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 Paying For Dental Work In Long Term Care

How can elderly long term care residents who are enrolled in Medicaid pay for the dental care they need? Approximately 1.3 million nursing facility residents face significant barriers to accessing dental care, and the number of residents is expected to increase rapidly with the aging of the baby boom generation.

Under federal law, nursing homes are required to provide both routine and emergency dental care for their residents. Unfortunately, these federal requirements create financial challenges for both long term care facilities and dental professionals, since dental services are not covered under Medicare and are inadequately covered, if covered at all, by Medicaid.

In most states, the largest single financial barrier to dental care is the lack of adequate dental coverage for residents who depend on Medicaid. Fortunately, a solution known as Incurred Medical Expense (IME) billing can help the majority of long term care residents who depend on Medicaid afford to pay for the dental treatment they need without imposing additional costs on providers.

Although IME billing is used routinely in many states to help pay for eyeglasses and hearing aids, this billing method has not been as widely used to pay for medically necessary dental care.

IME regulations can help nursing facility residents who are enrolled in Medicaid and who have Social Security or other retirement income use that income to pay for dental services that are not covered by Medicaid.

Essentially, it enables residents to use their monthly retirement income, usually applied to help pay for their nursing home care, to pay for medically necessary health care services not covered by their state’s Medicaid program.

Residents or their representatives must first make arrangements with their caseworkers to reduce monthly payments toward expenses at the nursing home for one or more months, and then are authorized to use those funds to pay for medically necessary dental care.

At the same time, the caseworker directs Medicaid to temporarily increase the amount it pays to the nursing facility by the same amounts each month. The end result of the IME billing process is that the facility’s residents receive necessary dental care, their dental providers are paid for the services they provided, and the nursing facility continues to be paid its normal monthly fees.

“Incurred Medical Expenses–Paying for Dental Care: A How-To Guide,” developed by the American Dental Association, provides more detailed information for three target audiences: dental professionals, Medicaid caseworkers, and nursing home residents and their representatives. It can be found at www.ada.org/IME. 

Barbara Smith, MPH, PhD, American Dental Association, and Michael Helgeson, DDS, chief executive officer of Apple Tree Dental
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