Pennsylvania Medical Assistance : Evaluation of Children ’ s Access to Dental Services
ages 1-6 are eligible for Medical Assistance if their family income is equal to or less than 133 percent of the FPL , which is $ 33,728 for a family of 4 .
Table 1 : Medical Assistance Income Eligibility Requirements for Children
Age |
% of the FPL |
Income limit for a family of 4 ( 2010 )* |
0-1 |
185 % |
$ 46,916 |
1-6 |
133 % |
$ 33,728 |
6-19 |
100 % |
$ 25,360 |
* https :// www . cms . gov / MedicaidEligibility / Downloads / POV10Combo . pdf
Children also qualify for Medical Assistance if they meet the Social Security Administration ( SSA ) level of disability . A child under age 18 is considered disabled if he or she has a medically determinable physical or mental impairment which results in marked and severe functional limitations and ( i ) can be expected to result in death or ( ii ) has lasted or can be expected to last for a continuous period of not less than 12 months . 3 In Pennsylvania , a child who meets the disability standards is eligible for Medical Assistance regardless of the family ’ s income and assets . 4 In FY09 , 35.5 percent of children in Pennsylvania , or about one million children , were covered by Medical Assistance . 5 Across the counties , coverage ranged from a high of 60 percent of children in Philadelphia County , to a low of 14.6 percent in Chester County ( Figure 1 ). 6
Dental Services
Delivery of Dental Services Two delivery models are used to provide dental services in Medical Assistance : managed care and fee-for-service ( FFS ). About 73 percent of children enrolled in Medical Assistance receive their dental services via managed care , while 27 percent access dental services via the FFS network . 7
Covered Dental Services for Children For Medicaid enrollees under the age of 21 , federallymandated services and benefits are provided under the Early and Periodic Screening , Diagnostic and Treatment ( EPSDT ) program . EPSDT is intended to assure the availability and accessibility of medically needed medical care and to help children and families use them effectively . 8 Dental services are an EPSDT benefit . Pennsylvania Medical Assistance covers all medically necessary dental services for children , including 9 :
• Periodic oral exams
• Diagnostic dental services
• Preventative dental services , such as sealants and topical fluoride treatment
• Emergency treatment for control of pain and infection
• Oral and maxillofacial surgery
• Fillings and tooth extractions
• Root canal treatments
• Prosthetic appliances , such as dentures and crowns
• Orthodontics for children who qualify
Figure 1 : FY09 Percentage of Children Covered by Medical Assistance by Pennsylvania County
Source : Pennsylvania Department of Public Welfare Medical Assistance Enrollment Data and estimates from the US Census Bureau
20 September / October 2010 • Pennsylvania Dental Journal