Does BadgerCare Cover Dentures? Limits, Copays, and Prior Auth

BadgerCare Plus does cover dentures. The program pays for complete dentures when you’ve lost all your teeth in an arch and partial dentures when you still have some natural teeth but meet specific clinical criteria. A new denture requires prior authorization from the state, and replacement is limited to once every five years per arch.

What Denture Services Are Covered

Complete dentures are covered when you’ve lost all teeth in one or both arches. Partial dentures are covered when you still have some natural teeth and meet one of the clinical thresholds: one or more front teeth missing, fewer than two back teeth per quadrant that meet the opposing teeth, or at least six teeth missing in an arch.¹ For a partial, your dentist must also confirm good oral hygiene and stable periodontal health.

Follow-up care for six months after insertion is built into the original reimbursement, so adjustments during that window cost you nothing extra. After six months, your provider can bill separately for adjustments. Repairs are also covered, including a cracked base, broken teeth, or a broken clasp on a partial.¹

Relining the gum-side surface of a denture is covered once every three years per arch when the fit has changed because of tissue shrinkage, weight loss, or general looseness. A sooner reline can be approved with written justification submitted alongside the prior authorization request.¹

What Isn’t Covered

Several things people often assume are included are not. For adults, BadgerCare Plus does not cover overlay dentures, overlay partials, duplicate dentures, or adjustments to duplicate dentures. Dental implants, tooth transplantations, and surgical repositioning are not covered either, with narrow exceptions for reimplantation. Any procedure done purely for appearance, including labial veneers, is excluded. Orthodontics is not covered except in narrow circumstances for specific conditions.² Members under 21 may qualify for additional services through the Early and Periodic Screening, Diagnostic, and Treatment benefit when a dental assessment identifies a clinical need.

One other limit worth knowing: partial dentures are reimbursed at the standard resin-base rate. If you and your dentist choose a cast metal framework instead, the program still pays only the resin-base amount, and no dentist is required to make the upgraded version.³ You would owe the difference if a provider agrees to make it.

The Five-Year Replacement Limit

BadgerCare Plus pays for one new complete or partial denture per arch every five years. A replacement before that mark won’t be approved without strong clinical justification. Exceptions do exist when something unusual has changed, such as a significant health event, and the state may ask for a physician’s statement confirming that a new denture is necessary for proper nourishment and digestion.¹

If Your Dentures Are Lost, Stolen, or Severely Damaged

A replacement inside the five-year window may be approved, but the standard is strict. All of the following must be true:

You took reasonable care of the denture.
The denture was in use up to the time of loss or theft.
This is not a repeated event.
You can give a reasonable explanation of what happened.
You, or the facility where you live, outline a plan to prevent it from happening again.¹

The prior authorization request must include documentation of the loss: a police report, accident report, fire report, or a written statement from a hospital, nursing home, group home administrator, or the member describing how, when, and where it happened. BadgerCare Plus will reimburse for only the first lost, damaged, or stolen denture per arch. After that, replacement is on you.¹

The Healing Period After Extractions

If teeth need to come out before your dentures are made, the program requires a minimum six-week healing period after the last extraction before a final impression can be taken. The prior authorization request can be submitted before the extractions happen, but the six-week wait still applies. Skip it, and payment for the dentures will be denied or recouped from the provider.⁴

A shorter wait, or no wait at all, can be approved when the provider documents medical necessity, such as an unusual medical condition, only a few teeth being extracted, or extractions in noncritical areas. Members whose jobs require public contact may also qualify for a shortened wait with a supporting statement from their employer. The request for a shortened healing period has to go in at the same time as the denture prior authorization.⁴

How Prior Authorization Works

No new denture gets made under BadgerCare Plus until the state approves it. Your dentist submits a Prior Authorization Dental Request Form with supporting documentation, which can include X-rays, photographs, clinical reports, and a treatment plan justification.⁵ For full dentures entered through the ForwardHealth Portal, the system automatically opens the required attachment panel for the provider to complete. Requests can also go in by fax or mail.

ForwardHealth makes a decision within 20 working days from the date it receives all the information it needs.⁶ Incomplete submissions are the usual reason for delay. It’s worth calling your dental office to confirm the request has actually been sent and that nothing was left out.

What You’ll Pay

Most members owe a small copay at each dental visit, scaled to what the program reimburses:

Denture procedures typically reimburse above $50, so plan on $3.00 per service for most denture visits. Your combined monthly premiums and copays cannot exceed 5% of your household’s monthly income.⁸

Some members owe nothing. Providers cannot collect copays from children under 19 or from nursing home residents.⁷ Pregnancy-related services are also copay-free for all members, though that exemption attaches to the type of service rather than to every visit a pregnant member has.

Finding a Dentist Who Accepts BadgerCare Plus

The ForwardHealth online directory lets you search participating dentists by location and service.⁹ If you’re in a managed care plan rather than fee-for-service, call your HMO for in-network providers, because the ForwardHealth directory may not reflect your plan’s network. Before you schedule, call the office to confirm they are currently accepting new BadgerCare Plus patients. Bring your ForwardHealth ID card to every visit so the office can verify enrollment and bill correctly.

If Your Request Is Denied

You can appeal a denied or modified prior authorization through a fair hearing with the Division of Hearings and Appeals. Only you, or someone authorized to act for you, can file the appeal. Your dentist cannot file it, though they can help you build your case.¹⁰

The deadline is 45 days from the date on the Notice of Appeal Rights letter sent after the denial. File a signed, written Request for Fair Hearing form (DHA-28) with the Division of Hearings and Appeals. Include a short explanation of why you disagree, the name of the agency that denied the service, and a copy of the denial notice.¹¹

1
ForwardHealth Portal. Covered and Noncovered Services – Prosthodontics (Removable)
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ForwardHealth Portal. Noncovered Services for Dentists and Physicians
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ForwardHealth Portal. Covered and Noncovered Services – Codes
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ForwardHealth Portal. Covered and Noncovered Services – Healing Period After Tooth Extraction
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ForwardHealth Portal. Prior Authorization – Forms and Attachments
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ForwardHealth Portal. Prior Authorization – Decisions
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ForwardHealth Portal. BadgerCare Plus and Medicaid Handbook – Reimbursement Copayment
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ForwardHealth Portal. Wisconsin Medicaid and BadgerCare Plus Copay Exemptions
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ForwardHealth Portal. Directory Search
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ForwardHealth Portal. Appeals
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Wisconsin Department of Administration. DOA Requesting a Hearing