ADULT DENTAL
Washington Apple Health (Medicaid)
Starting January 1, 2014
Client Handout
The Washington Apple Health (Medicaid) resumed covering dental services for all adults with Medicaid (clients 21 years of
age and older)
Includes people who already have Medicaid AND people who are eligible for “Expanded Medicaid,” part of health care reform.
Medicaid is now “Apple Health.”
WHAT’S COVERED?
ENDODONTIC (ROOT CANAL)
Anterior (front) teeth only – upper and lower
DENTURES / PARTIALS
Complete Dentures – covered, with Prior Authorization (PA)
required
Partial Dentures – Resin Based (Acrylic) – covered, but Prior
Authorization required
At least one anterior tooth or 4 posterior teeth, not
including 2
nd
or 3
rd
molars, missing per arch to be
considered for approval.
If in alternative living facility, requires medical diagnosis,
prognosis, and documentation of medical necessity to be
considered for approval.
Replacement of Partials – may be covered if existing
dentures are at least 3 years old.
Rebase and Reline of Dentures – once in a 3-year period, at
least 6 months after original dentures inserted.
ORAL SURGERY
Simple extractions, Surgical extractions, Biopsies, Intraoral
and Extraoral Incise, and Drain
Nitrous oxide sedation covered
Oral and other sedation methods NOT COVERED.
ORTHODONTICS
Clients over the age of 20 are NOT COVERED.
OTHER NON-COVERED SERVICES
Implants
Bridges
DIAGNOSTIC PROCEDURES
EXAMS
Initial Comprehensive Exam – Once per client, per
provider or clinic
Periodic Exam – 1 every 12 months
Limited Exam – as needed
X-RAYS
Complete Series (FMX) – 1 every 3 years
4 Bitewings – every 12 months
Panorex – every 3 years (A panorex is a two-dimensional
dental x-ray that displays both the upper and lower jaws
and teeth, in the same film).
Periapical – as needed (common need: a possible
abscess)
PREVENTIVE SERVICES
Prophylaxis ( Cleaning) – 1 every 12 months
Fluoride Application (Varnish)
21 and older– 1 every 12 months
Residents of alternative living facility – 3 every 12 months
BASIC RESTORATIVE (FILLINGS)
Composite or Amalgam restorations - once per tooth in a 2-
year period
Crowns – NOT COVERED
PERIODONTAL (GUM DISEASE)
Scaling and Root Planing – every 2 years per quadrant
Perio Maintenance – once every 12 months
DIVISION OF DEVELOPMENTAL DISABILITIES (DDD)
For adults with this designation, all coverage is the same as above with the following additions:
Topical Fluoride – 3 times per year
Sealants – covered for posterior teeth
Crowns – Stainless Steel only, covered for posterior teeth with supporting documentation
Prophylaxis, Scaling and Root Planing, and Perio Maintenance – any combination of the 3 in a 12-month period
For more information your covered dental benefits contact:
Health Care Authority/ProviderOne
1-800-562-3022
To find a provider that takes Apple Health visit:
https://fortress.wa.gov/hca/p1findaprovider/
