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.
This table provides more information about the covered adult dental services and 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.
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.