining in this is once the parents have seen the great results from SDF or orthodontic appliances to improve their child’s dental health and smile, they want to start the other children in the family. After 19 years of practice, I have found many of the children with Medicaid whom I provided a dental home, want to bring in their own children later in life, many whom have private insurance.

Get comfortable having the conversation with parents that "That while and Medicaid may not cover a dental procedure, their child will surely benefit in many ways that make it worth the investment." We have to remember that Medicaid covers a diverse population. While some are at the lowest end of poverty, many families are right at the cutoff and will cut expenses in other areas to assure their children have the recommended dental treatment. Most parents understand that when you intervene with a problem early, whether it be caries or malocclusion, it often means less treatment at a lower cost. That equates to less missed school, less missed work, and fewer tanks of gas to the dentist.

From a long-term solution standpoint, consider this. Dental Medicaid Programs were not designed to be the gold standard dental insurance plan that cover everything you think your patients need or their parents do. Each program has a limited amount of money that has to be spread amongst many recipients. Think of it like K-12 public education. If we want ideal and perfect Medicaid programs, we should be advocating to pay higher taxes and prioritize money away from other state funded programs like roads, state patrols, and higher educa- tion. Rarely do I hear dentists doing this.

However, that doesn’t mean you can’t have powerful influence over adding new services, and affecting frequency, limitations, and fees of those covered services. Get involved in your state’s Dental Medicaid Advisory Committee and be heard. AAPD’s Pediatric Dental Medicaid and CHIP Advisory Committee regularly communicates AAPD poli- cies and recommendations to state Medicaid Programs, state dental boards, and other related agencies on your behalf. But…nothing beats a face to face meeting with the people that make these decisions and building relationships with them. They often appreciate the feedback even if they feel their decisions may be limited by their state legislators.

For more information, download the AAPD Medicaid Toolkit for more tips on seeing children with Medicaid or contact Dental Benefits Director Mary Essling at (312) 337-2169 or

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