Dental “Benefit Limit Exceptions” Process Simplified

Pennsylvania’s Department of Human Services (DHS) issued new guidance in April that simplifies the process for Medicaid recipients seeking dental care and benefits that are only covered if a benefit limit exception is approved. This change does not impact the underlying Medicaid dental benefit for adults – the services covered by Medicaid for adults is not changing – but streamlines the process for adult Medicaid recipients who have one or more of the following conditions: 

  1. Diabetes  
  2. Coronary Artery Disease (or risk factors for the disease) 
  3. Cancer of the Face, Neck, and Throat  
  4. Intellectual Disability 
  5. Current Pregnancy 

Under MA Bulletin 08-21-01, an adult Medicaid recipient with any of these diagnoses will no longer need to submit medical documentation to support the requestfor a dental “benefit limit exception.”  Under this streamlined process, the state Medicaid agency and Medicaid managed care plans will confirm the underlying diagnosis using the recipient’s claim history rather than requiring additional documentation from a medical provider.   

Dental benefit limit exceptions (BLEs) apply to people age 21 and older and are required for Medicaid to cover root canals, crowns, periodontal services such as “deep cleaning” of the gums, and dentures once a recipient has exhausted their “one set of dentures per lifetime” coverage.  A dental BLE is not needed for routine cleanings, x-rays, or exams (available every six months) or a first set of dentures.  To meet the dental BLE standard, a recipient typically must show that they have a “serious health condition” and that the dental service requested is necessary to avoid “rapid, serious deterioration of the health.”  This previous PHLP newsletter article discusses the dental BLE process and appeal rights in more detail.    

In April, state officials in DHS’ Office of Medical Assistance Programs explained that, under this streamlined process, identification of one of the five conditions listed above will satisfy the dental BLE standard without the recipient needing to submit any additional medical records.  It is important to know that the dental  provider still needs to detail why the dental work is needed since the requests will be reviewed for medical necessity using the five medical conditions will not be automatically approved, however.  They will still be reviewed for medical necessity prior authorization process.  

These changes became effective on April 15, 2020 for consumers in Fee-for-Service MA and will take effect shortly for consumers in Medicaid managed care (both HealthChoices and Community HealthChoices).  State officials reported in April that the managed care plans were updating their dental authorization processes and are expected to comply soon with these new process requirements. 

For assistance with a Medicaid dental service denial, contact PHLP’s Helpline at 1-800- 274-3258 or