What Dental Procedures Are Covered By Illinois Medicaid?

As one of the better states for dental care in the country, Illinois Medicaid covers a range of dental procedures for kids and adults. However, the best way to know for sure is simply to ask your dentist (or your plan provider) about coverage. Smile League is here for you — we’ll do everything we can to help you get access to the dental care that you and yours need. Our Joliet family dental practice has plenty of experience with a wide range of insurance, Medicaid plan managers, and standard Illinois Medicaid. We even have some interest-free financing options for things that aren’t covered.

Understanding Illinois Medicaid

Illinois Medicaid can be confusing, even if you have had it for a while. Some people avoid going to the dentist just because they’re not sure if they have coverage. Especially for kids, most of the things you need are covered. Others have different ways to pay that you can probably afford. Our team is here to help you — our Joliet neighbors — figure out how to get the care you need for you and your family.

You’ll find a long list on our website of all the Medicaid versions our office handles. If you don’t want to read through it, that’s fine too. All we will need is your credentials, and we can confirm everything before we get started. You can even contact us to confirm coverage beforehand if you’re somewhere else in Chicagoland — or if you just don’t have time to stop by. The whole process should only take a few minutes, and then you’ll know.

Dental Procedures Covered By Illinois Medicaid

Illinois Medicaid offers a comprehensive range of dental procedures, particularly for children and medically necessary care for adults. The specific coverage can vary significantly based on factors such as the recipient’s age, dental condition, and the type of Medicaid plan they are enrolled in. Dental benefits are administered through both fee-for-service and managed care models, with major providers including DentaQuest and Blue Cross Community Health Plans. Coverage is more extensive for children and pregnant individuals, while adult benefits tend to be more limited unless there is a clear medical necessity.

Dental Coverage for Children and Young Adults

Under Illinois Medicaid, children and young adults under the age of 21 are entitled to comprehensive dental coverage as part of the federally mandated Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program. This program ensures that eligible children receive necessary dental services that promote long-term oral health. The services covered for this age group include, but are not limited to:

• Preventive Care – Routine dental exams, teeth cleanings, application of fluoride treatments, and dental sealants designed to prevent cavities.
• Diagnostic Services – Essential services such as X-rays to assess dental health, as well as thorough oral evaluations to identify any issues early.
• Restorative Care – Treatments including dental fillings to repair cavities, crowns to restore the shape of damaged teeth, and root canals to treat infected tooth roots.
• Oral Surgery – Procedures such as extractions and minor surgical interventions that may be necessary for dental health.
• Orthodontics – Coverage for braces is available if they are determined to be medically necessary, such as in cases of severe malocclusion (misalignment of teeth).

Children who are enrolled in the Illinois All Kids program or other Medicaid plans can access these services with minimal out-of-pocket costs, especially when they choose in-network dental providers.

Adult Dental Coverage

Adults aged 21 and older under Illinois Medicaid are eligible for basic dental services, but the coverage provided is more limited compared to that for children. Typically, Illinois Medicaid covers the following for adults:

• Preventive Care – Routine dental exams and cleanings, usually limited to two visits per year, aimed at maintaining oral health and preventing further issues.
• Diagnostic Services – Necessary services such as X-rays and oral evaluations to identify and diagnose dental problems.
• Restorative Care – Standard treatments such as dental fillings and limited coverage for crowns that restore tooth function.
• Extractions – This includes both simple and surgical removal of teeth that are damaged or problematic.
• Dentures and Partials – Coverage is available for full and partial dentures, but prior authorization is generally required.

Notably, more complex procedures like root canals, periodontal treatments, and dental implants are typically not covered unless they are deemed medically necessary. For instance, if a patient struggles to wear dentures due to significant bone loss or other oral deformities, implants may be considered—provided that sufficient medical documentation is submitted for approval.

Enhanced Coverage for Pregnant Individuals Illinois Medicaid recognizes the crucial link between dental health and pregnancy outcomes, offering enhanced dental benefits specifically for pregnant individuals. The expanded coverage may include services such as:

• More Frequent Cleanings –  Pregnant women can receive dental cleanings at increased intervals throughout their pregnancy to maintain oral health.
• Periodontal Evaluations and Treatment – Comprehensive assessments of gum health are essential during pregnancy, and appropriate treatments are covered.
• Emergency Dental Care – Pregnant individuals have access to emergency dental services, ensuring that urgent dental issues can be addressed promptly.

These benefits are not only available throughout the duration of the pregnancy but extend for 60 days postpartum, further supporting the health of new mothers during their recovery period.

What Constitutes “Medically Necessary” Dental Care?

In certain circumstances, Illinois Medicaid may approve dental procedures that are not typically covered, provided that they are classified as medically necessary. Examples of such situations include:

• Dental Care Required Prior to Organ Transplants or Cancer Treatments – Dental health is crucial for patients undergoing major medical procedures, and necessary treatments may be covered.
• Procedures Needed to Treat Infection, Pain, or Nutritional Impairment – This category includes interventions to address severe dental issues that might affect overall health and well-being.
• Oral Surgery for Trauma or Congenital Conditions – Necessary surgeries to correct congenital dental anomalies or to treat trauma-related injuries may be covered.

To have these procedures considered, dental providers must thoroughly document the medical necessity and submit prior authorization requests to the Illinois Department of Healthcare and Family Services (HFS) or the managed care organization overseeing the patient’s plan.

How to Access Covered Dental Services

For Illinois Medicaid recipients seeking to utilize their dental benefits, the following steps are recommended:

1. Choose a Medicaid Dental Plan – Select from available options like Aetna Better Health, Molina, or BCBSIL.
2.  Find an In-Network Dentist – Use your plan’s provider directory to locate a participating dentist.
3. Schedule Preventive Visits – Regular dental visits are essential not only for oral health maintenance but also for maintaining eligibility for enhanced services.
4. Request Prior Authorization – For complex treatments such as dentures or oral surgeries, ensure that proper prior authorization is obtained to avoid unexpected costs.

While a referral from a primary care provider is not required to see a dentist, it’s important to be aware that some advanced services may necessitate pre-approval.

Tips for Maximizing Your Dental Benefits

To make the most of your Illinois Medicaid dental coverage, consider these practical tips:

• Keep Contact Information Updated – Ensure your Medicaid plan has your most current contact details to avoid communication issues.
• Attend Regular Cleanings and Exams – Consistent visits help in preventing dental complications that could lead to more extensive treatments.
• Discuss Coverage with Your Dentist – Before undergoing treatment, ask your dentist to clarify what procedures are covered under your plan, as this can help avoid unexpected expenses.
• Utilize Online Portals – Platforms like DentaQuest provide easy access to manage your appointments and benefits, which can streamline your experience.

Illinois Medicaid offers a robust package of dental coverage for children, while adults receive essential but limited services. Medically necessary procedures may be approved with adequate documentation, and pregnant individuals benefit from expanded services. Understanding the specifics of your plan, alongside proactive communication with healthcare providers, ensures that you receive the necessary dental care while maximizing your benefits.

Get Some Personal Advice on Illinois Medicaid Dental Coverage

When it comes to dental procedures, we are talking about a very personal thing. This is your set of teeth, and any work you do should fit your personal needs. An appropriate procedure for someone else might not be the right one for you. If you’re ready to get started, please come by for a consultation. We’ll help you understand your options — both in terms of treatment and in terms of getting the most out of your Illinois Medicaid coverage.

 Contact Smile League Dental to discuss our dental implant service in Joliet at 815-782-6243 and take the next step toward your dream smile. We also serve the communities of Bolingbrook, Crest Hill, Lockport, New Lenox, Shorewood, Elwood, Romeoville, Homer Glen, Plainfield, and, Channahon