Alyssa Lane
Medicaid is a government-run health insurance program for people with limited income and resources. While Medicaid covers a wide range of health services, dental coverage under Medicaid varies depending on the state and the age of the beneficiary. States are required to provide dental benefits to children covered by Medicaid, but they have the flexibility to decide on the extent of dental coverage for adults. This article will explore the specifics of Medicaid dental insurance, including the benefits covered, the enrollment process, and the out-of-pocket costs associated with dental care under Medicaid. Additionally, we will discuss the recent initiatives by the Centers for Medicare & Medicaid Services (CMS) to enhance dental and oral health services for beneficiaries.
| Characteristics | Values |
|---|---|
| Dental coverage for children | Required |
| Dental coverage for adults | Optional |
| Dental coverage for adults with Medicaid | Varies by state |
| Dental coverage under Medicare | Not covered except in specific circumstances |
| Medicaid dental coverage for children | Covered under EPSDT |
| Medicaid dental coverage for adults | Varies by state |
| Marketplace dental plans | Can be purchased separately or as part of a health plan |
| Marketplace plan costs | Vary depending on coverage level |
| Enrollment period for Marketplace plans | Yearly: November 1 – January 15 |
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What You'll Learn
Dental coverage for children under Medicaid
Dental health is an essential component of overall health, and Medicaid recognizes this by offering dental coverage for children. All states are required to provide dental benefits for children covered by Medicaid and the Children's Health Insurance Program (CHIP). This mandate is part of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, which is a comprehensive child health program focusing on prevention, early diagnosis, and treatment of medical conditions.
The EPSDT benefit ensures that children under the age of 21 have access to dental services, regardless of whether a state chooses to cover adults. States have the flexibility to determine the specific dental benefits provided, but they must include certain minimum requirements. These include oral screenings, which can be part of a physical exam, but a referral to a dentist is still required for every child in accordance with the state's periodicity schedule.
Dental services for children under Medicaid must be provided at intervals that meet reasonable standards of dental practice. States must consult with recognized dental organizations involved in child healthcare to establish these intervals. Additionally, dental services cannot be limited to emergency cases for children entitled to EPSDT. If a condition requiring treatment is discovered during a screening, the state must provide the necessary services, regardless of whether they are included in the state's Medicaid plan.
While Medicaid provides dental coverage for children, utilization rates vary across states. In 2021, the share of children using dental services ranged from under 40% in states like Illinois and Ohio to over 60% in states like Montana and Connecticut. Rural areas generally have lower rates of dental service use compared to urban areas. Initiatives to improve access to dental care for children enrolled in Medicaid and CHIP are ongoing, such as the Oral Health Initiative (OHI) established in 2010 by the Centers for Medicare & Medicaid Services (CMS).
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Dental coverage for adults under Medicaid
Dental health is an important aspect of overall health. While states are required to provide dental benefits to children covered by Medicaid, they have the flexibility to determine what dental benefits are provided to adult Medicaid enrollees. There are no minimum requirements for adult dental coverage under Medicaid, and states may choose whether or not 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 mandatory service under state Medicaid programs, requiring all services to be provided if deemed medically necessary. States determine medical necessity, and if a condition requiring treatment is discovered during a screening, they must provide the necessary services, regardless of whether they are included in the state's Medicaid plan. Dental services for children must be provided at intervals that meet reasonable standards of dental practice and must include oral screenings, although these do not substitute for a dental examination by a dentist.
The Center for Medicaid and CHIP Services at the Centers for Medicare & Medicaid Services (CMS) is committed to improving access to dental services for children and adults enrolled in Medicaid and CHIP. The CMS established the Oral Health Initiative (OHI) in 2010 to enhance children's access to preventive dental care, and in 2023, an expert workgroup recommended broadening the OHI to focus on oral health access, quality, and outcomes across the lifespan.
Some states have made efforts to expand dental coverage for adults under Medicaid. For example, in 2023, Utah sought approval from CMS to expand dental coverage to all adult Medicaid beneficiaries, which would include diagnostic, preventive, endodontic, prosthodontic, and extraction services. Additionally, Connecticut expanded its Medicaid coverage to include certain periodontal services for qualifying adults starting in 2024, and Kansas is anticipated to introduce dental exam and cleaning coverage around the same time.
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Dental coverage for adults and children under Medicare
Dental Coverage for Children under Medicare
States are required to provide dental benefits for children covered by Medicaid and the Children's Health Insurance Program (CHIP). This is known as the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, which is a comprehensive set of benefits that focuses on prevention, early diagnosis, and treatment of medical conditions. The EPSDT benefit requires that all services deemed medically necessary be provided to children. This includes dental services, which must be provided at intervals that meet reasonable standards of dental practice as determined by the state in consultation with recognized dental organizations.
Dental Coverage for Adults under Medicare
Dental coverage for adults under Medicare is not mandatory and varies by state. States have the flexibility to determine what dental benefits, if any, are provided to adult Medicaid enrollees. While most states provide at least emergency dental services for adults, less than half of the states offer comprehensive dental care.
Dental Coverage under Medicare Advantage Plans
Some Medicare beneficiaries may have access to dental coverage through Medicare Advantage plans, but the scope of dental benefits offered can vary widely and may result in high out-of-pocket costs for those with serious dental needs. In 2021, the House of Representatives passed the Elijah E. Cummings Lower Drug Costs Now Act (H.R.3), which included provisions to add dental, vision, and hearing benefits to Medicare Part B. This act is set to take effect in 2025 if it is enacted into law.
Dental Coverage for Hospital Inpatient and Outpatient Services
Medicare may cover dental services that are deemed medically necessary and are connected to other covered inpatient or outpatient hospital services. For example, dental services required to treat an oral or dental infection prior to or during Medicare-covered dialysis services for end-stage renal disease (ESRD) may be covered. Additionally, dental services that are inextricably linked to the clinical success of other Medicare-covered procedures, such as an oral exam and tooth extraction before cancer treatment, may also be covered.
It is important to note that Medicare generally does not cover routine dental care, such as the care, treatment, filling, removal, or replacement of teeth or supporting structures. However, there may be specific circumstances where dental services are covered, such as when they are directly related to certain medical treatments like heart valve replacement or organ transplants.
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Marketplace dental plans
In the United States, dental coverage is offered as part of some health plans but not all. If you're enrolled in a health plan with dental coverage, you can't remove dental coverage from your Marketplace health plan. However, you can change health plans (with or without dental coverage).
There are two categories of Marketplace dental plans: high and low. High-option dental plans have a higher premium but lower copayments and deductibles. Low-option dental plans have lower premiums but higher copayments and deductibles.
If you pick a health plan without dental benefits, you can still get a separate dental plan. You can preview health plans with dental coverage and separate dental plans before purchasing. It's important to note that you can't buy a Marketplace dental plan unless you're buying a health plan at the same time.
Dental coverage is an essential health benefit for children aged 18 and under. This means that if you're buying health insurance for a child or teen through the Marketplace, insurers must offer dental benefits for your child, either as part of a health plan or through a separate dental plan. However, you are not required to purchase dental coverage.
The yearly period when people can enrol in a Marketplace health insurance plan is from November 1 to January 15. You may qualify for a Special Enrollment Period if you've had certain life events, such as losing health coverage, moving, getting married, having a baby, or adopting a child, or if your household income is below a certain amount.
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Medicaid dental benefits by state
Dental health is an important part of overall health. While Medicaid covers dental services for children under the age of 21 as a mandatory service, states have the flexibility to determine what dental benefits are provided to adult Medicaid enrollees. There are no minimum requirements for adult dental coverage, and dental benefits for adults are not required by federal law.
Dental Benefits for Children
States are required to provide dental benefits to children covered by Medicaid and the Children's Health Insurance Program (CHIP). The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit is a mandatory service required under a state's Medicaid program. It 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 must be provided at intervals that meet reasonable standards of dental practice, as determined by the state in consultation with recognized dental organizations involved in child health.
Dental Benefits for Adults
Dental benefits for adults enrolled in Medicaid are optional for states to provide. States have considerable discretion in defining Medicaid adult dental benefits, and there are no minimum requirements for adult dental coverage. Most states provide only limited coverage, often restricted to extractions or emergency services. However, rates of dental service use among adults are relatively low across all states, even in states with more extensive Medicaid dental coverage policies.
Improving Access to Dental Care
The Centers for Medicare & Medicaid Services (CMS) is committed to improving access to dental and oral health services for beneficiaries enrolled in Medicaid and CHIP. In 2010, CMS established the Oral Health Initiative (OHI) to improve children's access to appropriate preventive dental care by working with states, federal partners, the dental provider community, and advocates. CMS has received State Oral Health Action Plans (SOHAPs) from 25 states and encourages the remaining states to develop and submit their plans.
State Variation in Dental Coverage
There is variation among states in the extent of dental coverage provided for both children and adults enrolled in Medicaid and CHIP. While most states have made progress in increasing children's access to dental care, there are still barriers to accessing dental services, including dental workforce shortages and a lack of dental providers accepting Medicaid. States with more extensive dental coverage policies for adults tend to have higher rates of dental service use, but even in these states, there may be issues related to access to dental care.
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Frequently asked questions
There is a yearly enrollment period for Marketplace health insurance plans from November 1 to January 15.
States are required to provide dental benefits to children covered by Medicaid. Dental services for children must include oral screening, but this does not substitute a dental examination by a dentist. States choose whether to provide dental benefits for adults.
Medicaid dental insurance is treated differently for adults and children under 18. While dental coverage for children is available, it is not mandatory. Dental coverage is not an essential health benefit for adults, and health plans are not required to offer it.
If you are enrolled in a health plan with dental coverage, you cannot remove dental coverage from your Marketplace health plan. However, you can change health plans or get a separate dental plan.
A direct dental referral is required for every child in accordance with the periodicity schedule set by the state. The Centers for Medicare & Medicaid Services does not define specific dental services, but all services deemed medically necessary must be provided.
