§ 1992. Medicaid coverage for adult dental services

(a) Vermont Medicaid shall provide coverage for medically necessary dental services provided by a dentist, dental therapist, or dental hygienist working within the scope of the provider’s license as follows:

(1) Preventive services, including prophylaxis and fluoride treatment, with no co-payment. These services shall not be counted toward the annual maximum benefit amount set forth in subdivision (2) of this subsection.

(2)(A) Diagnostic, restorative, and endodontic procedures, to a maximum of $1,500.00 per calendar year, provided that the Department of Vermont Health Access may adjust the maximum pursuant to the process outlined in subdivision (B) of this subdivision (2) and may approve expenditures in excess of that amount when exceptional medical circumstances so require. Exceptional medical circumstances include emergency dental services, as defined by the Department by rule.

(B) The Department may set the maximum for coverage of diagnostic, restorative, and endodontic procedures in excess of the amount set forth in subdivision (A) of this subdivision (2) for a calendar year based on the Department’s annual assessment of available funds, provided that the Department submit a report to the House Committee on Health Care, the Senate Committee on Health and Welfare, and the House and Senate Committees on Appropriations, or to the Joint Fiscal Committee if the General Assembly is not in session, each time the Department adjusts the maximum.

(C) The following individuals shall not be subject to the annual maximum benefit amount set forth in this subdivision (2):

(i) individuals served through the Community Rehabilitation and Treatment and Developmental Disability Services programs pursuant to Vermont’s Global Commitment to Health Section 1115 demonstration; and

(ii) Medicaid beneficiaries who are pregnant or in the postpartum eligibility period, as defined by the Department by rule.

(3) Other dental services as determined by the Department by rule.

(b) The Department of Vermont Health Access shall develop a reimbursement structure for dental services in the Vermont Medicaid program that encourages dentists, dental therapists, and dental hygienists to provide preventive care. (Added 2019, No. 72, § E.306.1; amended 2021, No. 130 (Adj. Sess.), § 1, eff. May 24, 2022; 2023, No. 51, § 1, eff. July 1, 2023; 2023, No. 78, § E.307.1, eff. July 1, 2023.)