Below is a summary of significant changes to the Medicaid dental benefit that became effective July 1, 2023. These changes are in response to statewide dental access challenges and are intended to expand access to dental care for all Vermont Medicaid members.
- Effective July 1, 2023, the reimbursement rates for Medicaid-covered dental services were adjusted to 75% of general regional commercial dental rates. This reimbursement methodology change represents an approximate 50% increase in reimbursement for dental services provided to VT Medicaid members. The adult annual cap on dental expenditures was increased to $1,500 to coincide with the updated rates. For overall equity and continuity across its full provider network, VT Medicaid continues to maintain one dental code rate schedule for all dental providers. The updated fee schedule and rate adjustments apply to both general and specialty dental providers. Visit the Vermont Medicaid Fee Schedule: http://www.vtmedicaid.com/#/feeSchedule.
- Vermont Medicaid will cover emergency dental services for adults aged 21 and older after the annual $1,500 cap on expenditures has been met. Emergency dental services are those that treat acute pain, infection, or bleeding and can be delivered in a dental office rather than an emergency setting. Medically necessary emergency dental service codes will be covered under the dental benefit and no longer need approval by the Department for Children and Families General Assistance (GA) Voucher Program. Medicaid members served in the Developmental Disabilities Waiver, or Community Rehabilitation and Treatment Program, members under age 21, and people who are pregnant or in the 12-month postpartum period, are not subject to the annual cap.
- The KX modifier should be added for billing at the end of each emergency procedure code submitted for adult members after the annual cap has been met. The covered codes are listed in section 9 of the Dental Supplement. This will allow the claim to be paid after the cap has been met.
- In addition to waiving the annual cap, Vermont Medicaid provides coverage for medically necessary denture services for Medicaid members served by the Developmental Disability Services (DDS) Waiver Program or the Community Rehabilitation and Treatment (CRT) Waiver Program. To find out whether Medicaid members you are treating are in these groups, call Gainwell Provider Services at 800-925-1706.
- For the DAIL DDS Waiver Program only, the CG modifier should be added for billing at the end of each procedure code submitted for adult members. This will allow the claim (which could also apply to medically necessary dentures) to be paid without utilizing the annual cap.
The above changes represent great news for all participating Vermont Medicaid providers and Vermont Medicaid members. As a reminder, since January 2020, adult members have also been able to use key preventative visit codes twice per year without affecting the adult cap (see list below):
- D0120 Periodic Oral Evaluation
- D1110 Adult Prophylaxis
- D1206 Topical Application of Fluoride Varnish
- Dl208 Topical Application of Fluoride
- Dl320 Tobacco Cessation Counseling
A co-payment does not apply to preventative dental visits and prior authorization for the codes listed above is not required. Additional services may be provided if deemed medically necessary and should include concise medical documentation that provides and supports clinical determination and evidence to support medical necessity for additional dental services. Such documentation should be evident in the medical record.
Detailed information for providers is available in the updated Dental Supplement https://dvha.vermont.gov/providers/manuals.