Ohio Benefits Description

Medicaid Program

Under the Medicaid State Plan dental benefits are provided to eligible individuals under the age of 21 in compliance with the requirements of Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services.

State Program Name: Covered Families and Children (CFC) Program

If providing dental benefits other than as defined by EPSDT, States must complete the following:

CHIP Stand-Alone Program Dental Benefits
NOTE: Please identify any limits or other criteria using terms commonly recognized by individuals without extensive oral health terminology knowledge rather than using technical dental terminology. For example, use molar rather than posterior, or front versus anterior.

Schedule of Services
State EPSDT definition

Recommended Age for First Oral Health Examination:
Diagnostic and preventive dental services examinations are covered for children of any age and shall be provided to individuals at ages and at frequencies in accordance with American Academy of Pediatrics recommendations for preventive pediatric health care. Providers are encouraged to refer children, beginning at age two years, to a dentist or the County Department of Job and Family Services for a referral to a dentist.

Preventive Services: 

Cleanings
Recommended frequency: Every 180 days.
Fluoride treatments: yes
Ages: Covered for consumers under age 21.
Recommended frequency: every 180 days.
Also provided by physicians: yes
Also provided by hygienists:

Dental Hygienists are not eligible for direct reimbursement. However, their services are covered when provided within their scope of practice as part of a service rendered through a dental office or clinic.

Exceptions: Fluoride varnish provided by physicians covered to age 3.

Sealants
a. Ages: Covered for consumers under age 18.
b. Recommended frequency: Coverage once per tooth.
c. Exceptions: Coverage of first and second molars

Oral hygiene instruction
a. Ages: N/A
b. Recommended frequency: Included as part of EPSDT examinations/evaluations, prophylaxis, dental exams and other services.

Space Maintainers
a. Limits: based on medical need.
b. Prior approval required: Y/N No

Diagnostic Services:

Dental Examinations by Dentists
Recommended age of first visit: Diagnostic and preventive dental services examinations are covered for children of any age and shall be provided to individuals at ages and at frequencies in accordance with American Academy of Pediatrics recommendations for preventive pediatric health care. Providers are encouraged to refer children, beginning at age two years, to a dentist or the County Department of Job and Family Services for a referral to a dentist

1. Recommended frequency: every 180 days
2. Limits: Periodic oral exam every 180 days, comprehensive exam once per consumer/dentist relationship, problem focused exams as medically necessary.

X-Rays
a. Limits: Various limits based on procedure and medical need. For example, intra-oral, complete and panoramic x-rays once every 5 years, bitewings every 6 months and extraoral film as an adjunct to complex treatment.

Treatment Services:

Fillings
1. Silver amalgam: yes
a. Limits: Maximum of three restorations per tooth.
2. Tooth colored composite: Yes
a. Limits: Maximum of three restorations per tooth.

Crowns/Tooth Caps
1. Stainless steel crowns: Yes
a. Limits: Coverage for teeth where multi-surface restorations are needed and other materials have a poor prognosis. Stainless steel crowns with resin windows covered for anterior teeth.
b. Prior approval required: No
2. Metal/Porcelain crowns: Yes
a. Limits: Authorized for permanent anterior teeth.
b. Prior approval required: yes

Root Canals (endodontics)
1. Root canals on baby teeth (Pulpotomies): Yes
a. Limits: Covered for consumers under age 21.
b. Prior approval required:
2. Root canals on permanent teeth: Yes
a. Limits: Coverage for permanent teeth.

b. Prior approval required: No

Gum (periodontal) Therapy
a. Limits: Medical need.
b. Prior approval required: Yes

Dentures
1. Partial dentures: Yes
a. Prior approval required: No
2. Complete dentures: Yes
a. Prior approval required: Yes

Retainers (orthodontic)
a. Limits: Covered for consumers under age 21.
b. Prior approval required: Yes

Oral Surgery
1. Simple extractions: Yes
a. Limits: Medical need.
b. Prior approval required: No

2. Surgical extractions: Yes
a. Limits: Medical need.
b. Prior approval required: X PA on certain impacted tooth procedures.

3. Care of abscesses: Yes
a. Limits: Medical necessity.
b. Prior approval required: No

4. Cleft palate treatment: Yes
a. Limits:
b. Prior approval required:

5. Cancer treatment: Yes
b. Limits:
c. Prior approval required: No

6. Treatment of Fractures: Yes
a. Limits:
b. Prior approval required: No

7. Biopsies: Yes
a. Limits:
b. Prior approval required: No

Treatment of Jaw Joint (TMJ)
a. Criteria: Coverage based on review of radiographs, diagnostic cast and clinical findings and symptoms.
b. Prior approval required: Yes

Braces (Orthodontia)
a. Criteria: Coverage limited to most severe handicapping orthodontic conditions for consumers under age 21.
b. Prior approval required: Yes
c. Payment if eligibility lost: Yes. Coverage extended for remainder of current quarter.

Emergency Room Services
a. Identify services: Services to relieve pain, bleeding and infection.
b. Criteria: Medical need.

In-patient Hospital Services
a. Criteria: Covered dental services are covered in a hospital setting based on medical necessity.
b. Prior approval required: No

Special Anesthesia
a. Criteria: Coverage of analgesic and local anesthetic agents and general anesthesia.
b. Prior approval required: No

Excluded Services
1.       Identify services:
Bridges are not covered.