Paul Sanchez
Dental coverage is an important aspect of overall health, and while dental services are provided for children under Medicaid, the availability of dental insurance for adults varies by state. Each state has the flexibility to determine the extent of dental benefits provided to adult Medicaid enrollees, with most states offering at least emergency dental services and less than half providing comprehensive dental care. This is in contrast to children, where states are required to provide dental benefits as part of the Early and Periodic Screening, Diagnostic and Treatment (EDPDT) benefit. This ensures that children have access to necessary dental services, including teeth cleaning, x-rays, cavity fillings, and crowns.
| Characteristics | Values |
|---|---|
| Dental coverage | States are required to provide dental benefits to children covered by Medicaid and the Children's Health Insurance Program (CHIP). However, states choose whether to provide dental benefits for adults. |
| Dental services for children | Must minimally include teeth cleaning, x-rays, cavity fillings, crowns, and other services. |
| Dental services for adults | Adults enrolled in Medicaid are eligible at a minimum for surgical procedures and emergency services related to treating symptoms and pain. Some adults may be eligible for other dental services. |
| Dental coverage in separate CHIP programs | Must include coverage for dental services necessary to prevent disease, promote oral health, restore oral structures to health and function, and treat emergency conditions. |
| Medicaid and CHIP enrollment | There has been an increase in Medicaid and CHIP enrollment among children and adults. |
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What You'll Learn
Dental coverage for children
Dental health is an important aspect of overall health. States are required to provide dental benefits to children covered by Medicaid and the Children's Health Insurance Program (CHIP). This includes dental services for all child enrollees under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. The EPSDT benefit provides a comprehensive set of health care services, including screening, vision, hearing, and dental services, for children under the age of 21. States are required to cover all these services as well as any services necessary to correct or ameliorate a child's physical or mental health condition.
Dental services for children must be provided at intervals that meet reasonable standards of dental practice and at other intervals as medically necessary. States must consult with recognized dental organizations involved in child health care to establish these intervals. A referral to a dentist is required for every child in accordance with each state's periodicity schedule and at other medically necessary intervals. The periodicity schedule for other EPSDT services may not govern the schedule for dental services.
While oral screening may be part of a physical exam, it does not substitute a dental examination performed by a dentist. Dental coverage in separate CHIP programs must include coverage for dental services necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions. States with separate CHIP programs have the option to choose from two types of dental coverage: a package that meets CHIP requirements or a benchmark dental benefit package.
The benchmark dental package must be substantially similar to the most popular federal employee dental plan for dependents, the most popular plan selected for dependents in the state's employee dental plan, or dental coverage offered by the most popular commercial insurer in the state. States have the flexibility to determine what dental benefits are provided to adult Medicaid enrollees, and there are no minimum requirements for adult dental coverage. Rates of dental service use among children enrolled in Medicaid or CHIP vary substantially by state, ranging from under 40% in some states to over 60% in others. These rates also tend to be slightly lower in rural areas compared to urban areas.
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Dental coverage for adults
Medicaid is a health insurance program that provides coverage for various services, including dental care. However, the availability and extent of dental coverage for adults under Medicaid can vary by state. While states are required to provide dental benefits to children covered by Medicaid, they have the flexibility to decide whether to offer dental benefits to adults. This means that dental coverage for adults under Medicaid is not uniform across the country.
In 2010, the Centers for Medicare & Medicaid Services (CMS) established the Oral Health Initiative (OHI) to enhance children's access to preventive dental care. While this initiative primarily focused on children, it has also contributed to an increase in Medicaid and CHIP enrollment among adults. Additionally, some states have expanded dental benefits for adults enrolled in Medicaid, indicating a positive shift in oral health care accessibility.
The specific dental services covered under Medicaid for adults can vary. While most states provide at least emergency dental services for adults, less than half offer comprehensive dental care. States with separate Children's Health Insurance Program (CHIP) plans have the option to choose from two coverage alternatives. They can either select a package that complies with CHIP requirements or a benchmark dental benefit package comparable to popular federal employee dental plans or commercial insurer options within the state.
It is worth noting that certain populations may have enhanced dental coverage under Medicaid. For example, adults with disabilities, visual impairments, or those aged 65 and older may receive coverage for diagnostic, preventive, endodontic, prosthodontic, and extraction services. Similarly, pregnant individuals or those within the postpartum period may also qualify for expanded dental benefits.
To determine the exact dental coverage provided by Medicaid in a specific state, it is advisable to refer to the relevant state-specific resources and guidelines. The Adult Dental Medicaid Coverage Checker by CareQuest Institute can be a useful tool to understand the benefit package in each state, although it may not always reflect the most recent updates.
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Medicaid and CHIP
Dental health is considered an important part of overall health, and states are required to provide dental benefits to children covered by Medicaid and CHIP. This mandate is known as the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, which includes dental services such as teeth cleaning, x-rays, cavity fillings, and crowns. States must also develop a dental periodicity schedule in consultation with recognized dental organizations to ensure that dental services are provided at regular intervals and meet reasonable standards of dental practice.
While dental coverage for children under Medicaid and CHIP is guaranteed, states have the flexibility to determine what dental benefits are provided to adult enrollees in Medicaid. Most states provide at least emergency dental services for adults, and some offer comprehensive dental care. The specific dental services covered for adults can vary depending on the state and the eligibility category of the enrollee.
In 2010, the Centers for Medicare & Medicaid Services (CMS) established the Oral Health Initiative (OHI) to improve access to preventive dental care for children enrolled in Medicaid and CHIP. Since then, there have been positive changes, including increased enrollment, state expansion of dental benefits for adults, and the growth of dental managed care delivery systems. CMS continues to work towards improving oral health care access and quality for beneficiaries of Medicaid and CHIP.
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Dental services covered
Dental health is an important part of people's overall health. States are required to provide dental benefits to children covered by Medicaid and the Children's Health Insurance Program (CHIP). However, states have the flexibility to determine what dental benefits are provided to adult Medicaid enrollees, and there are no minimum requirements for adult dental coverage. While most states provide at least emergency dental services for adults, less than half provide comprehensive dental care.
Medicaid covers dental services for all child enrollees as part of a comprehensive set of benefits, referred to as the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. This program focuses on prevention, early diagnosis, and treatment of medical conditions. Oral screening may be part of a physical exam, but it does not substitute a dental examination performed by a dentist. A referral to a dentist is required for every child in accordance with the periodicity schedule set by each state.
Dental services must be provided at intervals that meet reasonable standards of dental practice and at other intervals as medically necessary to determine the existence of a suspected illness or condition. States must consult with recognized dental organizations involved in child healthcare to establish these intervals. The periodicity schedule for other EPSDT services may not govern the schedule for dental services.
Dental coverage in separate CHIP programs must include coverage for dental services "necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions." States with separate CHIP programs may choose from two options for providing dental coverage: a package of dental benefits that meets CHIP requirements or a benchmark dental benefit package. The benchmark dental package must be substantially equal to the most popular federal employee dental plan for dependents, the most popular plan selected for dependents in the state's employee dental plan, or dental coverage offered through the most popular commercial insurer in the state.
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Eligibility and enrollment
Eligibility for dental insurance under Medicaid depends on the state in which you reside and your age. States are required to provide dental benefits to children covered by Medicaid and the Children's Health Insurance Program (CHIP). However, states have the discretion to decide whether to offer dental benefits to adults. While most states provide at least emergency dental services for adults, less than half provide comprehensive dental care.
The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit is a comprehensive child health program that includes dental services as part of a mandatory service required under a state's Medicaid program. All states must provide dental services to individuals under the age of 21 who are enrolled in Medicaid as part of the EPSDT benefit. These dental services must be provided at intervals that meet reasonable standards of dental practice and may not be limited to emergency services. A referral to a dentist is required for every child in accordance with each state's periodicity schedule and at other intervals as medically necessary.
States with a separate CHIP program can choose from two options for providing dental coverage: a package of dental benefits that meets CHIP requirements or a benchmark dental benefit package. The benchmark dental package must be substantially equivalent to the most popular federal employee dental plan for dependents, the most popular plan chosen for dependents in the state's employee dental plan, or dental coverage offered by the most popular commercial insurer in the state. States with CHIP coverage for children through a Medicaid expansion program are required to provide the EPSDT benefit.
To improve access to dental services for children enrolled in Medicaid and CHIP, the Centers for Medicare & Medicaid Services (CMS) established the Oral Health Initiative (OHI) in 2010. CMS invited state Medicaid agencies to develop State Oral Health Action Plans (SOHAPs) to improve oral health care in their states. As of 2020, CMS has received SOHAPs from 25 states and is encouraging the remaining states to develop and submit their plans. CMS is committed to working with states, federal partners, the dental provider community, and advocates to enhance access to dental and oral health services for beneficiaries enrolled in Medicaid and CHIP.
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Frequently asked questions
States choose whether to provide dental benefits for adults with Medicaid. Most states provide at least emergency dental services, and less than half of the states provide comprehensive dental care.
All children covered by Medicaid are entitled to dental benefits. This includes teeth cleaning, x-rays, cavity fillings, crowns, and other services.
Dental health is an important part of people's overall health. The Centers for Medicare & Medicaid Services (CMS) is committed to improving access to dental and oral health services for beneficiaries enrolled in Medicaid.
