Improving Access to Medicaid Dental Benefits

By Bryan Kelley | Vol . 22, No. 8 | February 2014

NCSL NewsDid you know?

  • In 2011, 52 percent of children enrolled in Medicaid did not receive dental care, despite having coverage.
  • Between 2007 and 2011, almost half of states increased the proportion of Medicaid-enrolled children receiving a preventive dental service by at least 10 percent.
  • In 22 states, more than half of dentists did not treat any Medicaid-enrolled children in 2011.

Oral health care is an important—but often neglected—component of health for both children and adults. Many Americans are uninsured and even those who have insurance often have difficulty obtaining dental services. With little or no access, people who need dental care may have nowhere to turn except the emergency room (ER). In 2009, more than 830,000 Americans were treated in ERs for toothaches or other preventable dental problems. The cost of treating tooth-decay related cases in ERs was more than $110 million in 2006. Approximately 45 percent of these visits were from uninsured adults, and Medicaid was the most common payer for ER visits by children. Without dentists on staff in the ER, dental problems often are not fully treated for these patients. The American Dental Association’s Health Policy Resources Center reports that most dental emergency visits are for nontraumatic dental conditions, and in most cases medical providers give prescriptions to relieve pain or antibiotics for infection, while underlying problems remain unaddressed.

People without dental coverage are less likely to visit dentists, and are more likely to have poor dental health and know relatively little about the benefits of dental checkups. Even for those with dental coverage, however, accessing dental care is still often difficult because of a shortage of dental health professionals serving their community, an inadequate number of dentists willing to treat Medicaid-enrolled patients, a lack of transportation or flexible work schedule, and a lack of knowledge among some people about the importance of oral health. According to the Pew Children’s Dental Campaign, in 2011, 52 percent of children enrolled in Medicaid did not receive dental care (despite coverage of pediatric dental services), more than 45 million Americans live in designated dental health professional shortage areas—primarily in rural and densely urban areas—and in 22 states, more than half of dentists did not treat any Medicaid-enrolled children. In addition, children with special health care needs are at greater risk for dental problems and experiencing barriers to services. In light of these shortages and the costs of treating expensive problems that result from forgoing preventive care, many lawmakers are working to increase access to dental services for Medicaid-enrolled adults and children

Federal Action

Medicaid provides coverage for “medically necessary” pediatric dental services as a part of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit for children. Each state has some flexibility in determining the schedule of EPSDT screenings, but must cover treatments that include relieving pain and infections, restoring teeth and maintaining dental health. There is no federal requirement that dental coverage be provided to adults under Medicaid. According to 2010 data from the Kaiser Family Foundation, 47 states provide varying forms of coverage. For instance, some states provide coverage only for Medicaid-enrolled pregnant women or emergency treatment for the relief of pain and infection. Due to budget constraints, in the past decade 10 states substantially cut or eliminated funding for adult dental services in Medicaid, according to the Center for Health Care Strategies. Recently some states—such as California, Colorado, Massachusetts and Washington—moved forward with plans to increase or reinstate dental benefits for adult Medicaid enrollees. As of Jan. 28, 2014, 25 states and the District of Columbia chose to expand Medicaid eligibility to adults with an income of up to 138 percent of the federal poverty level. Dental services are not required in these expansions, but more than half of these states decided to include adult dental benefits.

State Action

Some states have found that investing in preventive dental care for Medicaid-enrolled children and adults saves money by avoiding expensive and complicated treatments. In North Carolina, a program called Into the Mouths of Babes established in 1999 reimburses medical providers, such as family doctors, delivering care to Medicaid-enrolled children up to 42 months old. The provider makes an oral evaluation and risk assessment, counsels the child’s primary caregivers on the importance of oral health and applies a topical fluoride varnish. According to a 2010 study in Pediatrics, this program has resulted in a 17 percent reduction in cavity treatments for participating children.

Some states are also expanding dental benefits to Medicaid-enrolled adults. A 2013 Colorado law providing coverage for Medicaid-enrolled adults is expected to reduce costs from dental-related ER visits by more than $2 million in the next two fiscal years. Colorado also increased reimbursement fees to incentivize dentists to accept patients with Medicaid. The state of Washington also restored dental coverage for Medicaid-enrolled adults, which includes restorative and preventive services, emergency services, dentures, root canals, cavity care, and routine checkups and cleanings.

Another strategy to improve access has been to offer dental services in settings outside of a traditional dentist’s office. In Massachusetts, the Oral Health Across the Commonwealth program offers preventive services in sites such as schools with many low-income students, and served almost 8,000 MassHealth (Medicaid and CHIP) beneficiaries during the 2010-2011 school year. The program was also designed to bring preventive oral health care to adults and children with intellectual and developmental disabilities.

A 2010 demonstration program in California—Virtual Dental Home—brings dental care to low-income and underserved children and adults by forming telehealth-enabled teams. Dental hygienists and dental assistants collect diagnostic records, provide preventive services and educate people in underserved communities. Dentists can view these records remotely, provide direction to hygienists and assistants, develop treatment plans or refer patients to a dental office for further caretry.

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