NYC Department for the Aging, Planning Division, Program Development
3 | P a g e
Mainstream Medicaid (Fee-for-Service)
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Roughly 6.5 million New Yorkers are enrolled in Medicaid, with approximately 32 percent in the
mainstream fee-for-service (FFS) program.
The New York State Medicaid Program – which provides
health insurance coverage for low-income individuals, families, children, pregnant women, elderly, and
people with disabilities – offers limited coverage of only essential, but not comprehensive, dental care.
Individuals with mainstream Medicaid are not required to pay a premium for their insurance, and do
not have co-pays for services provided at a dentist (e.g., x-rays).
According to New York State regulations (§18 CRR-NY 506.2)
, dental care covered under Medicaid
only includes “preventive, prophylactic and other routine dental care, services and supplies, and dental
prosthetic and orthodontic appliances required to alleviate a serious health condition.”
Examples of
covered services include emergency care, acute infection, and extraction of infected or non-restorable
teeth. Although services are covered, there is a limit to the number of times a member can receive
the service in a year. Dental prophylaxis and oral exams will be covered once per six month period.
In addition, effective November 12, 2018, dentures may be replaced prior to eight years after initial
placement, and dental implants will be covered, assuming prior approval and supporting
documentation (i.e. letters, x-rays) have been obtained from both the dentist and primary care
physicians to explain the medical necessity.
Medicaid Managed Care (MMC)
Of the 6.5 million New Yorkers enrolled in Medicaid, about 68 percent are enrolled in Medicaid
Managed Care, which allows beneficiaries to have their care managed through private health insurance
plans such as Healthfirst, Aetna, and Empire BlueCross BlueShield.
These health plans usually
require enrollees to access care through their own network of providers and often contract with other
vendors (e.g., Healthplex or Dentaquest) to administer their dental benefit. Since 2012, all Medicaid-
covered dental services are also covered by Medicaid managed care programs.
As with regular
Medicaid, there is no monthly premium, although an individual may have a co-pay that is paid directly
to the provider at the time of service. Depending on the plan, some services may require prior
approval and documentation before care can be received.
Table 1. Dental Coverage under Government Insurance Plans
Federal insurance program for adults
aged 65 and older covering health
services.
Limited to what is needed for
hospitalization and when it is needed to
treat a non-dental condition.
Also known as Medicare Part C,
Medicare-covered services are
coordinated by a private health
insurance plan. There are currently 44
different plans offered in New York
City.
Dental coverage and limits vary with
plan.
Federal-state insurance program for the
poor, elderly and disabled.
Covers preventive, routine, and
acute/emergency dental care, with limits.
Medicaid-covered services are
coordinated by a private health
insurance plan. There are currently 11
different plans offered in New York
City.
Includes all Medicaid-covered dental
services.