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Provider Manual

Dental/Oral Surgery Benefits

Last Updated on January 24, 2019

There are two levels of dental benefits offered. They are listed below:

Level I – Benefits when using a Family Health Center dental center provider

General dentistry services: Services received using a Family Health Center dental center provider are covered at the same benefit level as the state Medical Assistance program. Members will not have any out-of-pocket expenses for covered dental services.

Examples of covered services include:

  • Diagnostic – exams, X-rays (frequency limits apply)  
  • Preventive – cleanings, fluoride, sealants (age and frequency limits apply – different for adults and children) 
  • Restorative – fillings (amalgam or resin) stainless crowns (upgraded crown typically not covered – different for adults and children) 

Level II – Benefits when care is provided by a contracted dental provider other than a Family Health Center dental center provider

Services for adults:

  • Oral Surgery (limited): Services received by a contracted provider are covered at 100 percent (some services are subject to prior approval). Exclusions apply
  • Extraction of erupted tooth: Covered at 100 percent (includes exams and X-rays related to extractions
  • Dental accidents (excluding chewing accidents): Covered at 100 percent for approved services on sound natural teeth up to one year from date of accident (accidents must occur while a Family Health Center member and coverage must be continuous throughout treatment period).
  • Cleaning and fluoride treatment: Covered at 100 percent

Services for minors (17 years of age or younger):

Oral examination: Services received by a contracted provider are covered at 100 percent. 

  • Full mouth X-rays 
  • Pulp treatment  
  • Pulp cap 
  • Amalgam fillings 
  • Resin restoration 
  • Sealants 
  • Stainless steel crowns 
  • Cement base 
  • Root canals 
  • Space maintainer (band loops) 
  • Space maintainers (lingual arches) 
  • Re-cement bands 

Dental exclusions and limitations 
Alveoloplasty, dentures, dental implant services, periodontia surgery, root canal, TMJ (temporomandibular joint) dysfunction treatment (except for surgical services performed by an oral surgeon), orthodontic braces, chewing accidents, or services not specifically listed as benefits are not covered. Any services in preparation for these services are not covered when using a contracted provider.

Note: There may be exceptions when services are provided at one of Family Health Center’s dental centers.

Call Family Health Center Customer Service at 1-800-942-5420 with questions.