Dental and vision care can play a major role in a person’s overall well-being, but Medicaid may not provide coverage for certain procedures. It’s important to understand the standards of care for routine or medically necessary services under Medicaid.

Routine vs Medically Necessary Dental Care 

If your oral health is in good standing and you’re not experiencing any symptoms of tooth decay or gum disease, the American Dental Association recommends seeing a dentist once or twice a year for routine check-ups. During these check-ups, you may have x-rays taken of your teeth and you may receive a professional cleaning.

Regular visits like these help prevent damage and decay from occurring in the first place, but they can also help your dentist catch early signs of trouble before major issues have a chance to develop. Once significant damage, decay or disease is present, then you may require certain medically necessary procedures in order to prevent infection or tooth loss.

Emergency dental conditions include:

  • Loose, broken or chipped tooth (with or without pain).
  • Jaw or facial fracture or injury.
  • Pain or swelling in the gums or tongue.
  • Bleeding or discharge around decayed or broken tooth.
  • Lost or broken crown, dentures or bridges.

Some health conditions and medications can also negatively impact your oral health. Discuss any of these possible concerns with your oral healthcare professional so that your care plan can reflect your specific needs.

Unless someone suspects their vision is impaired, it’s unlikely they’ll seek out an eye exam on a regular basis, but it’s important to monitor your vision health so that any disease or deterioration can be detected early. Your need for vision care can change as you age, so yearly eye exams should continue as part of your routine healthcare plan.

The Centers for Disease Control and Prevention (CDC) notes that adults over the age of 60 experience an increased risk for developing glaucoma, which means they should receive a dilated eye exam at least every 2 years. Other age-related vision issues such as cataracts and macular degeneration are also concerns that should be factored into how frequently anyone over the age of 60 sees an eye doctor.

Medicated eye drops and corrective surgeries are the most common treatments for vision problems with chronic, clinically significant symptoms. When cataracts are present in both eyes, only one eye will be treated at a time in order to preserve the use of the other eye during recovery.

Emergency vision conditions include:

  • Sudden decrease in vision.
  • Infection or excessive discharge around the eyes.
  • Pain in the eyes or sockets.
  • Blurred or disrupted vision, like seeing flashes of light or floating specks.

Your healthcare professional should know about any family history with vision problems or if you have diabetes. These can both indicate an increased risk of developing vision problems.

Medicaid Coverage for Dental and Vision Care 

Medicaid is a program jointly funded by states and the federal government, but is administered by each state, so coverage rules for dental and vision care vary between states and the providers available in each state. In some areas, recipients may only be eligible for coverage if there is an emergency, such as an infected tooth in need of extraction or a vision problem that requires surgery to restore sight. Other states may provide a more comprehensive coverage plan that pays for routine care, such as yearly exams, dental cleanings and x-rays, in addition to certain emergency procedures.

These policies can change from year to year, which means you will need to check with your Medicaid provider to confirm what type of coverage you have for your dental and vision care needs. In certain cases, you may be able to discuss different types of treatment with your healthcare professional in order to find one that falls under your provider’s coverage guidelines.

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