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General Coverage Scope of Coverage Level of Coverage Routine Dental Care Preventive Dental Care Includes procedures which help prevent oral disease from occurring, including but not limited to:  Prophylaxis: scaling and polishing the teeth at 6 month intervals  Topical fluoride application at 6 month intervals where local water supply is not fluoridated  Sealants on unrestored permanent molar teeth.  Space Maintenance: unilateral or bilateral space maintainers will be covered for placement in a restored deciduous and/or mixed detention to maintain space for normally developing permanent teeth. Routine Dental Care  Dental examinations, visits and consultations covered once within 6 month consecutive period (when primary teeth erupt)  X-ray, full mouth x-rays at 36 month intervals, if necessary, bitewing x-rays at 6-12 month intervals, or panoramic x-rays at 36 month intervals if necessary; and other x-rays as required (once primary teeth erupt)  All necessary procedures for simple extractions and other routine dental surgery not requiring hospitalization including preoperative care and postoperative care  In office conscious sedation  Amalgam, composite restorations and stainless steel crowns  Other restorative materials appropriate for children Endodontics Includes all necessary procedures for treatment of diseased pulp chamber and pulp canals, where hospitalization is not required. Prosthodontics Removable: Complete or partial dentures including six months follow-up care. Additional services include insertion of identification slips, repairs, relines and rebases and treatment of cleft palate.

Fixed: Fixed bridges are not covered unless 1) Required for replacement of a single upper anterior (central/lateral incisor or cusped) in a patient with an otherwise full complement of natural, functional and/or restored teeth; 2) Required for cleft-palate treatment or stabilization; 3) Required, as demonstrated by medical documentation, due to the presence of any neurologic or physiologic condition that would preclude the placement of a removable prosthesis.

NOTE: Refer to the Medicaid Management Information System (MMIS) Dental Provider Manual for a more detailed description of services.