AmeriHealth Caritas North Carolina does not cover dental care. Dental is carved out of every NC Medicaid managed care plan, so your dental benefits come through NC Medicaid Direct on a fee-for-service basis, and you can see any dentist in the state who accepts Medicaid regardless of which health plan you belong to.1AmeriHealth Caritas NC. Other Coverage2Equity PN. Dental Coverage for Medicaid Beneficiaries
AmeriHealth Caritas’s own site lists dental under benefits you can only get from a Medicaid provider outside the plan, and refers members to the state’s provider lookup tools.1AmeriHealth Caritas NC. Other Coverage You don’t need a referral from your AmeriHealth primary care provider, and you don’t need to switch plans to see a dentist.
What Adult Dental Covers Through NC Medicaid
Adult dental benefits in North Carolina include routine exams, cleanings, preventive care, amalgam and composite fillings, some oral surgeries, periodontal care, and tooth restorations.3North Carolina Health News. Medicaid Expansion Oral Health Challenges NC Dentists2Equity PN. Dental Coverage for Medicaid Beneficiaries
Several bigger-ticket services are covered with limits:
- Complete dentures can be replaced once every ten years, partial dentures once every eight years, with medical necessity exceptions.
- Root canal therapy is covered for anterior teeth.
- Full-mouth X-rays are allowed once every five years.
Dentures, denture relines, periodontal services, orthodontic services, elective root canals, and complex oral surgery all require prior approval before treatment begins. Emergency dental care does not.4Medicaid.gov. NC Medicaid State Plan Amendment Your dentist submits the prior approval request through NCTracks.5NCTracks. Prior Approval
What Children Get Under EPSDT
Children under 21 have broader dental coverage than adults through the federal Early and Periodic Screening, Diagnostic, and Treatment benefit. EPSDT entitles a child to any medically necessary dental service that can correct or improve a physical or mental health condition, and there is no cap on the number of dental visits. A service that is not normally covered under North Carolina’s standard Medicaid plan may still be covered for a child if it is medically necessary and falls within federal Medicaid law.6NC DHHS. EPSDT Policy Description
AmeriHealth Caritas directs parents with questions about accessing EPSDT dental services to Member Services at 1-855-375-8811, even though the care itself is delivered outside the plan.7AmeriHealth Caritas NC. Children’s Services
How to Find a Medicaid Dentist
Because dental is carved out, the AmeriHealth Caritas provider directory won’t help you find a dentist. Two state-maintained tools will:
- The Medicaid Provider and Health Plan Lookup Tool at ncmedicaidplans.gov, where you can search by provider or practice name.
- Insure Kids Now at insurekidsnow.gov, which lists dentists for both adults and children.
Enrolled providers include general dentists, pediatric dentists, endodontists, oral surgeons, orthodontists, periodontists, prosthodontists, and dental clinics at local health departments, federally qualified health centers, and rural health centers.8NC DHHS. Medicaid Dental Providers A directory listing doesn’t mean the office is accepting new Medicaid patients, so call first.
If you need help, the NC Medicaid Contact Center is at 888-245-0179, and your AmeriHealth primary care provider can also point you toward dental resources.1AmeriHealth Caritas NC. Other Coverage
The One Exception: AmeriHealth Caritas VIP Care
If you qualify for both Medicare and Medicaid, you may be enrolled in AmeriHealth Caritas VIP Care, a Medicare-Medicaid plan that works differently from standard AmeriHealth Caritas NC. VIP Care includes dental directly in its benefits package.
Preventive dental under VIP Care covers oral exams and cleanings every six months, fluoride treatments every six months, and dental X-rays on a periodic schedule, at no cost to you. Comprehensive dental services sit under a $3,000 combined annual limit and include fillings, extractions, dentures (one per arch every five years), denture repairs, oral surgery, periodontal and endodontic care, and crowns (one every five years per tooth, up to four per calendar year). Lower-arch mini-implants and implant-supported dentures are covered every five years. Fixed bridges and most other dental implants are excluded.9AmeriHealth Caritas VIP Care. Summary of Benefits
VIP Care members use the plan’s own provider directory rather than the state Medicaid lookup tools.10AmeriHealth Caritas VIP Care. Provider Directory
Expect Some Difficulty Finding a Dentist
Coverage and access aren’t the same thing in North Carolina. Only about 45 percent of state dentists accept Medicaid patients, and many of those are not taking new ones. As of 2023, 94 of the state’s 100 counties were federally designated dental health professional shortage areas, with just 5.6 dentists per 10,000 residents compared to a national average of 6.1.3North Carolina Health News. Medicaid Expansion Oral Health Challenges NC Dentists
Reimbursement is the reason. NC Medicaid dental rates have not been raised since 2008 and sit at roughly 35 percent of average dental charges, which makes it hard for practices, especially in rural areas, to take Medicaid patients.11North Carolina Health News. Lawmakers Propose Higher Medicaid Reimbursement Rates for Dentists Plan on calling several offices, and consider federally qualified health centers and local health department dental clinics if you’re having trouble getting an appointment with a private practice.