Adult Dental Benefit
AmeriHealth Caritas New Hampshire is the only Medicaid plan in New Hampshire currently offering an adult dental benefit.
Adult members (21 and older) are covered for a range of dental services including:
- preventive services (cleanings),
- diagnostic services (exams and x-rays),
- restorative services (fillings),
- some periodontal services (root planning and scaling).
The NH Department of Health and Human Services will continue to cover extractions, and that is a separate program.
Benefits are covered only within the network.
Covered Services
This table provides more information about the covered adult dental services and limits.
| Code | Description | Limits |
|---|---|---|
| D0120 | Periodic oral evaluation - established patient | 2 per 12 months |
| D0150 | comprehensive oral evaluation - established or new patient | 2 per 12 months |
| D0274 | Bitewings - four radiographic images | 1 per 24 months |
| D1110 | Prophylaxis - Adult | 1 per 12 months |
| D2140 | Amalgam - one surface - primary or permanent | 1 per 24 months |
| D2150 | Amalgam - two surfaces - primary or permanent | 1 per 24 months |
| D2160 | Amalgam - three surfaces - primary or permanent | 1 per 24 months |
| D2161 | Amalgam - four or more surfaces - primary or permanent | 1 per 24 months |
| D2330 | Resin-based composite - one surface anterior | 1 per 24 months |
| D2331 | Resin-based composite - two surfaces anterior | 1 per 24 months |
| D2332 | Resin-based composite - 3 or more surfaces - anterior | 1 per 24 months |
| D2335 | Resin-based composite - 4 or more surfaces - anterior | 1 per 24 months |
| D2391 | Resin-based composite - one surface posterior | 1 per 24 months |
| D2392 | Resin-based composite - two surfaces - posterior | 1 per 24 months |
| D2393 | Resin-based composite - three surfaces - posterior | 1 per 24 months |
| D2394 | Resin-based composite - four or more surfaces - posterior | 1 per 24 months |
| D4341 | Periodontal scaling and root planing - four or more teeth per quadrant | 1 per 24 months |
| D4342 | Periodontal scaling and root planing - one to three teeth per quadrant | 1 per 24 months |
| D4355 | Full mouth debridement to enable comprehensive exam | 1 per 24 months |
Limits above for D2140-D2394 are per tooth.
Network
A listing of dentists participating in our network is available in our online provider directory.