Adult Dental Benefit
All adults need and deserve access to oral health care. Without regular preventive care, oral health problems can develop and worsen, leading to overall health and social issues that can harm individuals. We need to protect and expand adult dental benefits — within both Medicaid and Medicare.
Gaps in Coverage
Medicaid is a key source of health care coverage for more than 80 million people in the United States. Within Medicaid, comprehensive dental coverage is mandatory for children, but benefits for Medicaid-eligible adults are optional. And states have flexibility in how they interpret “benefits,” often looking at them for potential cuts when budgets get tight. Not surprisingly, then, Medicaid adult dental coverage varies tremendously across states. Today, nearly one-third of all states do not provide dental care beyond emergency procedures.
Medicare suffers from similar gaps: It does not mandate coverage for the treatment of dental disease, nor does it cover most dental care, procedures, or supplies. In fact, nearly half of Medicare beneficiaries, or 26 million people, do not have dental coverage as of 2021.
There was momentum behind adding dental to Medicare in the fall of 2021, but the social spending proposal was trimmed, keeping the benefit out of the program for now.
The Need for Reform
Medicaid Coverage by State
The Medicaid Adult Dental Coverage Checker is an interactive tool for policymakers, administrators, and advocates to easily understand where a given state’s Medicaid adult dental benefits package falls on a continuum from no dental benefits to extensive benefits, helping them identify areas for improvement and expansion. It looks at coverage of specific procedures and services, including allowed frequency, in eight service categories that are most commonly reimbursed by employer-based dental benefit plans and are critical to maintaining lifelong oral health.
The Coverage Checker was developed by leading oral health organizations, including CareQuest Institute. These organizations collaborated to create an updated evidence-based definition of an extensive Medicaid adult dental benefit. The group then developed a consensus-driven assessment survey, completed by state dental directors, to collect detailed information about adult dental benefits offered through the Medicaid program in each state. The Coverage Checker compiles this data and makes it easy to interact with and analyze.
The Coverage Checker sets a new standard for administrators, policymakers, and advocates in designing and refining dental benefits in Medicaid that meet the oral health needs of low-income adults across the US.
Lack of Access
Lack of access to oral health services disproportionately affects older adults of color and those living in rural areas. In 2020, according to a nationally representative survey, 7 in 10 Black Medicare participants and 6 in 10 Hispanic enrollees did not see a dental provider. Roughly 1 in 5 rural seniors have not seen a dentist in over five years.
Medicare’s lack of dental coverage is a key reason why many older adults lack access and endure untreated oral health conditions.
Those in poverty spend 10 times more as a proportion of their family income on dental services compared to high-income families.
The Costs to the System
The search for dental care for adults can be challenging, which means that those without coverage often delay treatment until issues become severe or painful. This leads to visits to the emergency department (ED), which are significantly more expensive, costing an estimated $2.1 billion per year. ADA research indicates that nearly 79% of these visits could have been addressed in a dental office, which translates into potential savings of up to $1.7 billion per year.
The Risk for Individuals
The lack of preventive care puts people at higher risk not only for dental problems but for other chronic health issues. A growing body of research shows that oral health is connected to overall health. Poor oral health is connected to a higher risk for diabetes, cardiovascular disease and stroke, complications in pregnancy and childbirth, adverse mental health outcomes, and other conditions that are costly to treat. It is also closely linked with employability, financial security, and social connectedness.
adults in their Medicaid program, 60% report that the appearance of their mouth and teeth affects their ability to interview for a job.
Advocacy to Protect and Expand Benefits
Advocates have been working hard to expand adult dental benefits — and they’ve made progress. In 2019, at least 14 states implemented legislative or administrative changes to mandate more dental coverage. Still, there is a long road ahead to achieving full coverage for all adults. The Adult Dental Medicaid Coverage Checker is one tool that will help administrators, policymakers, and advocates refine and expand dental plans to better meet the needs of Medicaid beneficiaries. Doing so will help reduce costs for patients, providers, and states and can lead to better overall health outcomes.