MassHealth Insurance
Overview
Eligibility
MassHealth dental coverage is available to Massachusetts residents who meet specific income, residency, and citizenship or immigration requirements. Eligibility varies based on age, medical needs, disability status, pregnancy, or enrollment through programs such as the Department of Developmental Services (DDS).
Our team can check your eligibility in just a few minutes—simply bring your MassHealth ID when you arrive.
Understanding Your Benefits
| Service category | Children under 21 (Standard / CommonHealth / Family Assistance / CarePlus) | Adults 21+ (Standard / CommonHealth / Family Assistance / CarePlus) | DDS adults (qualifying programs) | MassHealth Limited (emergency only) | CMSP (Children’s Medical Security Plan) |
| Exams, cleanings, fluoride | Covered (routine preventive care) | Covered (medically necessary) | Expanded preventive coverage in many cases | Covered only when part of an emergency visit | Covered up to annual plan maximum |
| X-rays and diagnostics | Covered | Covered (when medically necessary) | Covered, often at expanded levels | Covered when needed to treat an emergency | Covered, subject to CMSP limits |
| Sealants and preventive services | Covered on eligible teeth | Plan-dependent | Often covered similarly to children | Not typically covered | Covered, subject to CMSP limits |
| Fillings and basic restorative care | Covered | Covered (medically necessary) | Covered, often with expanded benefits | Covered only to relieve pain or infection | Covered for many basic needs until maximum is reached |
| Root canals | Covered (with some exceptions) | Plan-dependent | Often covered when medically necessary | Covered only when part of an emergency | Limited coverage; varies by CMSP plan tier |
| Crowns and major restorative | Covered when medically necessary | Covered when medically necessary | Often covered when medically necessary | Covered only if required to treat an emergency | Limited; varies by plan tier and annual maximum |
| Extractions and oral surgery | Covered | Covered | Covered | Covered when needed for pain, swelling, or infection | Covered when medically necessary within plan limits |
| Dentures and partials | Covered | Covered (medically necessary) | Often covered; enhanced benefits may apply | Covered only if part of emergency stabilization | Limited or not covered; depends on CMSP plan |
| Periodontal treatments | Covered when medically necessary | Covered on a plan-dependent basis (may require prior authorization) | Often covered when medically necessary | Only when needed in an emergency setting | Limited; varies by CMSP plan |
| Sedation / general anesthesia | Covered when medically necessary | Covered when medically necessary | Covered when medically necessary | Covered only if required to manage an emergency | Limited; varies by CMSP plan |
| Orthodontics | Covered only when medically necessary, with prior authorization | Generally not covered | May be covered when medically necessary with prior auth | Not covered | Not typically covered |
Services for Children (Under Age 21)
Children under 21 may receive a comprehensive range of preventive and restorative services, including:
- Routine exams, cleanings, and fluoride treatments
- Sealants and preventive care
- X-rays and diagnostic imaging
- Fillings and crowns
- Root canals (with some exceptions)
- Tooth extractions and oral surgery
- Dentures, partials, and plates
- Space maintainers
- Sedation or general anesthesia (when medically necessary)
- Some orthodontic treatment (with prior authorization)
Services for Adults (21+)
Adult members may receive medically necessary services, including:
- Dental exams and cleanings
- X-rays and fluoride treatments
- Fillings and basic restorative care
- Root canals (plan-dependent
- Crowns (when medically necessary)
- Extractions and oral surgery
- Full and partial dentures
- Some periodontal treatments, which may require prior authorization
DDS (Department of Developmental Services) Patients
Adults enrolled in DDS programs may qualify for expanded dental benefits, often similar to coverage provided to children. This may include additional preventive, restorative, and medically necessary services. Our team works closely with DDS case managers to help ensure coordinated and appropriate care.
Prior Authorization
Certain dental services require MassHealth approval before treatment begins—especially orthodontics, periodontal therapy, major restorative procedures, and complex oral surgery. Our administrative team manages all prior authorization requests and keeps you informed throughout the process.
MassHealth Limited
MassHealth Limited provides emergency dental coverage only. Emergency services include treatment needed to relieve severe pain, control infection, reduce swelling, or address conditions that pose a health risk. If you are enrolled in MassHealth Limited, contact our office and we will review which emergency services may be covered.
Children’s Medical Security Plan (CMSP)
Smiley Dental Waltham accepts CMSP, which provides dental coverage for eligible children up to a specific annual maximum based on the child’s plan tier. Covered services may include:
- Exams and cleanings
- Fluoride treatments
- Sealants
- Fillings
- Limited restorative procedures
Coverage varies by CMSP plan. Our team will review your benefits with you at your visit.
Frequently Asked Questions
Does MassHealth cover crowns?
Crowns are covered when medically necessary, such as for teeth that are severely decayed or fractured. Prior authorization may be required.
What dental services are covered for adults under MassHealth?
Adults may receive exams, cleanings, X-rays, fillings, extractions, dentures, crowns when medically necessary, root canals on certain teeth, and some periodontal services. Coverage varies by plan.
Are children fully covered under MassHealth?
Yes. Children under 21 receive comprehensive benefits, including preventive care, restorative services, fluoride treatments, sealants, X-rays, fillings, extractions, certain periodontal procedures, and medically necessary orthodontics with prior authorization.
What is MassHealth Limited?
MassHealth Limited provides emergency-only dental coverage. This includes treatment to relieve pain, stop bleeding, or manage infection. Routine care is not covered.
Will I have out-of-pocket costs?
Most medically necessary services are covered. Any non-covered services or optional upgrades may involve out-of-pocket costs, which we always explain in advance.
Do I need a referral from my primary care provider?
No. MassHealth does not require a referral for dental appointments.
What if I’m unsure whether I’m eligible?
Our team can verify eligibility quickly. Bring your MassHealth card or provide your member information by phone.
Are dentures covered under MassHealth?
Yes. Full and partial dentures are covered when medically necessary. Replacement dentures may require justification.
Is periodontal (gum) treatment covered?
Periodontal services such as scaling and root planing are covered when medically necessary. Frequency depends on individual treatment needs.
Does MassHealth cover cosmetic dentistry or whitening?
No. Cosmetic procedures such as whitening, veneers, and elective cosmetic services are not covered.
Can adults receive sealants under MassHealth?
Sealants are typically covered for children and teens. Adult coverage varies by plan.
How often are cleanings covered?
Most members are covered for two preventive cleanings per year, with additional periodontal maintenance visits if required.
Does MassHealth cover root canals on all teeth?
Coverage depends on the tooth. Front teeth and premolars are generally covered, while molars may require additional justification or may not be covered depending on the plan.
Our Service Area
Smiley Dental Waltham proudly serves patients from Waltham and nearby MetroWest communities, including Newton, Watertown, Belmont, Lexington, Weston, and surrounding areas.
Call us today at 781-666-6000 to schedule your appointment.
