Insurance

Dental Care | Medicaid

Dental health is an important part of a person’s overall health. States are required to provide dental benefits to children covered by Medicaid and the Children’s Health Insurance Program (CHIP), but states choose whether to provide dental benefits to adults. See the 2010 Medicaid/Chip Oral Health Services Fact Sheet (pdf, 49.06 kb) for information on children’s access to dental services and the opportunities and challenges in obtaining care.

children’s dental benefits on medicaid

Medicaid covers dental services for all enrolled children as part of a comprehensive set of benefits, called the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) benefit. Although the oral exam can be part of a physical exam, it does not replace a dental exam by a dentist. a referral to a dentist is required for each child according to the periodicity schedule established by the state.

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Dental services for children must include at a minimum:

  • pain and infection relief
  • tooth restoration
  • dental health maintenance
  • epsdt benefit requires that all services be provided if determined to be medically necessary. states determine medical necessity. If a condition that requires treatment is discovered during an evaluation, the state must provide the services necessary to treat that condition, whether or not those services are included in a state’s Medicaid plan.

    Each state must develop a dental periodicity schedule in consultation with recognized dental organizations involved in children’s health care. dental services may not be limited to emergency services for children eligible for epsdt.

    Dental services must be provided at intervals that meet reasonable standards of dental practice, and at other intervals as indicated by medical necessity, to determine the existence of a suspected disease or condition. states should consult with recognized dental organizations involved in children’s health care to establish these intervals. A referral to a dentist is required for each child according to each state’s periodicity schedule and at other intervals as medically necessary. the periodicity schedule for other epsdt services may not govern the schedule for dental services.

    dental benefits for children on chip

    states that provide chip coverage to children through a medicaid expansion program must provide the epsdt benefit. Dental coverage is required under separate chip programs to include coverage for dental services “necessary to prevent disease and promote oral health, restore the health and function of oral structures, and treat emergency conditions.”

    States with a stand-alone chip program can choose between two options for providing dental coverage: a chip-compliant dental benefit package or a benchmark dental benefit package. the baseline dental package must be substantially the same as (1) the most popular federal employee dental plan for dependents, (2) the most popular plan selected for dependents in the state employee dental plan, or (3) the dental coverage offered through the most popular commercial insurer in the state.

    States are also required to post a list of all participating chip and medicaid dental providers and benefit packages at insurekidsnow.gov.

    dental benefits for adults on medicaid

    States have flexibility in determining which dental benefits are provided to adults enrolled in Medicaid. While most states provide at least emergency dental services for adults, fewer than half of states currently provide comprehensive dental care. there are no minimum requirements for dental coverage for adults.

    children’s oral health initiative

    the centers of medicare & Medicaid Services (CMS) is committed to improving access to dental and oral health services for children enrolled in Medicaid and CHIP. We have made considerable progress (pdf, 303.79 kb) in our efforts to ensure that low-income children have access to oral health care. From 2007 to 2011, nearly half of all states (24) achieved at least a ten percentage point increase in the proportion of children enrolled in Medicaid and Chip who received a preventive dental service during the reporting year. however, tooth decay remains one of the most common chronic childhood diseases.

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    to support continued progress, in 2010 cms launched the children’s oral health initiative and set goals (pdf, 283 kb) for improvement by ffy 2015. to achieve those goals, we have adopted a national oral health strategy through which we are working diligently with state and federal partners, as well as the dental provider community, children’s advocates, and other stakeholders to improve children’s access to dental care.

    To help state Medicaid and Chip programs achieve their improvement goals, we developed Keep Kids Smiling: Promoting Oral Health Through the Children and Teens Medicaid Benefit (pdf, 578.09 kb). Provides an overview of the children’s Medicaid dental benefit, support for evidence-based policies at the state level, and details of successful strategies with state examples.

    We are also intensifying our efforts to educate consumers, health care providers and the public about positive oral health practices. Three oral health education materials, with messages geared toward parents of young children and pregnant women, are available for download or bulk order. Tips for using the materials are also available.

    tools to help states improve the delivery of dental and oral health services

    emergency department visits for adult medicaid beneficiaries for non-traumatic dental conditions

    • presentation slides (pdf, 484.03 kb)
    • guidance to report the size of the dental sealant in the basic children’s set

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