Coordinated Care does not cover dental services directly. Dental care for Coordinated Care members is covered separately through Washington’s Apple Health fee-for-service program, and you access it with your ProviderOne services card rather than your Coordinated Care member ID.1Coordinated Care. Member FAQ Washington carves dental out of every Apple Health managed care plan, so the same arrangement applies regardless of which plan you’re enrolled in.
Which Card To Bring and How To Find a Dentist
Every Apple Health member receives a ProviderOne services card in the mail roughly seven to ten days after their application is processed.2DentistLink. Apple Health Medicaid Covers Dental Care Bring that card to every dental appointment. The office uses it to verify your coverage and bill the state. To confirm whether a specific service is covered, call the number on the back of the ProviderOne card.1Coordinated Care. Member FAQ
You need to see a dentist who accepts Apple Health. A few free tools can help:
- DentistLink, a free referral service run by the Arcora Foundation and the Health Care Authority. Call or text 844-888-5465, search the online directory, or submit a referral form. The service also offers interpretation and help arranging transportation.3Coordinated Care. Dental, Hearing, and Vision4DentistLink. DentistLink Home
- The ProviderOne Find a Provider directory, maintained by the Health Care Authority at 1-800-562-3022.3Coordinated Care. Dental, Hearing, and Vision
- For kids, the InsureKidsNow website, or the Access to Baby and Child Dentistry (ABCD) program for children age five and under.3Coordinated Care. Dental, Hearing, and Vision
The Arcora Foundation has acknowledged that low Medicaid reimbursement rates in Washington have historically made it difficult for dental providers to participate, meaning “Apple Health dental coverage, while essential, does not always equate to access to care.”5Arcora Foundation. Apple Health Dental Rates Increase Expect to call around.
What’s Covered for Adults
Adults age 21 and older have coverage for a defined set of dental services, with no copays or deductibles.6Washington State Health Care Authority. Apple Health Adult Dental Coverage The covered categories include:
- Diagnostic care: comprehensive, periodic, and limited exams; full-mouth X-ray series, bitewings, panoramic, and periapical X-rays.
- Preventive care: cleanings and fluoride.
- Restorative care: composite or amalgam fillings and stainless steel crowns. Fillings are limited to once per tooth in a two-year period.7King County. Adult Dental Coverage Apple Health
- Root canals on anterior (front) teeth only.
- Periodontal scaling, root planing, and maintenance. Members with diabetes may receive up to four periodontal maintenance visits in a 12-month period.6Washington State Health Care Authority. Apple Health Adult Dental Coverage
- Complete and partial dentures, including rebasing and relining. These require prior authorization.8Justia Regulations. WAC 182-535-1090
- Oral surgery: extractions, biopsies, and surgical denture preparation.
- Sedation: nitrous oxide, general anesthesia, and intravenous conscious sedation.
When an adult has a problem with a back tooth that would normally call for a root canal, extraction followed by dentures is typically the covered path, since root canals on posterior teeth are not covered.7King County. Adult Dental Coverage Apple Health
Services excluded from adult coverage include bridges, porcelain crowns, dental implants, orthodontics, cosmetic procedures such as teeth whitening and veneers, and root canals on back teeth.
Adults with a Developmental Disabilities Administration designation receive expanded coverage, including sealants for posterior teeth and stainless steel crowns with supporting documentation.7King County. Adult Dental Coverage Apple Health Members eligible for Developmental Disabilities Community Services or living in a skilled nursing or alternate living facility may also receive certain services at increased frequency.6Washington State Health Care Authority. Apple Health Adult Dental Coverage
What’s Covered for Children
Children age 20 and younger receive broader coverage than adults. Covered services include routine exams, cleanings, X-rays, sealants, fillings, crowns, fluoride, and extractions.2DentistLink. Apple Health Medicaid Covers Dental Care Orthodontics is available for children with cleft palate or other serious dental problems and requires prior authorization.
Under the federal Early and Periodic Screening, Diagnostic, and Treatment requirement, children may also request prior authorization for services that fall outside the standard coverage list. The Health Care Authority reviews those requests case by case for medical necessity.9Washington State Health Care Authority GovDelivery. EPSDT Dental Prior Authorization
The ABCD Program for Young Children
The Access to Baby and Child Dentistry program serves children from birth through age five, and children with a Developmental Disabilities Administration designation through age 12.10Arcora Foundation. Access to Baby and Child Dentistry Program ABCD connects families with specially trained and certified dentists, provides one-on-one family oral health education, and offers help with scheduling, transportation, and interpretation.11ABCD Dental. About ABCD Certified ABCD providers receive enhanced reimbursement rates, which helps keep more dentists in the program.12Washington State Health Care Authority. ABCD Billing Guide
When You’ll Need Prior Authorization
Some procedures require advance approval from the Health Care Authority before treatment. Dentures are the most common example: all complete dentures, replacement dentures, resin partial dentures, and denture repairs exceeding the standard once-per-year limit need prior authorization.8Justia Regulations. WAC 182-535-1090 Certain surgical procedures for children, such as frenulectomy codes for patients ages zero through 12, also require authorization.13Washington State Health Care Authority. Dental-Related Services Program Billing Guide
Under Washington Administrative Code 182-535-1220, providers submit authorization requests with clinical documentation showing medical necessity. The agency may request X-rays, photographs, or an independent review by another dentist before granting approval. Authorization confirms medical necessity but is not a guarantee of payment; you must still be eligible on the date of service.14Cornell Law Institute. WAC 182-535-1220
Vision and Hearing Work the Same Way
Dental is not the only benefit carved out of Coordinated Care. Hearing and vision are also accessed through your ProviderOne card rather than through the plan directly.3Coordinated Care. Dental, Hearing, and Vision Members under 21 receive one eye exam every 12 months, with eyeglass frames, lenses, and contacts covered through ProviderOne. Members 21 and older receive one exam every 24 months, plus a $100 discount on glasses or contacts every two calendar years through participating Envolve Vision providers. Hearing exams and screenings are covered for all members, and hearing aids are available for children 20 and younger and for adults who meet program criteria.