Dental Benefits for Adults with Medicaid

By Kristine Goodwin | Vol . 23, No. 26 | July 2015

NCSL NewsDid you know?

  • Dental-related emergency room visits increased from 1.1 million in 2000 to 2.1 million in 2010.
  • In 2010, it cost up to $2.1 billion to treat dental problems in hospital emergency rooms.
  • States determine whether to cover dental benefits for adults enrolled in Medicaid.

Oral health care is a vital—but often overlooked—component of overall health for adults in the United States, according to a 2011 Institute of Medicine report. Many Americans lack dental coverage, and even those with insurance face barriers to dental care. Low-income adults are less likely to have visited a dentist within the last year than those with higher incomes, and they are more likely to have untreated tooth decay. Complications from dental disease are associated with increased risk for diabetes, heart disease, stroke, and pre-term birth and other adverse pregnancy outcomes.

A growing number of Americans forego critical preventive care only to end up in a hospital emergency room (ER), often for preventable dental emergencies. In 2010, more than 2 million Americans visited the ER for a dental problem—most of which were non-traumatic dental conditions, according to the American Dental Association’s Health Policy Institute. In most cases, ER providers give prescriptions to relieve pain or antibiotics for infection, but they may not address underlying problems.

The trend comes at a high price to states. Dental-related ER visits cost the health care system up to $2.1 billion in 2010, including for Medicaid patients with untreated dental problems. Many dental ER visits can be prevented through less costly, preventive care delivered in health centers, dental offices and other community-based settings. However, budget pressures and the cost of providing dental benefits have led some states to reduce or eliminate Medicaid dental benefits or consider other short-term cost-containing policies, such as limiting covered services and sharing costs with enrollees.

State Action

States have taken several steps to improve health, increase access to dental care and reduce avoidable costs for adult Medicaid enrollees.

Provide Adult Dental Benefits for Medicaid Enrollees. Although dental coverage is not a required benefit for adult Medicaid enrollees under federal law (as it is for children), most states provide at least some dental benefits for this group. Some states provide dental benefits to all qualified adults, while others cover targeted groups, such as pregnant women or those with developmental disabilities.

According to a 2015 report from the Center for Health Care Strategies Inc., 45 states and the District of Columbia currently cover at least emergency dental services (e.g., relief for uncontrolled bleeding or trauma) for adults with Medicaid; of those, 14 states cover emergency care only, 16 states and the District of Columbia cover certain limited services, and 15 states offer extensive coverage. Compared to states with limited coverage, states with extensive benefits cover more diagnostic, preventive and restorative procedures and have a higher annual benefit limit.

  • Several states have restored adult dental coverage in recent years. A 2014 California law covers certain dental benefits for all adults on Medi-Cal (the state’s Medicaid program). In 2014, Idaho lawmakers reinstated dental benefits for adults enrolled in Medicaid, including coverage for routine exams and preventive and other dental services. In 2013, Washington restored dental coverage for Medicaid-enrolled adults, which includes restorative and preventive services, emergency services, root canals, cavity care, and routine checkups and cleanings.
  • Some states are providing preventive dental benefits to adults for the first time. In 2013, Colorado lawmakers passed Senate Bill 242, which provided dental benefits to all adult Medicaid enrollees, with up to $1,000 in dental benefits each year. South Carolina will cover cleaning, fillings and extractions for adults with very low incomes or disabilities.

Expanding Workforce Capacity. Dental coverage alone does not guarantee access to care. More than 8 million adults were eligible to gain Medicaid dental benefits in 2014, but many states and communities do not have an adequate workforce to handle the increased demand. A 2015 report by the Colorado Health Institute found that the number of Coloradans eligible for Medicaid dental benefits tripled to 1.1 million, while the number of dentists who treat Medicaid patients increased by just 125.

Some states have adopted financial and other incentives—including enhanced reimbursement or reduced administrative burden—to increase the number and availability of oral health providers who are willing to provide care to Medicaid patients. States also have taken steps to increase the capacity of the existing oral health workforce to meet demand, for example, through use of tele-health or through changes to provider roles and practice settings. California lawmakers passed legislation in 2014 to reimburse hygienists and dentists for tele-health dental services.

Other Related Strategies. Other strategies for the adult Medicaid population focus on coordinating physical, mental, behavioral and oral health for those enrolled in Medicaid. Most state Medicaid programs reimburse primary care providers for performing oral exams and screenings and for providing preventive services, such as fluoride treatments and education. States also have reached out to inform and enroll adults who may not know they are eligible. Several states are gathering data about the costs, benefits and return on investment for offering adult dental benefits.

Federal Action

As of May 2015, 29 states and the District of Columbia expanded Medicaid eligibility to adults with incomes up to 133 percent of the federal poverty level, as allowed under the Affordable Care Act. The ACA provides federal funds for states that expand Medicaid.

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