Coverage for Dental Implants?

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Implant coverage for Medi Cal – Medicare Medicare Advantage with SCAN.

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• Summary for PPO Enhanced 

• Sorry to say but here is generally No coverage for implants.   
  • Medi – Cal generally does not cover implants. 
  • Nor does Medicare.
  • Check out alternatives to Implants    Like Dentures.
• However, check out  Dental for Everyone  and Quotit they have plans that will cover implants!  Remember though, there is no free lunch.  Insurance Companies have to take in more money in premiums than the pay in claims…  MLR Medical Loss Ratio and all.
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  • Delta Dental No Wait plan and
  • Renaissance Dental Max Choice Plan
    • renaissance benefits.com
• Check out Medicare Advantages plans – some may offer $400/quarter that rolls over quarterly, but not annually and may also offer “essential extra’s” like a $500 flex card
  • Blue Cross Dual Medi Medi Medicare Advantage Plan offers a $4k allowance for implants See page 82 of the EOC Evidence of Coverage.
    • See our webpage on Anthem Blue Cross Medicare Advantage Plans
  • Dental Benefits in Medicare [Advantage]  and Medi-Cal  Fact Sheet  DCHS.CA.Gov 
• Dentists Are Pulling ‘Healthy’ and Treatable Teeth To Profit From Implants, Experts Warn   CA Health Line  11/2024
• Researchers in Japan Discover Medicine Capable of Regrowing Third Set of Teeth for Humans   Dentistry Today  4/2025
• How to Get Dental Implants Covered by Medical Insurance   Peak Dental.com

Medical Loss Ratio 80% Claims - 20% Operating Costs & Profit

Image from BCBS.com

Steve's Explanation of MLR Medical Loss Ratio

More Video's 

• Kaiser Health News - Medical Loss Ratio
• Department of Managed Health Care on MLR in Affordable Care Act
• White House – YouTube Channel on Health Care Reform
• Tom Petersen Insurance 101 History of Lloyds to present  EXCELLENT!!!
• Our Webpage on MLR & Actuarial Value 

FAQ’s Medi Cal & Dental #Implantsx

• “OFFICIAL” explanation from Medi Cal on how implants are covered or not?
  • A Medi-Cal member is eligible for dental services provided by the Medi-Cal Dental Program.  Eligibility for benefits is determined by the member’s local county social services office and reported to the State of California.  The State, in turn, issues a Medi-Cal Benefits Identification Card (BIC) to members who are eligible for Medi-Cal Benefits. Limitations or restrictions of dental services may apply in certain situations.
  • Medi-Cal offers a broad base of dental benefits, please refer to SmileCalifornia.org for information about Medi-Cal’s dental benefits.
  • With respect to your specific question regarding full mouth implants, implant services are a benefit only when exceptional medical conditions are documented, and those conditions are reviewed by the Medi-Cal Dental Program for medical necessity (as defined by law) for prior authorization.  Some of those exceptional medical conditions are:
    • Cancer of the mouth requiring extensive surgery such that a conventional denture can no longer be worn.
    • A skeletal deformity that precludes the use of a conventional denture.
    • Traumatic destruction of jaw, face or head which makes a conventional denture impossible to wear.
      • SAMPLE clinical bulletin
  • Furthermore, single tooth implants are not a benefit of the Medi-Cal Dental Program. If the member has an exceptional medical condition, the assigned dental and medical providers will need to get together and fully document the medical and dental needs in writing.
    • Providers shall submit a complete case documentation (to include such items as radiographs, scans, operative reports, craniofacial panel reports, diagnostic casts, intraoral/extraoral photographs and tracings) necessary to demonstrate the medical necessity of the requested implant services.
      • If the member has existing dentures that do not fit, there are ways to modify them (such as tissue conditioners and relining them) to aid in their retention. This is a conversation the member will need to have with their regular dentist.  Modification of existing dentures and even fabrication of new dentures (a benefit once in a five-year period) are benefits of the Medi-Cal Dental Program with prior approval.

  • Monique Garcia

    Chief of Provider and Beneficiary Services Section

    Medi-Cal Dental Services Division

• Denti Cal – Medi Cal Member Handbook.  I
  • The Denti-Cal provider handbook does mention Implants, so I guess it’s covered. I suggest you ask your dentist. Your question is beyond my pay grade! (Zero, as Medi Cal doesn’t pay agents)These are the “codes” in the provider manual that related to implants:
    • • • Implant ServicesD6010, D6040, D6050, D6053, D6054, D6055, D6056,D6057, D6058, D6059, D6060, D6061, D6062, D6063,D6064, D6065, D6066, D6067, D6068, D6069, D6070,D6071, D6072, D6073, D6074, D6075, D6076, D6077,D6078, D6079, D6080, D6090, D6091, D6094, D6095,D6194, D6199See also Dental Economics.com
  •  justice in aging.org/
    • “Single tooth implants are not a benefit of the Medi-Cal Dental Program” Some legal advocates have attempted to make compelling medically necessary arguments, and the provider manual allows for that “Implant services are a benefit only when exceptional medical conditions are documented and shall be reviewed for medical necessity.”But generally speaking not a benefit and not one we want to promote as available to Medi-Cal beneficiaries since they are so limited. they pointed out this section in the provider handbook:
    • Implant Services General Policies (D6000-D6199)a) Implant services are a benefit only when exceptional medical conditions are documented and shall be reviewed by the Medi-Cal Dental Program for medical necessity for prior authorization. Exceptional medical conditions include, but are not limited to:
      • i) cancer of the oral cavity requiring ablative surgery and/or radiation leading to destruction of alveolar bone, where the remaining osseous structures are unable to support conventional dental prostheses.
      • ii) severe atrophy of the mandible and/or maxilla that cannot be corrected with vestibular extension procedures or osseous augmentation procedures, and the patient is unable to function with conventional prostheses.
      • iii) skeletal deformities that preclude the use of conventional prostheses (such as arthrogryposis, ectodermal dysplasia, partial anaodontia and cleidocranial dysplasia).
      • iv) traumatic destruction of jaw, face or head where the remaining osseous structures are unable to support conventional dental prostheses.
        • b) Providers shall submit complete case documentation (such as radiographs, scans, operative reports, craniofacial panel reports, diagnostic casts, intraoral/extraoral photographs and tracings) necessary to demonstrate the medical necessity of the requested implant services.
        • c) Single tooth implants are not a benefit of the Medi-Cal Dental Program.
        • d) Implant removal, by report (D6100) is a benefit. Refer to the procedure for specific requirements.They also told me about this guide for dental care for older adults
    • Do you have Medicare?  We could look into MAPD Medicare Advantage plans that might offer implant coverage or a quarterly spending account that could be used for implants?
• Not in CA   NAHU National Assoc. of Health Underwriters Agent finder,   of course try your EOC evidence of coverage or the SHIP State Health Insurance Assistance Program finder 
• alternatives to Implants?
• See our FAQ and comments section below for more FAQ’s or to ask a question

Medical Tourism

We are not advising or recommending.   We just have an expansive website.

• medical tourismco.com/dental-implants-in-mexico
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• npr.org/a-reason-to-smile-mexican-town-is-a-destination-for-dental-tourism
• Go Fund Me???    Cheyenne’s Journey to Dental Implants  $28,685 raised of $38,000 goal • 1.2K donations
•  health check box.com/
  • world’s most trusted medical tourism company