An official State of Texas website.
Revision 21-2; Effective March 10, 2021
Dental services are those services provided by a dentist to preserve teeth and meet the medical needs of the member. Dental services must be provided by a dentist licensed by the State Board of Dental Examiners and enrolled as a Medicaid provider with Texas Medicaid & Healthcare Partnership (TMHP). The managed care organization (MCO) service coordinator arranges the needed dental services for STAR+PLUS Home and Community Based Services (HCBS) program members with licensed and enrolled dentists.
The MCO must discuss with the STAR+PLUS HCBS program member any available resources to cover the expense of dental services and consider those resources before authorizing dental services through the STAR+PLUS HCBS program. If dental services are on the individual service plan (ISP), the MCO must authorize and coordinate a referral to a dental provider within 90 days of request by the member, unless there is documentation that the member requested a later date.
8510 Allowable Dental Services
Revision 21-2; Effective March 10, 2021
Allowable dental services include:
- emergency dental treatment procedures necessary to control bleeding, relieve pain and eliminate acute infection;
- preventative procedures required to prevent the imminent loss of teeth;
- treatment of injuries to the teeth or supporting structures;
- dentures and the cost of fitting and preparing for dentures, including extractions, molds, etc.; and
- routine and preventative dental treatment.
The managed care organization (MCO) must ensure dental requests meet the criteria for allowable services before authorizing services, except in an emergency situation. Dental services are provided by the STAR+PLUS Home and Community Based Services (HCBS) program when no other financial resource for such services is available and when all other available resources are exhausted, with the exception of value-added services (VAS). VAS are not required to be used prior to STAR+PLUS HCBS program dental benefit. VAS vary by MCO.
Texas Health and Human Services Commission (HHSC) allows a member to select a relative or legal guardian, other than a spouse, to be the member’s provider for this service if the relative or legal guardian meets the requirements to provide this type of service. Payments for dental services are not made for cosmetic dentistry.
The annual cost limit of this service is $5,000 per individual service plan (ISP) year. The $5,000 cost limit may be waived by the MCO upon request of the member only when the services of an oral surgeon are required.