Yes, HMSA QUEST does cover dental care. Children under 21 have had comprehensive dental benefits through the federal EPSDT program for years, and since January 1, 2023, adults 21 and older have had a full range of dental benefits as well, including cleanings, fillings, extractions, root canals on molars, and dentures.1 There are no premiums, deductibles, or copays for covered services, and no annual dollar cap. Dental claims are handled by Hawaii Dental Service rather than by HMSA directly, and Community Case Management Corporation helps members find a dentist.
What Adult Dental Benefits Include
Before 2023, adult coverage under Hawaii Medicaid was limited to pain management and extractions. The Med-QUEST Division expanded the adult benefit effective January 1, 2023, to include preventive, diagnostic, restorative, endodontic, periodontal, prosthodontic, oral surgery, and emergency services.
The main categories and frequency limits for adults are:
- Cleanings twice per year, topical fluoride or fluoride varnish twice per year, and scaling for moderate or severe gingival inflammation for ages 14 and up.
- Periodic oral evaluations twice per year at least four months apart, a comprehensive oral evaluation once every five years per dentist, bitewing X-rays twice per year, and a full-series X-ray once every five years.
- Amalgam fillings on posterior teeth and composite fillings on anterior and posterior teeth, plus pin or post reinforcement, cast cores, recementing of inlays and crowns, and stainless steel crowns.
- Root canal treatment, limited to permanent molars.
- Scaling and root planing once every 24 months, and periodontal maintenance twice per year.
- Complete upper and lower dentures once every five years, interim partial dentures once per year, and denture relines once every two years.
- Extractions and emergency or palliative dental care, including treatment for gingival hyperplasia.
Providers must accept the Medicaid payment as payment in full. Balance billing a patient for a covered service is prohibited.
What Is Not Covered
Several services sit outside the adult dental benefit:
- Orthodontics for adults. Braces are not a covered adult benefit.
- Dental implants. Standard implants are not covered under either the adult or children’s dental program, and implant codes are not on the Medicaid dental fee schedule. Certain implant procedures tied to trauma, such as mandibular implants, may be covered under the medical plan.
- Gold crowns for adults. These are covered for children only. An adult who wants gold instead of stainless steel can pay out of pocket, but the dentist has to explain the covered alternative and get a signed financial agreement first.
- Cosmetic procedures, including cosmetic orthodontia and the related exams and X-rays.
- Extractions purely for orthodontic reasons, and removal of third molars without documented pathology.
- Fixed bridges, which are not listed as a covered prosthodontic service for adults.
If you want a service that is not covered or you have already hit the frequency limit, the dentist can perform it on a self-pay basis. They must first explain the covered alternatives, obtain a signed acknowledgment of the cost, and cannot charge more than their usual and customary rate.
Dental Coverage for Children Under 21
Children and adolescents under 21 are covered through EPSDT, which is broader than the adult benefit. It includes diagnostic and preventive care every six months (X-rays, cleanings, topical fluoride), fillings, endodontic therapy, oral surgery, periodontic therapy, and prosthodontic services. Orthodontic treatment is covered only when medically necessary, such as for orofacial clefts, and requires prior authorization. Cosmetic orthodontia is not covered.
What You Pay
HMSA QUEST dental has no premiums, deductibles, or copays for members, and no annual dollar cap on covered services. The Medicaid payment covers the full cost of a covered service, and the dentist cannot bill you for the balance.
When Prior Authorization Is Required
Most routine dental services do not require prior authorization. As of 2024, preauthorization is required only for orthodontic services and for dental procedures done under general anesthesia.
General anesthesia is treated as a last resort. It is approved when a patient has an intellectual or developmental disability that prevents cooperation, a medical condition that makes local anesthesia ineffective, or extensive orofacial trauma. It may also be approved when a patient is extremely uncooperative, needs extensive treatment, delay would harm their health, and alternatives such as behavioral management, nitrous oxide, or Silver Diamine Fluoride have been tried and failed. The dentist has to submit forms and clinical documentation to get approval.
Dental Procedures Covered Under the Medical Plan
Some procedures that look dental are billed through the HMSA QUEST medical plan instead. They have to be performed by an oral surgeon or physician and billed with CPT codes on a medical claim. Covered procedures include excision of tumors and cysts, fracture repair of the jaw and facial bones, TMJ dysfunction surgeries, abscess drainage, and reconstructive procedures such as Le Fort osteotomies and salivary gland surgeries. General anesthesia and hospital stays for these procedures are also covered when medically necessary, but they require precertification and a referral from your primary care physician.
How to Find a Dentist and Get Help
To find a Medicaid-enrolled dentist, contact Community Case Management Corporation at 808-792-1070 on Oahu or 1-888-792-1070 toll-free from the neighbor islands, Monday through Friday from 7:45 a.m. to 4:30 p.m. Hawaii time. CCMC can also arrange foreign language and sign language interpreters, and can coordinate travel to Oahu for neighbor island members who need specialist care that is not available on their home island.
For claims questions, call HDS Customer Relations at 808-529-9248 or 1-844-379-4325. If you do not have your Medicaid ID card, contact the Med-QUEST Division at 808-524-3370 on Oahu or 1-800-316-8005 from the neighbor islands.