For low-income adults, accessing affordable dental care can be a major challenge. Medicaid, the government health insurance program for those with limited incomes, is one important option to get the oral health services needed to maintain healthy teeth and gums. But what exactly does Medicaid cover when it comes to dental benefits for adults? The answer is not always simple, as coverage varies significantly from state to state.
While Medicaid requires dental coverage for children, dental benefits for adults are an optional service that states can choose to include in their Medicaid programs. Currently, less than half of states provide comprehensive dental care to adults on Medicaid, with some states offering only limited benefits or emergency services. This means millions of low-income adults may lack access to critical preventive care and treatment.
However, the landscape of adult dental coverage under Medicaid has been improving in recent years. As of 2023, 39 states and Washington D.C. now provide at least some level of dental benefits beyond just emergency services to adult enrollees. Several states have also expanded or enhanced their coverage since 2020. Understanding what is currently available can help adults on Medicaid better access the oral health care they need.
Medicaid Adult Dental Coverage Varies By State
States have flexibility to determine the scope of dental services covered for adults in their Medicaid programs. Benefits can range from:
- No coverage: A few states, like Alabama, Tennessee and Maryland (prior to 2023), provide no dental coverage at all for general adult enrollees.
- Emergency-only: Some states, such as Florida and Mississippi, only cover emergency dental services for the relief of pain and infection.
- Limited: States like Texas and South Carolina offer a limited set of services, covering less than 100 diagnostic, preventive and minor restorative procedures. Annual spending caps are typically $1000 or less per patient.
- Extensive: A growing number of states, including California, New York, and Washington, now provide a more comprehensive mix of dental services to adult Medicaid recipients. Coverage includes diagnostic, preventive, and major restorative procedures, sometimes up to an annual limit of at least $1000 per person.
As of 2023, 7 states plus Washington D.C. were categorized as providing “extensive” adult dental benefits through Medicaid – an increase from only 3 states in 2020. However, the majority of states still fall into the “limited” coverage category.
Even within these categories, the specific procedures, frequency limits, and copayments can differ between state Medicaid programs. For example, one state may allow a dental exam and cleaning every 6 months, while another only covers one per year. Some common dental services that may be included in adult Medicaid plans are:
- Exams and x-rays
- Cleanings
- Fillings
- Extractions
- Root canals
- Crowns
- Dentures
- Periodontal (gum) treatment
The best way for Medicaid enrollees to find out exactly what dental benefits are available to them is to check with their state Medicaid agency. Most states provide detailed information on adult dental coverage and participating providers on their Medicaid website or member handbooks.
Dental Benefits for Specific Adult Populations
In addition to general coverage for adult enrollees, some states provide enhanced dental benefits to certain higher-risk populations on Medicaid, such as:
- Pregnant individuals: Gum disease during pregnancy is linked to adverse outcomes like premature birth and low birthweight. As of 2022, all states offer some level of dental coverage for pregnant Medicaid recipients, though the scope of services varies.
- Elderly and disabled: Poor oral health in older adults and those with disabilities can worsen chronic health problems and impact quality of life. Some states have expanded dental benefits to these groups, even if general coverage is limited.
- Adults with chronic conditions: Research shows providing dental care to Medicaid enrollees with diabetes, heart disease and other chronic illnesses can improve health and lower medical costs. A few innovative states have piloted dental coverage for these groups.
Targeting dental benefits to high-risk adult populations on Medicaid can be a cost-effective way for states to improve health outcomes. However, many advocates argue all low-income adults need access to comprehensive oral health care for better overall health and wellbeing.
The Impact of Medicaid Adult Dental Coverage
Studies show that providing dental insurance through Medicaid makes a difference in adults’ access to care and oral health status. Low-income adults in states with extensive Medicaid dental benefits are more likely to have a dental visit and less likely to have untreated tooth decay, compared to those in states with no or emergency-only coverage.
After Colorado added extensive adult dental benefits to Medicaid in 2014, enrollees were 2-3 times more likely to receive preventive dental care. In California, utilization of dental services doubled among Medicaid adults after benefits were reinstated in 2018. Increased access to care also translated to improved oral health outcomes and lower rates of tooth loss.
Lack of dental coverage is a key reason low-income adults avoid or delay getting dental care. When Medicaid programs cut adult dental benefits due to budget shortfalls, enrollees often end up seeking treatment in costly emergency departments instead. Investing in preventive dental services can help reduce ER visits and associated medical costs down the line.
Barriers to Dental Care Access on Medicaid
While expanding Medicaid adult dental benefits is an important first step, other barriers to accessing care remain. Only about one-third of dentists nationwide accept Medicaid patients, citing low reimbursement rates and administrative burdens as reasons why. This can make it difficult for enrollees to find Medicaid providers, especially in rural or underserved areas.
Raising Medicaid payment rates for dental services to be more competitive with private insurance could encourage greater dentist participation. States can also implement other reforms to reduce barriers, such as:
- Streamlining provider credentialing and claims processes
- Recruiting more dental providers in shortage areas
- Authorizing new mid-level dental providers to expand capacity
- Educating Medicaid members on their dental benefits and how to access care
Oral health advocates continue to push for policy changes at the state and federal level to strengthen adult dental coverage and access in Medicaid. Proposals include making comprehensive adult dental benefits a mandatory Medicaid service nationwide and providing additional funding to states to support implementation. Improving the oral health of low-income adults will require a sustained, multi-pronged approach.
The Bottom Line
Dental coverage for adults in Medicaid is slowly improving but still varies widely between states, leaving many low-income individuals without access to the full range of services needed for good oral health. While more states have added or enhanced dental benefits in recent years, millions remain uninsured or underinsured for dental care.
Medicaid enrollees should check with their state program to find out what specific dental services are currently covered for adults and how to access care from participating providers. Advocates can continue to educate policymakers on the importance of comprehensive dental benefits for all adults in Medicaid.
The evidence is clear that providing extensive dental coverage through Medicaid improves access, health outcomes and quality of life for low-income adults. Investing in preventive and restorative dental care is also cost-effective for states in reducing expensive emergency visits and medical complications down the road. Oral health is an integral part of overall health – it’s time for Medicaid to treat it that way.
