Shouldn't Medicaid Dental be available to adults as well as children?

There is a proven link between bad teeth and bad health. For many in the lower socio-economic sections, lower income people cannot afford a basic visit to a dentist. So they will wait until the agony of an abscess will drive them to a clinic where the most cost effective , read cheap, remedy is extraction.

Bad teeth affects all aspects of a persons health. Not fixing one's teeth has a domino effect on the health care system. To leave the mouth out of the health equation is to ignore the part that it plays in the health of the entire body. People with severe dental problems find it difficult to eat. Pain in the mouth is just as debilitating as pain anywhere else, if not worse.

Managing population health is about prevention. Ensuring that everyone gets access to a checkup once a year will do a lot to reduce dental problems and guarantee that when they do present, they are at the cheap and simple end of the treatment spectrum.

According to the Federal Government, Dental services under Title XIX of the Social Security Act, the Medicaid program, are an optional service for the adult population, individuals age 21 and older. However, dental services are a required service for most Medicaid-eligible individuals under the age of 21, as a required component of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit.

Individuals under Age 21

EPSDT is Medicaid's comprehensive child health program. The programs' focus is on prevention, early diagnosis and treatment of medical conditions. EPSDT is a mandatory service required to be provided under a state's Medicaid program.

Dental services must be provided at intervals that meet reasonable standards of dental practice, as determined by the state after consultation with recognized dental organizations involved in child health, and at such other intervals, as indicated by medical necessity, to determine the existence of a suspected illness or condition. Services must include at a minimum, relief of pain and infections, restoration of teeth and maintenance of dental health. Dental services may not be limited to emergency services for EPSDT recipients.

Oral screening may be part of a physical exam, but does not substitute for a dental examination performed by a dentist as a result of a direct referral to a dentist. 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 further define what specific dental services must be provided, however, EPSDT requires that all services coverable under the Medicaid program must be provided to EPSDT recipients if determined to be medically necessary. Under the Medicaid program, the state determines medical necessity.

If a condition requiring treatment is discovered during a screening, the state must provide the necessary services to treat that condition, whether or not such services are included in the state's Medicaid plan.

Individual age 21 and older

States may elect to provide dental services to their adult Medicaid-eligible population or elect not to provide dental services at all as part of its Medicaid program. While most states provide at least emergency dental services for adults, less than half of the states provide comprehensive dental care. There are no minimum requirements for adult dental coverage.

The American Dental Association has this to say:
Medicaid is the nation’s largest publicly funded health insurance program. It is the primary source of health care for 28 million low-income children and provides coverage to millions of additional low-income families, the elderly and the disabled. Medicaid is jointly financed by the states and the federal government and is administered by the states. Federal law requires that states offer a set of mandatory benefits and provide coverage for certain populations.

Dental services for children enrolled in Medicaid are regulated through the Early and Periodic Screening, Diagnosis and Treatment program (EPSDT). However, states are not required to provide dental services to adults. Unfortunately, access to dental benefits is limited as a result of benefit designs and low reimbursement rates to dentists.

Payment rates for Medicaid dental services typically fall well below the cost of providing treatment. Poor financing ultimately leads to patients’ inability to access oral health care services, which only intensifies the severity of their need for help. Improving financing and program administration will improve access for Medicaid beneficiaries who need assistance.

ADA Priorities

* The ADA urges the Congress to maintain the federal requirement for dental  services under EPSDT and extend medically necessary services to Medicaid-eligible adults.
* The ADA urges the Congress to preserve the federal financing role in the Medicaid program and update the federal matching formula to address economic changes.
* The ADA believes preventive dental services should be exempt from cost-sharing requirements.

What does this mean for you?

Medicare generally does not cover dental care services. It does, however, cover hospitalization for non-covered dental services when the severity of the procedure or the condition warrants it. On the other hand, Medicaid, which is a public assistance program financed by federal, state, and local governments, offers more preventive-care services. Each state designs its own plan according to federal guidelines. Low-income people who fit into the following categories receive Medicaid coverage: the aged (sixty-five years or older), the blind, the disabled, members of families with dependent children, and some other children. Some states provide coverage for other groups of low-income people who, although qualified for welfare, aren’t able to afford medical care.

Because each state designs its Medicaid program to meet the needs of its own residents, and because Medicaid is subject to funding problems, states that might have covered a benefit at one period of time may no longer do so. Consequently, it’s prudent to ask your state or county department of public welfare whether the Medicaid program in your state covers dental care services, for children as well as for adults over the age of twenty-one. Dental care under the Medicaid program is an optional service for the adult population, which includes individuals twenty-one years of age and older. However, dental services are a requirement for most Medicaid-eligible individuals under age twenty-one, as a mandatory component of the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit. States may elect to provide dental care services to their adult Medicaid-eligible population, or elect not to provide dental services at all as a part of their Medicaid program. Most states provide at least emergency dental services for adults, but less than half of all states provide comprehensive dental care. There are no minimum requirements for adult dental coverage.

People with low incomes have the least access to dental care, and dental care has been a particular concern in many state Medicaid programs where the utilization of dental services by beneficiaries has been low. This lack of utilization among Medicaid beneficiaries is due to two major factors: a lack of dentists willing to serve Medicaid beneficiaries and the low priority many Medicaid families may place on obtaining dental care (low-income families have many competing needs, are often unaware of the importance of oral health care, and may be unwilling or unable to wait for appointments or arrange transportation to a dental appointment).