“One Set Per Lifetime” Dentures Limit Reset

From Pennsylvania Health Law Project

Recent changes to the Medicaid benefit package will allow more beneficiaries to obtain dentures. In undoing his predecessor’s Healthy PA initiative, Governor Wolf simplified Medicaid expansion and enacted a new Adult Benefit Package. The Adult Benefit Package, which went into effect in April, replaced three different benefit packages for adults and removed a number of benefit limits, such as the six drugs per month pharmacy limit. Even though the new Adult Benefit Package still includes the dental benefit limits that started in 2011, including the “one per lifetime” limit on dentures, the dental benefits were effectively “reset” when the system updated in April to start the new Adult Benefit Package.

In practice, this means that Medicaid consumers who need dentures can now receive them under normal prior authorization guidelines, even if Medicaid covered full or partial dentures for the consumer in the past.
A consumer who gets dentures paid for by Medicaid after April 2015, and then needs another set in the future, will have to meet the more restrictive “Benefit Limit Exception” (BLE) criteria in order to get the second set of dentures covered.

Recent guidance issued to Medicaid managed care plans clarified that this change applies to Medicaid consumers in Fee-for-Service (ACCESS) as well as consumers in the HealthChoices system.

Dental services covered by
Medicaid for adults include exams, x-rays, cleanings, fillings, and extractions. Exams and cleanings are limited to two times per year. One set of dentures are covered. Root canals, crowns, and deep cleanings are only covered if a Benefit Limit Exception is approved. For a full listing of benefits and limits contained in the Adult benefit package, see the “Consumer Resources”section of healthchoicespa.com.