Special Health Care Needs Benefit

Medicare Advantage Plans header

Enhanced benefit for individuals with special health care needs

For 6.5 million people in the U.S. with intellectual or developmental disabilities, oral health care can be inaccessible or overwhelming. Delta Dental is changing that. Effective January 1, 2022, employee group plans may include enhanced benefits for covered members with qualifying special health care needs. 

Before rendering services, providers should check the member’s eligibility file in the Dental Office Toolkit® to verify whether they have coverage under this enhanced benefit. If the member has coverage, you will see that a “Special Health Care Needs” attribute is checked in their file. There is no age limit on these benefits. 

If a member says they are eligible but the attribute is not checked, the subscriber must work with their group to have the member’s file updated accordingly. 

Note: The “Special Health Care Needs” attribute is different from the “Handicap” attribute.

What is included in this benefit?

Beginning January 1, 2022, the below services will be covered under this enhanced benefit for qualifying members. Providers must include remarks regarding the special health care need benefit on applicable claims to indicate that treatment was provided for a patient with special health care needs. 

  • Additional visits to the dentist’s office and/or consultations that can be helpful prior to the first treatment to help patients learn what to expect and what is needed for a successful dental appointment. Additional exam benefits will be allowed for this purpose. 
  • Up to four total dental cleanings in a benefit year. 
  • The use of silver diamine fluoride (SDF) that can be applied to cavities for patients who can’t tolerate the use of dental instruments. 
  • Treatment delivery modifications necessary for dental staff to provide oral health care for patients with sensory sensitivities, behavioral challenges, severe anxiety or other barriers to treatment. 

Training opportunity

With support from the Delta Dental Foundation, Penn Dental Medicine has established a free continuing education series aimed at building awareness of the barriers to equitable oral health care for individuals with disabilities, and developing competency to provide oral health care to this vulnerable population.

Learn more about the Center for Persons with Disabilities Presentation Series.