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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 1 per 12 months
D0150 comprehensive oral evaluation - established or new patient 1 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.

Prior Authorization is NOT required for any of the above services.

Network

The dental provider network is being finalized. A listing of dentists participating in the initial network is available in our online provider directory. The network will continue to grow after September 1 as well.