Texas Medicaid & CHIP dental plans accepted — Texas Health Steps for children, emergency care for adults.
Our dental practice participates in Texas Medicaid and the Children's Health Insurance Program (CHIP), providing diagnostic, preventative, restorative, endodontic, periodontal, prosthodontic, and oral surgery services in accordance with Texas Health and Human Services Commission (HHSC) guidelines and the Texas Medicaid Provider Procedures Manual (TMPPM). In Texas, Medicaid and CHIP dental services for children and adolescents are managed through three state-contracted Dental Maintenance Organizations (DMOs): DentaQuest, MCNA Dental, and UnitedHealthcare Dental. Adult dental coverage under standard Texas Medicaid is restricted to emergency treatments to control acute pain, infection, or trauma.
Always verify which Dental Maintenance Organization (DMO) your child is assigned to — authorizations and claims go directly to that plan. Children's Medicaid carries a $0 deductible, $0 copay, and no annual maximum.
Texas Health Steps Dental provides comprehensive preventative and therapeutic oral health benefits under the federal Early and Periodic Screening, Diagnostic and Treatment (EPSDT) mandate, which guarantees coverage for all medically necessary dental treatments to restore oral health, correct defects, and manage dental diseases.
CHIP provides preventative, basic, and major therapeutic dental care to eligible uninsured children from working families who do not qualify for Children's Medicaid, subject to annual copay schedules and plan maximums:
Standard Texas Medicaid provides no routine preventative or restorative dental benefit for adults. Coverage is strictly limited to emergency relief of severe acute dental pain, management of acute infection or bleeding, and surgical extractions necessitated by trauma or life-threatening systemic complications.
Prior authorization (PA) is the mandatory review through which your child's DMO verifies medical necessity before elective services. It cannot be granted retroactively, and state regulations prohibit billing the Medicaid client for denied unauthorized services.
Frequency limits by program under Texas Medicaid and CHIP, as published in the Texas Medicaid Provider Procedures Manual and the DMO benefit schedules. Children's Medicaid (Texas Health Steps) covers ages 0 to 20, CHIP covers ages 0 to 18, and adult Medicaid covers ages 21 and older. Our team verifies your specific plan before treatment.
| Dental Program Name | Dental Benefit Administrator | Administered Networks | Provider Portal | Provider Contact Phone |
|---|---|---|---|---|
| Texas Health Steps Dental (Medicaid Ages 0–20) | DentaQuest Texas | Texas Medicaid DMO / CHIP Dental | providers.dentaquest.com | 1-800-896-2374 |
| Texas Health Steps Dental (Medicaid Ages 0–20) | MCNA Dental Texas | Texas Medicaid DMO / CHIP Dental | portal.mcnadental.net | 1-855-699-6262 |
| Texas Health Steps Dental (Medicaid Ages 0–20) | UnitedHealthcare Dental Texas | Texas Medicaid DMO / CHIP Dental | uhcdental.com | 1-800-445-9090 |
| Texas Children's Health Insurance Program (CHIP) | DentaQuest / MCNA / UHC Dental | Texas CHIP Dental Plan Network | Respective Dental MCO Portals | Plan-Specific Provider Lines |
| Texas Adult Medicaid (Ages 21 and Older) | Texas Medicaid & Healthcare Partnership (TMHP) | Texas Fee-for-Service & STAR/STAR+PLUS MCOs | tmhp.com | 1-800-925-9126 |
| Service Description | Children's Medicaid (Texas Health Steps, Ages 0–20) | Texas CHIP Dental (Children Ages 0–18) | Texas Adult Medicaid (Adults Ages 21+) | Prior Auth (PA) |
|---|---|---|---|---|
| Program Financial Terms | Coinsurance: 100% Covered Deductible: $0.00 | Coinsurance: 100% Covered Deductible: $0.00 (Copays apply on higher tiers) | Coinsurance: 100% Covered for emergency services Deductible: $0.00 | No |
| Annual Benefit Maximum | No Annual Maximum (Exempt under EPSDT) | $500.00 to $1,000.00 / Year (Tier-dependent) | Emergency medical/surgical only; no routine maximum | No |
| Service Description | Children's Medicaid (Texas Health Steps, Ages 0–20) | Texas CHIP Dental (Children Ages 0–18) | Texas Adult Medicaid (Adults Ages 21+) | Prior Auth (PA) |
|---|---|---|---|---|
| Periodic oral evaluation | 1 every 6 months per patient | 1 every 6 months per patient | Not a covered benefit for routine adults | No |
| Limited oral evaluation – problem focused | Covered for trauma, infection, acute pain; 1 per day | Covered for emergency evaluation; 1 per day | Covered for emergency evaluation of severe pain/infection | No |
| Oral evaluation under age 3 | 1 every 6 months for children ages 6 to 35 months | Covered for eligible infants and toddlers | Not Applicable | No |
| Comprehensive oral evaluation | 1 every 36 months (or initial visit per provider/group) | 1 every 36 months (or initial visit per provider/group) | Not a covered benefit for routine adults | No |
| Comprehensive periodontal evaluation | 1 per year when clinically indicated | Covered with clinical documentation | Not a covered benefit for routine adults | No |
| Intraoral – comprehensive complete series (FMX) | 1 every 36 months (3 years); covered for ages 6 and older | 1 every 36 months (3 years); covered for ages 6 and older | Not covered for routine diagnostic screening | No |
| Intraoral – periapical first radiographic image | Covered as clinically indicated; diagnostic quality required | Covered as clinically indicated | Covered for emergency surgical diagnosis | No |
| Intraoral – periapical each additional image | Covered as clinically indicated; diagnostic quality required | Covered as clinically indicated | Covered for emergency surgical diagnosis | No |
| Intraoral – occlusal radiographic image | Covered as clinically indicated (up to 2 per 12 months) | Covered as clinically indicated | Covered for emergency trauma evaluation | No |
| Bitewing radiographs (single, two, or four images) | 1 set every 6 months for high caries risk; 1 per 12 months routine | 1 set every 6 to 12 months | Not a covered benefit for routine adults | No |
| Panoramic radiographic image | 1 every 36 months (shared interval with complete series); ages 6+ | 1 every 36 months (shared interval with complete series) | Covered for trauma, facial fracture, or surgical extraction | No |
| Caries risk assessment and documentation | 1 every 6 months (low, moderate, high risk documentation) | Covered for preventative care tracking | Not a covered benefit | No |
| Diagnostic casts | Covered for orthodontic evaluation or major surgery | Covered with clinical documentation | Not a covered benefit | Yes |
| Service Description | Children's Medicaid (Texas Health Steps, Ages 0–20) | Texas CHIP Dental (Children Ages 0–18) | Texas Adult Medicaid (Adults Ages 21+) | Prior Auth (PA) |
|---|---|---|---|---|
| Routine dental cleaning (Prophylaxis – child / adult) | 1 every 6 months (2 per year) | 1 every 6 months (2 per year) | Not a covered benefit for routine adults | No |
| Topical application of fluoride varnish or topical fluoride | 1 every 6 months for children through age 20 | 1 every 6 months for children through age 18 | Not a covered benefit for routine adults | No |
| Pit and fissure sealants – per tooth | 1 every 36 months on unrestored permanent 1st and 2nd molars | 1 every 36 months on unrestored permanent molars | Not a covered benefit | No |
| Interim caries arresting medicament (SDF) | Covered up to 2 applications per tooth per year | Covered up to 2 applications per tooth per year | Not a covered benefit | No |
| Space maintainers (fixed unilateral & bilateral) | Covered for premature loss of primary posterior teeth | Covered for premature loss of primary posterior teeth | Not a covered benefit | No |
| Space maintainers (removable unilateral & bilateral) | Covered for premature loss of primary posterior teeth | Covered for premature loss of primary posterior teeth | Not a covered benefit | No |
| Re-cement or re-bond space maintainer | Covered as needed; 1 every 12 to 24 months | Covered as needed | Not a covered benefit | No |
| Service Description | Children's Medicaid (Texas Health Steps, Ages 0–20) | Texas CHIP Dental (Children Ages 0–18) | Texas Adult Medicaid (Adults Ages 21+) | Prior Auth (PA) |
|---|---|---|---|---|
| Amalgam restorations (1 to 4+ surfaces) | 1 per 12 months per tooth per surface | 1 per 12 months per tooth per surface | Not a covered benefit for routine adults | No |
| Resin composite restorations – anterior (1 to 4+ surfaces) | 1 per 12 months per tooth per surface | 1 per 12 months per tooth per surface | Not a covered benefit for routine adults | No |
| Resin-based composite crown – anterior | Covered for primary anterior teeth with excessive breakdown | Covered for primary anterior teeth | Not a covered benefit | No |
| Resin composite restorations – posterior (1 to 4+ surfaces) | 1 per 12 months per tooth per surface | 1 per 12 months per tooth per surface | Not a covered benefit for routine adults | No |
| Single crowns (porcelain, PFM, full cast metal) | 1 every 5 years per permanent tooth when direct filling is unviable | 1 every 5 years per permanent tooth (subject to plan max) | Not a covered benefit for routine adults | Yes |
| Re-cement or re-bond crown, inlay, or onlay | Covered; not payable within 6 months of delivery to same dentist | Covered after initial post-delivery period | Not a covered benefit for routine adults | No |
| Prefabricated stainless steel crowns – primary teeth | 1 per lifetime of primary tooth when coronal decay is extensive | Covered for primary molars with extensive decay | Not Applicable | No |
| Prefabricated stainless steel crowns – permanent teeth | 1 every 36 to 60 months on permanent teeth | Covered for permanent teeth | Not a covered benefit for routine adults | No |
| Prefabricated resin / esthetic coated crowns | Covered for primary anterior teeth (teeth C–H, M–R) | Covered for primary anterior teeth | Not Applicable | No |
| Protective restoration (sedative direct) | Covered for emergency treatment or short-term pulpal healing | Covered for emergency pain treatment | Covered as emergency palliative procedure | No |
| Core buildup, including any pins | 1 every 5 years per permanent tooth | Covered with documentation of structural loss | Not a covered benefit for routine adults | Yes |
| Pin retention – per tooth, in addition to restoration | Covered up to 3 to 4 pins per tooth | Covered with clinical documentation | Not a covered benefit | No |
| Prefabricated post and core in addition to crown | 1 every 5 years per permanent tooth | Covered for endodontically treated teeth | Not a covered benefit for routine adults | Yes |
| Service Description | Children's Medicaid (Texas Health Steps, Ages 0–20) | Texas CHIP Dental (Children Ages 0–18) | Texas Adult Medicaid (Adults Ages 21+) | Prior Auth (PA) |
|---|---|---|---|---|
| Therapeutic pulpotomy – primary teeth | 1 per lifetime per primary tooth | 1 per lifetime per primary tooth | Not Applicable | No |
| Pulpal therapy (resorbable filling) – anterior primary teeth | 1 per lifetime per primary anterior tooth | Covered for primary anterior teeth | Not Applicable | No |
| Endodontic therapy (root canal) – anterior tooth | 1 per lifetime per permanent tooth | 1 per lifetime per permanent tooth | Not covered for routine adult endodontics | No |
| Endodontic therapy (root canal) – premolar tooth | 1 per lifetime per permanent tooth | 1 per lifetime per permanent tooth | Not covered for routine adult endodontics | Yes |
| Endodontic therapy (root canal) – molar tooth | 1 per lifetime per permanent tooth | 1 per lifetime per permanent tooth | Not covered for routine adult endodontics | Yes |
| Apexification / recalcification (initial, interim, final visits) | Covered for permanent teeth with open apices | Covered for permanent teeth with open apices | Not a covered benefit | Yes |
| Apicoectomy / periradicular surgery | 1 per lifetime per permanent tooth | Covered with clinical justification | Not a covered benefit for routine adults | Yes |
| Service Description | Children's Medicaid (Texas Health Steps, Ages 0–20) | Texas CHIP Dental (Children Ages 0–18) | Texas Adult Medicaid (Adults Ages 21+) | Prior Auth (PA) |
|---|---|---|---|---|
| Gingivectomy or gingivoplasty | Covered for severe hyperplasia or medication-induced enlargement | Covered with medical necessity narrative | Not a covered benefit for routine adults | Yes |
| Gingival flap procedure, including root planing | 1 every 24 months per quadrant | Covered with full periodontal charting | Not a covered benefit for routine adults | Yes |
| Clinical crown lengthening – hard tissue | 1 per lifetime per permanent tooth | Covered with clinical justification | Not a covered benefit | Yes |
| Osseous surgery (flap entry and closure) | 1 every 24 to 36 months per quadrant | Covered with full periodontal charting | Not a covered benefit for routine adults | Yes |
| Bone replacement grafts & soft tissue grafts | Covered with medical documentation | Covered with medical documentation | Not a covered benefit | Yes |
| Periodontal scaling and root planing | 1 every 24 months per quadrant (pocket depths 4mm or greater) | 1 every 24 months per quadrant | Not a covered benefit for routine adults | Yes |
| Full mouth debridement | 1 every 36 months to enable comprehensive evaluation | 1 every 36 months to enable comprehensive evaluation | Not a covered benefit for routine adults | No |
| Periodontal maintenance | Covered following active periodontal therapy (2 per year) | Covered following active periodontal therapy | Not a covered benefit for routine adults | No |
| Service Description | Children's Medicaid (Texas Health Steps, Ages 0–20) | Texas CHIP Dental (Children Ages 0–18) | Texas Adult Medicaid (Adults Ages 21+) | Prior Auth (PA) |
|---|---|---|---|---|
| Complete dentures (maxillary & mandibular) | 1 every 5 years (60 months) per arch | 1 every 5 years (60 months) per arch | Not covered under standard adult Medicaid | Yes |
| Immediate dentures (maxillary & mandibular) | 1 per lifetime per arch | 1 per lifetime per arch | Not covered under standard adult Medicaid | Yes |
| Partial dentures (resin base, cast metal framework) | 1 every 5 years (60 months) per arch | 1 every 5 years (60 months) per arch | Not covered under standard adult Medicaid | Yes |
| Denture repairs, tooth replacements & clasp additions | Covered as needed after 6 months from delivery | Covered as needed after 6 months from delivery | Not a covered benefit for routine adults | No |
| Denture relines (chairside & laboratory) | 1 every 24 to 36 months per arch (after 6 months from delivery) | 1 every 24 to 36 months per arch | Not a covered benefit for routine adults | Yes |
| Fixed bridge pontics & retainer crowns | Restricted to permanent anterior teeth replacement (ages 0–20) | Subject to strict anterior criteria and plan maximum | Not a covered benefit | Yes |
| Service Description | Children's Medicaid (Texas Health Steps, Ages 0–20) | Texas CHIP Dental (Children Ages 0–18) | Texas Adult Medicaid (Adults Ages 21+) | Prior Auth (PA) |
|---|---|---|---|---|
| Simple extraction (erupted tooth or exposed root) | 1 per lifetime per tooth | 1 per lifetime per tooth | Covered for emergency pain, infection, or severe pathology | No |
| Surgical extraction (removal of bone and/or sectioning of tooth) | 1 per lifetime per tooth | 1 per lifetime per tooth | Covered for emergency pain, infection, or severe pathology | No |
| Removal of impacted tooth (soft tissue, partial bony, complete bony) | Covered with documented symptoms, pathology, or orthodontic need | Covered with documented symptoms or pathology | Covered for acute infection, cysts, or severe disease | Yes |
| Removal of residual tooth roots (cutting procedure) | 1 per lifetime per tooth | 1 per lifetime per tooth | Covered for emergency pain or acute infection | No |
| Tooth reimplantation and stabilization | Covered for accidental avulsion or displacement (permanent teeth) | Covered for accidental avulsion or displacement | Covered for traumatic emergency stabilization | No |
| Surgical access of unerupted tooth & eruption device placement | Covered under approved orthodontic treatment plan (ages 0–20) | Covered under approved orthodontic treatment plan | Not a covered benefit | Yes |
| Biopsy of oral tissue (soft tissue, hard bone, salivary) | Covered; pathology report required with claim | Covered; pathology report required with claim | Covered for diagnostic pathology of suspected neoplasm | No |
| Alveoloplasty (in conjunction with or without extractions) | 1 per quadrant in a lifetime | 1 per quadrant in a lifetime | Covered when preparing arch for emergency treatment | Yes |
| Removal of benign cyst, tumor, or lateral exostosis / torus | Covered with clinical documentation and pathology report | Covered with clinical documentation and pathology report | Covered for acute functional obstruction or pathology | Yes |
| Incision and drainage of abscess (intraoral & extraoral soft tissue) | Covered for acute infection and abscess management; 1 per day | Covered for acute infection and abscess management; 1 per day | Covered for acute infection, cellulitis, and abscess drainage | No |
| Frenectomy (buccal, labial, lingual) & frenuloplasty | Covered for severe ankyloglossia or orthodontic interference | Covered with clinical documentation | Not a covered benefit for routine adults | Yes |
| Excision of hyperplastic tissue – per arch | Covered with narrative of medical necessity | Covered with narrative of medical necessity | Not a covered benefit for routine adults | Yes |
| Service Description | Children's Medicaid (Texas Health Steps, Ages 0–20) | Texas CHIP Dental (Children Ages 0–18) | Texas Adult Medicaid (Adults Ages 21+) | Prior Auth (PA) |
|---|---|---|---|---|
| Comprehensive orthodontic treatment – adolescent | Covered for severe handicapping malocclusion (HLD score 26+) | Covered for medically necessary severe malocclusions | Not a covered benefit | Yes |
| Pre-orthodontic treatment examination, periodic visits & retention | Covered under authorized orthodontic treatment plan (ages 0–20) | Covered under authorized orthodontic treatment plan | Not a covered benefit | Yes |
| Service Description | Children's Medicaid (Texas Health Steps, Ages 0–20) | Texas CHIP Dental (Children Ages 0–18) | Texas Adult Medicaid (Adults Ages 21+) | Prior Auth (PA) |
|---|---|---|---|---|
| Emergency palliative treatment of dental pain | Covered per visit; cannot be billed with routine operative on same day | Covered per visit | Covered for immediate relief of acute pain | No |
| Deep sedation & general anesthesia (first 15 minutes & subsequent) | Covered with documented medical, behavioral, or surgical necessity | Covered with documented medical or surgical necessity | Covered for emergency hospital oral surgery procedures | Yes |
| Inhalation of nitrous oxide / analgesia | Covered per visit for children and anxious pediatric patients | Covered per visit | Not a covered benefit for routine adults | No |
| Intravenous moderate conscious sedation | Covered with medical necessity narrative and treatment plan | Covered with medical necessity narrative and treatment plan | Covered for emergency hospital oral surgery procedures | Yes |
| Enteral & non-intravenous parenteral sedation | Covered with comprehensive clinical documentation | Covered with comprehensive clinical documentation | Not a covered benefit for routine adults | Yes |
| Hospital or ambulatory surgical center call | Covered when dental care must be rendered in operating room | Covered when dental care must be rendered in operating room | Covered for acute medical-surgical emergencies | Yes |
| Behavior management, by report | Covered for severe physical, developmental, or intellectual disabilities | Covered with clinical documentation | Not a covered benefit for routine adults | No |
| Occlusal guard (hard or soft appliance) | 1 every 36 to 60 months for documented severe bruxism | Covered with clinical documentation | Not a covered benefit | Yes |
| Teledentistry (synchronous & asynchronous) | Covered for triage and remote consultation; 1 per day | Covered for triage and remote consultation | Covered for emergency triage | No |
| Dental case management | Covered for children with special health care needs | Covered for patients with special health care needs | Not a covered benefit | No |
| Treatment | What Must Be Documented |
|---|---|
| Every prior authorization request | Submitted through the DMO's secure web portal, clearinghouse EDI, or the standardized Texas DSHS / Texas Medicaid Dental Prior Authorization Form, with diagnostic-quality pre-treatment radiographs (complete crown to apex), full-mouth periodontal charting within the prior twelve months, intraoral photographs where pathosis is not evident on X-rays, study casts where indicated, and a comprehensive written narrative signed by the treating dentist. Authorization cannot be granted retroactively. |
| Single cast and ceramic crowns on permanent teeth | Porcelain, porcelain-fused-to-metal, and full cast noble or predominantly base metal crowns require pre-operative periapical and bitewing radiographs demonstrating sound root anatomy, absence of untreated periapical pathosis, adequate periodontal bone support, and documentation that coronal destruction exceeds 50% of the natural tooth structure so a filling cannot restore form and function. |
| Core buildups and prefabricated post and core foundations | Mandatory prior authorization. |
| Endodontic therapy (root canals) on permanent bicuspids and molars | Mandatory prior authorization. |
| Complete and partial removable prosthodontics | Initial dentures and replacement appliances after the statutory 5-year waiting period require documentation that all active decay across the arch is treated, extractions are completed and healed, and remaining partial denture abutment teeth show at least 50% bone support without active periodontal disease. |
| Denture relines and rebase procedures | Mandatory prior authorization. |
| Surgical periodontal procedures | Gingivectomy, osseous surgery, crown lengthening, and tissue grafts require documentation of severe drug-induced gingival hyperplasia or full-mouth periodontal pocket depths exceeding 4mm that have been refractory to scaling and root planing. |
| Periodontal scaling and root planing | Mandatory prior authorization. |
| Surgical removal of impacted third molars | Radiographic and narrative demonstration of active pathology, recurrent pericoronitis, impaction-induced root resorption of adjacent teeth, dentigerous cysts, or associated systemic infection. Routine prophylactic extraction of asymptomatic, disease-free impacted teeth is not covered. |
| Surgical exposure of unerupted teeth and orthodontic eruption devices | Mandatory prior authorization. |
| Level 4 deep sedation and general anesthesia | Comprehensive medical histories documenting why cognitive, developmental, or acute physical disabilities preclude local or conscious sedation, in outpatient or hospital operating room environments. |
| Comprehensive adolescent orthodontic treatment | Children and adolescents under age 21 only; requires documented handicapping craniofacial anomalies or a validated Handicapping Labio-Lingual Deviation (HLD) index score of 26 or greater, supported by cephalometric radiographs, tracings, photographic series, and diagnostic study models. |
| EPSDT requests beyond standard limits (birth through age 20) | Clearly indicate the request is submitted under EPSDT rules, with an extensive written justification, complete diagnostic imaging, and physician or dental specialist documentation proving that denial would result in progressive dental infection, functional impairment, or severe deterioration of the child's systemic well-being. |
Important Coverage Disclaimer: Texas Medicaid and CHIP dental benefits vary by member eligibility category, age bracket, and clinical necessity. Benefit coverage is contingent upon active eligibility on the exact date of service, provider network participation, verified procedure frequency limitations, and prior authorization approval where mandated by Texas Health and Human Services Commission (HHSC) policy. Children from birth through age 20 have comprehensive protections under federal EPSDT guidelines when medically necessary. This page is compiled for patient education and does not guarantee payment, reimbursement rates, or benefit approval. Official claims determinations by the respective dental plan administrators supersede this summary.
Everything you need to know before your first visit. Have another question?
Call 512-430-4472 →Children's Medicaid (Texas Health Steps, ages 0 to 20) has no annual maximum, a $0 deductible, and 100% coverage — it is exempt under EPSDT. Texas CHIP Dental (ages 0 to 18) has a yearly maximum of $500 to $1,000 depending on tier, with copays on higher tiers. Adult Medicaid covers emergency medical and surgical services only, with no routine maximum.
Only emergencies. Standard Texas Medicaid provides no routine preventative, basic restorative, periodontal, endodontic, or removable prosthodontic dental coverage for adults age 21 and older. Adult benefits are restricted to emergency medical-surgical services to control acute pain, infection, hemorrhage, or trauma. Limited adult dental benefits may be available only through specific STAR+PLUS Home and Community-Based Services (HCBS) waiver programs.
Texas Medicaid and CHIP dental services for children are managed through three state-contracted Dental Maintenance Organizations: DentaQuest Texas (providers.dentaquest.com, 1-800-896-2374), MCNA Dental Texas (portal.mcnadental.net, 1-855-699-6262), and UnitedHealthcare Dental Texas (uhcdental.com, 1-800-445-9090). Adult Medicaid is administered through the Texas Medicaid & Healthcare Partnership (tmhp.com, 1-800-925-9126). The HHSC client hotline is 2-1-1. Always verify your assigned DMO, since authorizations and claims go directly to that plan.
Bring your State of Texas Your Texas Benefits Medicaid identification card or active DMO health plan card (DentaQuest, MCNA Dental, or UnitedHealthcare Dental); valid government-issued photo identification of the adult patient, parent, or legal guardian; a complete list of current prescription medications and the treating physician's contact information (required for sedation and surgical prior authorization reviews); and the official school or daycare dental screening referral form if the child was referred following a community oral health check.
Children's Medicaid covers services at 100% with a $0 deductible and no annual maximum. Network dentists must accept Medicaid reimbursement as payment in full and are strictly prohibited by federal and state law from balance billing Medicaid members or charging out-of-pocket upgrade fees (such as extra charges for cosmetic all-ceramic restorations or flexible partials) when Medicaid provides standard covered benefits. If a non-emergency service requiring prior authorization is performed without approval, it is denied and the Medicaid client cannot be billed for it. CHIP plans may apply copays on higher tiers.
Crowns on permanent teeth, core buildups and post and core, root canals on premolars and molars, complete and partial dentures, denture relines and rebases, surgical periodontal procedures, scaling and root planing, surgical removal of impacted third molars, surgical exposure of unerupted teeth, deep sedation and general anesthesia, and comprehensive orthodontics all require prior authorization from your child's DMO. Emergency services — limited emergency evaluations, emergency radiographs, palliative treatment of dental pain, incision and drainage of acute infection, and simple extractions for acute pain, infection, or trauma — never require prior authorization.
It may be. Under the federal and state EPSDT mandate, children from birth through age 20 are entitled to any medically necessary dental service required to correct, ameliorate, or maintain physical, dental, or mental health conditions, even if it exceeds standard Texas Medicaid frequency limits or is excluded from adult schedules. We submit the prior authorization under EPSDT rules with an extensive written justification, complete diagnostic imaging, and physician or dental specialist documentation.
For children under 21 only, and only for severe handicapping malocclusion — a validated HLD index score of 26 or greater, or documented handicapping craniofacial anomalies — supported by cephalometric radiographs, tracings, photographs, and study models, with prior authorization. Orthodontic evaluations, braces, appliance therapy, and retainers are not covered for adults age 21 and older.
Dental implants, abutments, and implant-supported crowns are not covered under Texas Medicaid, except for severe craniofacial developmental deformities or extensive trauma reconstruction approved under medical necessity review. Fixed bridges are not covered for adults and are restricted to children under 21 for replacing missing permanent anterior teeth where all other restorative care is completed, subject to prior authorization.
No. Texas Medicaid and CHIP dental benefits vary by member eligibility category, age bracket, and clinical necessity, and coverage depends on active eligibility on the exact date of service, provider network participation, verified frequency limitations, and prior authorization approval where mandated by HHSC policy. This page is for patient education and does not guarantee payment, reimbursement rates, or benefit approval. Official claims determinations by the respective dental plan administrators supersede this summary.
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