CMS-10291 Benefit Template

OMB Approval Number: 0938-1065

ATTACHMENT A

Description of Dental Benefits Provided Under

Medicaid and the Children’s Health Insurance Program (CHIP)

State: 

Updated:

The following information will identify the general categories of services available in your State. Please note that while a service may be available, you must consult with your dental provider to ensure that the service is medically necessary for your specific condition. For more specific information, please contact your State program.

State Contact:

Telephone Number:

E-mail Address:

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:

CHIP Program

  CHIP Medicaid Expansion Program ONLY, i.e., offering complete oral health services under Early and Periodic Screening, Diagnostic and Treatment (EPSDT)

             State Program Name:

CHIP Stand-Alone/Separate Program ONLY

             State Program Name:

Dental Services Provided through State-defined benefit package

            Benchmark Equivalent Program:             

                                    Name of :

    Optional Supplemental Dental Coverage for CHIP eligible children with private or group

insurance

    CHIP Medicaid Expansion and Stand-Alone Program (dental services are as described above)

            State Program Name:

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 

OR

Nationally Recognized Standard

        Name and Description:

Recommended Age for First Oral Health Examination:

Preventive Services:

Cleanings

1. Recommended frequency:

2. Exceptions:

Fluoride treatments

1. Ages:

2. Recommended frequency:

3. Also provided by physicians: 

4. Also provided by hygienists: 

5. Exceptions:

Sealants

1. Ages:

2. Recommended frequency:

3. Exceptions:

  Oral hygiene instruction

1. Ages:

2. Recommended frequency:

  Space Maintainers

1. Limits:

2. Prior approval required:  Y/N

Diagnostic Services:

  Dental Examinations by Dentists

1. Recommended age of first visit:

2. Recommended frequency: 

3. Limits:

  Dental Screens and Other Services by Hygienists

1. Recommended frequency:

2. Limits:

  X-Rays

1. Limits:

Treatment Services:

Fillings

1. Silver amalgam: 

1. Limits:

2. Tooth colored composite: 

1. Limits:

  Crowns/Tooth Caps 

1. Stainless steel crowns: 

1. Limits:

2. Prior approval required:

2. Metal (only) crowns

1. Limits:

2. Prior approval required:

3. Metal/Porcelain crowns:

1. Limits:

2. Prior approval required:

4. Porcelain (only): 

1. Limits:

2. Prior approval required: 

  Root Canals (endodontics)

1. Root canals on baby teeth (Pulpotomies):

1. Limits:

2. Prior approval required: 

2. Root canals on permanent teeth:   

1. Limits:

2. Prior approval required: 

  Gum (periodontal) Therapy

1. Limits: 

2. Prior approval required: 

  Dentures

1. Partial dentures: 

1. Prior approval required:

2. Complete dentures: 

1. Prior approval required: 

  Retainers (orthodontic)

1. Limits:

  Bridges

1. Limits:

2. Prior approval required: 

  Implants:

1. Criteria:

  Oral Surgery

1. Simple extractions:  

1. Limits:

2. Prior approval required:

2. Surgical extractions:

1. Limits:

2. Prior approval required:

3. Care of abscesses: 

1. Limits:

2. Prior approval required:

4. Cleft palate treatment: 

1. Limits:

2. Prior approval required:

5. Cancer treatment: 

2. Limits:

3. Prior approval required:

6. Treatment of Fractures: 

1. Limits:

2. Prior approval required:

7. Biopsies:

1. Limits:

2. Prior approval required: 

  Treatment of Jaw Joint (TMJ)

1. Criteria:

2. Prior approval required: 

  Braces (Orthodontia)

1. Criteria:

2. Prior approval required: 

3. Payment if eligibility lost: 

  Emergency Room Services

1. Identify services:

2. Criteria:

  In-patient Hospital Services

1. Criteria:

2. Prior approval required: 

  Special Anesthesia

1. Criteria:

2. Prior approval required: 

Excluded Services

1. Identify services:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1065. The time required to complete this information collection is estimated to average 40 quarterly hours and 20 hours annually per response, including the time to review instructions, search existing data resources, gather the data needed, and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to CMS, 7500 Security Boulevard, Attn” PRA Reports Clearance Officer, Mails Stop C4-26-05, Baltimore, Maryland 21244-1850.