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Coverage for Dental Implants?

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What are Dental #Implants?

Dental implants (ADA Codes) may be thought of as artificial tooth roots which allow the fabricated teeth to be firmly attached to the mouth.  One may consider the jaw bone as a piece of wood and a dental implant as a screw

Learn more from REAL Dentists:

Write implants off your Taxes – using Health Savings Accounts

The average cost of placing a single dental implant ranges from $1,600 to $2,200, not including the cost of a restoration. Redd Road *

Implants may be covered under health insurance, if there is a “medical necessity” like cancer, major accident or skeletal deformity.  View sample Delta policy page 40 #32.

You can include in medical expenses the amounts you pay for dental treatment. This includes fees paid to dentists for X-rays, fillings, braces, extractions, dentures, etc.   including artificial teeth (IRS Publication 502 Page 5 & 7)

Implants are done when one doesn’t want a bridge because it more permanent and look better even in the back of the mouth and in view of this it’s considered cosmetic.

Unfortunately, implants are not generally a covered benefit. However, it is possible that Delta would provide an allowance for the covered benefit. It’s best that the enrollee ask their dentist to submit a pre-determination to Delta so that Delta can determine the covered benefit (if any) and the enrollees responsibility for payment in advance.  Alternatives for Implants

Limitations:

The replacement of lost or stolen dentures, crown and bridge work, dental procedures and charges incurred as part of implants (placement or removal) and prosthetic devices placed on implants (fixed or removable, for example: bridges, crowns) are not covered.  Smile Saver Brochure

Implants

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Blue Shield Small Group Dental  Plans – Dental Implant Explanation

Alternatives for Implants  

Dental For #Everyone,
has an excellent  website with full brochures, Instant online quoting and enrollment

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Delta Dental – Covered CA Plans 

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#Delta1 Dental No Wait

  • Delta Dental offers implant coverage for both groups and individuals:
    • Group-sponsored Delta Dental PPO™ plans vary and may include implant coverage.
    • Groups with DeltaCare® USA coverage can choose the i‑series plans for comprehensive implant coverage.
    • For individuals, the Delta Dental PPO Premium Plan covers implants at 50%, after a 12-month waiting period.

 

Delta No Wait

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Liberty Dental Plan!
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Liberty Dental DHMO (Dental HMO) plan features large group type benefits, for individuals and families.

 Benefits Include: 

No Annual Maximums, No Claim Forms, Coverage for Pre-Existing Conditions, No Waiting Periods, Orthodontia, Dental Implants and More. 

More information 

#Understanding Medicare Advantage Plans (PDF) #12026

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Insurance Companies get a fee from the Federal Government, when you enroll in an MAPD plan.  MAPD Plans must cover all A & B services Medicare.Gov *

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FAQ’s Medi Cal & Dental #Implantsx

 

  • Do you have an “OFFICIAL” explanation from Medi Cal on how implants are covered or not?
    • Hi Steve,
    • 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.
    • 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.

    • Thank you,

      Monique Garcia

      Chief of Provider and Beneficiary Services Section

      Medi-Cal Dental Services Division

  • Can I get implants from iehp? Medi Cal? Denti-Cal?
      • I’m In need for dental implants and am low income. Two pair of dentures that don’t fit properly. Can’t chew food without teeth.
    • REPLY
      • See below or to the right  for the Denti Cal – Medi Cal Member Handbook.  I’ll grant, that I don’t see on that page anything about implants, so here’s our research.
      • Here’s why I don’t like to guess or answer questions on the phone. I checked with justice in aging.org/ and said
        • “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 quartley spending account that could be used for implants?
  • I’m not in CA.   Can you help me with questions on Medicaid or Medicare Advantage plans in my state.
  • 1. Searching for a reasonable rate plan for bone grafting…?
    2. How does dental cal, provide for patients that need bone grafting before implants…?

     

  • What Type of Dentist Should I See for Dental Implants?
  • See our FAQ and comments section below for more FAQ’s or to ask a question

 

#Alternatives to Implants

 

Gum Disease Treatment

If you have a tooth that is loose and may be “hopeless,” it might still be saved with gum disease treatment . If the gums are receding and there has been bone loss around the tooth, that doesn’t mean that the tooth is guaranteed to be lost.

With gum disease treatment, we can clean out the infection around your tooth, and hopefully the tooth will heal. Sometimes we might splint the loose tooth or teeth to natural teeth that are stable. This can help stabilize the loose teeth and give them time to heal. Then you’ll still have your natural tooth for longer, potentially the rest of your life. This costs significantly less than a dental implant. And Pinhole ® Gum Therapy can be used to restore the natural contour of your gums.

Caveats: For a tooth that is designated “hopeless,” the success rate is lower than that for dental implants. And because we’re preserving your natural tooth, it will continue to look as it had, so if you’re unhappy with the appearance of this threatened tooth, it might not be the best choice. Plus, sometimes the infection is so serious that we want to remove teeth to better control the risk that the infection could spread to other parts of your body.

 

Root Canal Therapy

 

If your tooth is threatened by an infection inside the tooth, we can use  root canal therapy to clean out the tooth and make it stable again. The tooth will be reinforced and topped with a dental crown . The success rate for root canal therapy is comparable to that for dental implants, and it has the benefit of retaining your natural tooth. Plus the dental crown means that the appearance of the tooth will be improved, too. If you later need to replace the treated tooth, you will usually be able to get a dental implant, and in the meantime, you get to enjoy the benefits of having a natural tooth rather than an implant. Cost is slightly less than for a dental implant.

Caveats: Whether a root canal is appropriate or not depends on the state of your tooth. If the tooth root is damaged, a root canal is not recommended. Sometimes an infected tooth can be a serious risk and needs to be extracted right away. Extraction is best for badly damaged or seriously infected teeth.

 

Dental Bridge

 

If you can’t save the tooth with either gum disease treatment or root canal therapy, you can often get a dental bridge that will perform the same function as a dental implant. With a dental bridge, the replacement tooth is supported by dental crowns on teeth next to the missing tooth.

Dental bridges are fully fixed in your mouth. They’re not loose and won’t slip out, so your diet won’t be impacted, and they can look as good as dental implants. Plus the dental crowns on neighboring teeth can be very helpful if they have been damaged.

Caveats: Dental bridges don’t stimulate your jawbone and gums the way a dental implant does. This may not matter, but it can potentially cause collapse of the gums under the replacement tooth. And if the supporting teeth aren’t fully healthy and strong, they may be put at risk by having a dental bridge placed over them. That’s because two teeth are now being asked to do the work of three. Because of this restriction, we only recommend dental bridges in limited situations where they don’t cause much increased risk to your natural teeth.

 

What about #Dentures  ?

 

The Denture Fountain of Youth®, which replaces all your natural teeth. This type of denture looks natural and encourages better biting and chewing function. While not as good as implant-supported dentures, they are close.   Kuzma *

Experts say 90% of patients with complete tooth loss opt for dentures.  Ivy Rose *

 

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Medi Cal renewal form mc 216

MAGI - Medi Cal Renewal Form - MC 216

 

You'll be getting the MAGI Medi Cal Renewal Form - MC 216 (ONLINE pdf)  soon, say  March 2023  Cal Matters * CMA Docs.org * hhs.gov * , when the COVID Public Health Emergency ends.  During COVID you couldn't be terminated, from Medi Cal  Disability Rights * Footnotes * .

VIDEO Explanation Kaiser

The renewal is usually automatic and done through the Federal Hub.  So, if you get the MC 216 form, that means Medi Cal couldn't automatically renew you. So you have to fill out the form or risk losing your coverage.

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FAQ’s

Medical Necessity #Orthodonture

 

  • QUESTION I was born without my upper lateral incisors so I guess that would b considered  congenital Maxillofacial deformity. It’s the tooth next to my two front teeth on both sides.
    • I’m 37 Caucasian female and I currently have medi cal.
    • I’ve worn a Hawley retainer for about 20 yrs.
    • It has been a real struggle the whole time with it breaking and having to go days and at one point 18 months with missing teeth near the front of my mouth. It has caused me severe self consciousness, distress, trauma, anxiety, depression. I avoid social gatherings where eating in public settings together which is 96% of the time.
    • Have u heard of this type of dental issue before?
    • And can u point me in the right direction with more information about medically necessary billing coverage for my particular issue.
    • And I already know I’d have to pay for bones grafting out of pocket.
    • But my mom thinks maybe some type of implant secured denture would be cheaper but I don’t think that would apply to my needs due to I have all my other teeth minus a molar on the bottom of both left and right sides of mouth.
    • I appreciate any help as this is the worst thing I’ve struggled with my whole life and had severe trauma in life that has impeded my ability to obtain proper permanent treatment.
  • Answer  Here’s the research, but it’s way beyond my pay grade to give you any real direction.  Check with your dentist and here’s the phone # for Denti Cal – Smile CA  1-800-322-6384 Here’s the Medi Cal Ombudsmans website  No, I’ve never had this type of question before.
  • Our main webpage on Medical Necessity
  • Medically necessary orthodontic treatment is orthodontic treatment that is rendered by an orthodontist or pediatric dentist to satisfy a demonstrated need for significant functional improvement of the teeth, jaws or related anatomy and is not rendered primarily for esthetic improvement.
  • In order to demonstrate need for significant functional improvement, a patient must present with one or more of the following general conditions that can be definitively diagnosed (using generally accepted clinical standards) to be directly related to their malocclusion or jaw relationship:
    •  Severe impairment of oral function
    •  Chronic moderate pain or chronic severe pain that cannot be adequately managed through alternative treatments.
    •  Traumatic injury to the orofacial structures that requires reparative treatment with orthodontic appliances.
    •  Craniofacial anomaly or systemic disorder involving the dentition (see list).
    •  A malocclusion which, if left untreated, substantiates a prognosis of:
      • o Premature loss and/or severe debilitation of an essential tooth or teeth
      • o Severe debilitation of the dentition, periodontium, and/or temporomandibular joint(s).
      • o A sustained or deteriorating condition that in an advanced state will no longer be treatable through orthodontic means alone and that, in an advanced state, will require more invasive or complicated treatment such as orthognathic surgery.
  • Furthermore, medically necessary orthodontic treatment should be prescribed within generally accepted standards of orthodontic practice (evidence-based when possible).  Read More Medically Necessary Orthodontic Treatment Med Mutual

28 comments on “Dental Implants – Denti Cal – Coverage?”

  1. I was born without my upper lateral incisors so I guess that would b considered congenital Maxillofacial deformity. It’s the tooth next to my two front teeth on both sides.

    I’m 37 Caucasian female and I currently have medi cal.

    I’ve worn a Hawley retainer for about 20 yrs.

    It has been a real struggle the whole time with it breaking and having to go days and at one point 18 months with missing teeth near the front of my mouth. It has caused me severe self consciousness, distress, trauma, anxiety, depression. I avoid social gatherings where eating in public settings together which is 96% of the time.

    Have u heard of this type of dental issue before?

    And can u point me in the right direction with more information about medically necessary billing coverage for my particular issue.

    And I already know I’d have to pay for bones grafting out of pocket.

    But my mom thinks maybe some type of implant secured denture would be cheaper but I don’t think that would apply to my needs due to I have all my other teeth minus a molar on the bottom of both left and right sides of mouth.

    I appreciate any help as this is the worst thing I’ve struggled with my whole life and had severe trauma in life that has impeded my ability to obtain proper permanent treatment.

    Reply

  2. My front teeth several are missing and it’s hard to get a better job because I’m working out in public my career and my occupation holds me up because of my missing teeth .

    Ty so much for your time.

    Sincerely , Samantha

    Reply

  4. Need some teeth to eat. But only have medi- cal to cover cost?

    A bad choice I made. Went to a “free dental”, but got left with no teeth on top and was schedule for more mis-treatment that following week.

    Went back and the team had left.

    F**k! I’m just looking for a way to enjoy meals. Like, apples, peanuts, corn on the cob, etc. etc. I have suffered for years and hope for a solution.

    If not please just say so.

    Thank you for your time. Sincerely, Larry.

    Reply

  5. I have medi-cal.. I have dental implant posts which I paid for on my own . One of my bridge crowns fell out and was lost . will medi-cal cover all or part of that bridge/crown?

    I want the snapped in dentures. I have (medi-cal,medicare a. b. C.)
    And kaiser Medi-cal

    I need urgent APPOINTMENT

    Reply

  6. I have medical community health I received dental implants which I paid for previously I’ve lost a bridge crown that strings from one implant post to another. Can my medi-cal cover all or part of that bridge / crown?

    Reply

  9. I’m exploring supplemental insurance options with Partnership Health in ca http://www.partnershiphp.org/ for full mouth implants for myself and my husband.

    I have a full upper denture and partial lower, the implant sites were set at the time of tooth removal.

    My husband has extensive tooth decay, broken and missing teeth .

    Reply

  10. give Medicare the power to negotiate for lower drug prices, add new benefits to Medicare

    Adding dental, hearing and vision benefits to Medicare.

    Making new investments in home and community-based services to “help seniors, persons with disabilities and home care workers,”

    Extending a boost to ACA income-based subsidies that were included in the American Rescue Plan Act. The boosted subsidies are set to expire after the 2022 coverage year.

    https://www.fiercehealthcare.com/payer/framework-for-3-5t-senate-package-seeks-to-close-medicaid-gap-add-new-medicare-benefits-and

    Reply

  11. What if I need MAJOR, EXPENSIVE Dental work and don’t have coverage.

    Can I buy it now?

    What are best options to open – start a dental plan to reduce this out of pocket cost?

    Any restrictions such as waiting periods to obtain this care after purchasing a plan?

    Reply

  12. This is a FAQ from a page we culled from the website

    would be beneficial to me to switch to the enhanced 94 plan when I’m currently Under full scope of benefits Medi-Cal and denti-cal for about $7,000 worth of dental work that denti-cal won’t cover that needs to be performed?

    Are there any available plans Under The Inn at Silver 94 which offer Dental Care better than what is normally offered through denti-cal?

    Reply

    I really don’t know where you can get coverage for $7k worth of dental work. Most all plans I’ve seen limit coverage to $1k or $1.5k – $1,500/year.

    Silver 94 doesn’t have adult dental, other than if they call it medical services. See specimen policy page 72

    Check out Dental for Everyone or Covered CA’s dental program, which I believe you can get, even if you don’t have a health plan.

    What do you mean by “under the inn?”

    Reply

  13. Does iehp or Medi Cal insurance get me or cover implants?

    IEHP covered my cancer, my liver and copd

    can I get implants from IEHP? Medi Cal? Denti-Cal?

    *******

    I’m In need for dental implants and am low income. Two pair of dentures that don’t fit properly. Can’t chew food without teeth.

    Reply

      • I AM 44YO ON SSDI I AM HIV HEP C

        I HAVE 10 MISSING / CRACKED TEETH AND

        THIS DETRAMENTAL TO MY MEDICAL HEALTH WITH ALL RISKS INVOLVED BY NOT HAVING MEDICALLY NECESSARY IMPALNTS TO REPLACE MISSING OR CRACKED TEETH

        IT ALSO MAKES IT DIFFICULT TO EAT THUS I EAT LESS OR UNABLE TO EAT MEATS MAKING NUTRITION A HEALTH CONCERN ..

        I RECEIVE DISABILITY INCOME AND CAN NOT AFFORD THE 15,000-20,000 BILL FOR IMPLANTS

        I HAVE AETNA MEDICARE ADVANTAGE DENTAL AND HEALTH BUT ITS A JOKE ON HOW LITTLE THEY WILL COVER

        WHICH LEAVES ME WITH A MOUTH FULL OF BROKEN / CRACKED/ MISSING TEETH AND

        I DONT KNOW WHO TO ASK FOR HELP OR

        WHAT INDIVIDUAL DENTAL POLICY I CAN BUY TO HELP MYSELF SO I CAN BE ABLE TO EAT, LIVE A HEALTHY LIFE BECAUSE STATISTICS SHOW IF I DONT DO SOMETHING ABOUT THIS NOW OR SOON IT WILL DECREASE MY LIFE EXPECTANCY AND IVE ALMOST DIED SEVERAL TIMES SO FAR IN MY LIFE SO I VALUE A LONG LIFE EXPECTANCY

        SO IF YOU COULD HELP ME PLEASE OR DIRECT ME ON WHAT TO DO OR WHO TO TALK TO BECAUSE I FEEL SOO LOST NO ONE OFFERS SOLUTIONS OR OPTIONS

        ONLY THAT THE MAX COVERAGE ANNAULLY IS 1500 AND NO SOLUTION ON HOW TO COME UP WITH THE REST.

        I MISS EATING STEAK, PISTACHIOS, ETC..

        I HATE THAT I EAT VANILLA YOGART A LOT BECAUSE ITS WHAT I CAN EAT NOT THAT I LIKE IT OR ITS A FAVORITE BECAUSE ITS NOT.

        I JUST FEEL LIKE I CANT DO ANYTHING WITH IN REACH TO HELP ME

        SO THIS IS WHY I AM CONTACTING YOU WITH HOPES YOU HAVE A SOLUTION.

        PLEASE HELP ME. SO FAR NO ONE HAS BEEN ABLE TO AND I BEEN ASKING FOR 2 YEARS AND THE LONGER TIME GOES BY THE WORSE THINGS WILL GET AND IMPLANT OPTION BECOMES LESS OF AN OPTION WITH EVENTUAL MORE TEETH LOSS WICH MEANS THE GAW BONE MIGHT NOT EVENTUALLY BE ABLE TO ALLOW IMPLANT OPTION AND

        I DONT WANT TO WAIT THAT LONG

        WERE NOT THERE YET BUT EVENTUALLY IF NOT SOON IF SOMETHING ISNT DONE

        I DONT KNOW WHAT TO DO SO AGAIN

        I ASK OF YOU STEVE I AM A 44YO MALE ON SSDI MEDICARE ADVANTAGE PPO WITH DENTAL OPTION INCLUDED

        WHAT DO I DO? I LIVE IN SAN DIEGO xxxx3 IS MY NUMBER IT WORKS WHEN I CAN CONNECT TO FREE WIFI SO PHONE CONVERSATIONS HAVE TO BE SCHEDULED..

        I LOOK FOWARD TO YOUR HELP. KIND REGARDS, JOSEPH R

        Reply

    • I have Epilepsy and have been advised not to get dentures but recommend to only receive dental implants. I only have dental through Medi-Cal. I’ve received a quote of $50,000 to receive the implants that are needed. Will Medi-Cal pay for some or all the cost of my fee’s to receive the implants?

      Reply

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