Your Medicaid Questions Answered

Kelsey Creehan Featured News

From the Winter 2019 Journal of the Colorado Dental Association


What are the opioid prescribing limitations for Medicaid dentists?
Colorado’s Medicaid program recently enacted new opioid prescribing limitations for dentists. Effective Nov. 15, 2018, dentists may prescribe only four days of short-acting opioids at a time, with a maximum of 24 pills (six pills per day) containing a 200 total daily morphine milligram equivalent (MME). Dentists may issue up to three of these four-day prescriptions.

Prior authorization can be obtained for cases where medical indication demonstrates the need to exceed this allowance. Dentists performing complex dental procedures may be approved for higher, medically appropriate limits after consultation with a pharmacist or pain management physician. After prior authorization, prescribing limits will typically be extended for patients undergoing traumatic orofacial tissue injury, major mandibular/maxillary surgery, severe cellulitis of the facial planes, and surgery for severely impacted teeth with facial space infection requiring surgical management. Additional procedures will be considered on a case-by-case basis if additional pain management is justified by the procedure. Long-acting opioids and short-acting fentanyl agents also require prior authorization.

In cases where a complex procedure will require pain management that exceeds the traditional policy, dentists are encouraged to apply for a prior authorization up front, rather than when limits have been reached, to streamline the process. Prior authorizations may also be obtained after the initial prescriptions have been exhausted in cases with unusual complications. Dentists needing exceptions to these new opioid prescribing policies should contact the Colorado Pharmacy Call Center at 800-424-5725. 

What rates does Medicaid pay?
The CDA has advocated strongly in recent years to improve Medicaid rates to more sustainable levels for dental practices. The CDA has been successful in improving reimbursement for many codes, and particularly codes for diagnostic, preventive and basic restorative services. Some Medicaid rates are now on par (and even better at times) than some private pay plans. Of course, there is always room for additional improvement (which the CDA continues to pursue), but much progress has been made in helping ensure a reasonable baseline for offices that want to help Medicaid patients within their local communities. A current full fee schedule may be accessed under the “Resources” section at

Do I have to provide translation services for Medicaid patients?
Since October 2016, providers who accept payment plans that receive federal funding (Medicaid or CHP) have been required to post taglines in the top 15 languages in their state as well as notices of nondiscrimination in their offices and on their websites. The required taglines note that your dental office will take reasonable steps to provide free-of-charge language assistance services to people who speak languages other than English or who don’t speak English well enough to talk to providers about the care they are providing. The American Dental Association has compiled a list of useful resources for members who must comply with these ACA Section 1557 requirements (

What are the treatment options when an adult Medicaid patient hits their annual treatment cap?
Adults with Medicaid dental coverage are limited to $1,000 of covered treatment services during each state fiscal year (July to June). Emergency dental services and dentures are subject to separate limits outside of the $1,000 cap. For services that are not covered by Medicaid, that exceed frequency limitations or that are provided once a patient has exceeded the $1,000 adult benefit cap, a dentist may enter into a written agreement with the patient where the patient agrees to pay out-of-pocket for the services. This written agreement must be completed on a Medicaid-approved form (found in the current DentaQuest ORM) and be signed and dated by both the dentist and patient in advance of services being provided. A best practice is to submit a claim for the non-covered service and keep the Medicaid denial for payment on file for documentation. Also, while not required, dentists are encouraged to charge a reduced fee or a fee in alignment with the Medicaid fee schedule when possible, for non-covered services provided to Medicaid patients. 

State law prohibits providers, including dentists, from collecting fees from Medicaid patients related to a Medicaid-covered service. This restriction applies regardless of whether the dentist is enrolled as a Medicaid provider or not. A dentist who collects fees on a covered service from a Medicaid patient must refund all fees collected to the patient, and, if a patient files a complaint, the dentist may be subject to fines or penalties for unlawfully collecting these payments.

In addition, dentists should be aware that out-of-pocket billing for non-covered services is a situation that primarily applies to the adult dental benefit, as federal requirements mandate that states cover any medically necessary services for children. These federal requirements trump any frequency limitations or exclusions in the child dental benefit, which means there are very few non-covered services for children (some exceptions are cosmetic orthodontics and some third molar extractions). We encourage dentists to exercise extra caution in out-of-pocket billing involving a child with Medicaid coverage, and again to keep a Medicaid denial for payment related to the service provided on file.

If I have a Medicaid patient who is routinely missing appointments, is there anything I can do to address this?
Medicaid patients should be treated no differently than non-Medicaid patients. Any patients who are chronically late and don’t give appropriate notice for cancellations can be dismissed from a practice. You should have a consistent policy for all patients that is explained up front to all patients, regardless of their insurance status. There is a misconception that Medicaid providers are not allowed to dismiss patients—this is not true. But it’s also important to see patients on time—you can’t expect them to show up on time if the dentist/practice is chronically running late. DentaQuest also has a patient care team that can help address any physical or logistical barriers that might be preventing a patient from getting to their appointment.   



 Can a dentist not enrolled in Medicaid treat a Medicaid patient?
State law and policy dictate that a dentist who is not enrolled in Medicaid may not bill a Medicaid patient who seeks care from their office. This policy creates some challenges, especially around patient choice of providers, but is upheld as a patient protection measure.

As a non-enrolled provider, you may:

  1. See Medicaid patients pro bono (no charge to the patient would be permitted).
  2. Provide services that are not covered by Medicaid (with the patient able to pay your usual and customary rates or discounted/sliding fee scale rates as you offer).
  3. Provide services for adult patients who have exceeded their $1,000 program allowance (with the patient able to pay your usual and customary rates or discounted/sliding fee scale rates as you offer; however, you should obtain documentation that they have reached their cap prior to treatment).
  4. Refer the patient to another dentist via direct referral or DentaQuest’s patient help line at 855-255-1729.

It’s wise to include a signed form in your intake paperwork that asks the patient to attest whether they have any coverage under Medicaid (medical or dental). If the patient indicates they are covered by Medicaid in any regard, they will have dental coverage through Medicaid in almost every case and you need to consider the options above in terms of their care. The state can hold providers accountable for any payment collected from a Medicaid patient unless the patient has been dishonest about their coverage status.

Can non-Medicaid providers collect copays for dual covered patients?
The state Medicaid program recently issued a bulletin that clearly allows a non-Medicaid provider to collect a required co-pay or deductible from a patient who has dual coverage (both Medicaid and a private dental plan) in order to bill the private plan for a covered service. Before collecting the copay or deductible, the patient must sign a voluntary informed consent agreeing to the cost sharing. These dual covered patients may not be balance billed for any amount that the private plan does not pay, unless the service provided is a noncovered benefit under the Medicaid dental plan. The full Medicaid policy, including a template consent form, is available for reference here: This policy applies only to dentists who are not enrolled as Medicaid providers.

How do I become a Medicaid provider?
In order to become a Medicaid provider, you must complete the Medicaid credentialing process with Health First Colorado. Visit the Health First website to initiate a new provider enrollment application, resume enrollment, or check the status of your current application.

Why should I accept patients on Medicaid?
When the Medicaid dental benefits for adults took affect in 2014, over 300,000 eligible adults across the state gained dental coverage under the program. As a dentist, you know the vital importance of good dental care and good oral health. It’s important that the dental community step-up and care for these recently-covered Medicaid patients. If every Colorado dentist accepted a modest number of Medicaid patients, it could make a profound difference in the oral health of some of Colorado’s most vulnerable people. These are the patients who need help the most.

Do I control the number of Medicaid patients I see in my practice?
In Colorado, a dental practice is always free to cap the size of its Medicaid caseload at a level that is viable for its business plan. Dentists are also free to see only certain types or categories of patients (e.g., adults, children, seniors, DIDD, foster children, cleft palate, etc.), so long as the categorization used to select patients does not violate any protected class under the Americans with Disabilities Act. Further, dentists can also choose whether they are publicly listed in Medicaid provider databases so that patients can contact their offices directly for appointments, or whether they participate in Medicaid based solely on referrals from other practitioners and are not publicly listed in provider directories.