Dental care is necessary to keep your teeth and gums healthy, but many low-income people may have no access to dental care. As of 2016, about 74 million Americans don’t have any dental insurance.¹ Medicaid, is a federal-state assistance program for low-income people and children, that helps fill in the gaps for health and hospital care and typically provides limited dental coverage for adults.
What Medicaid covers depends on where you live. While Medicaid guidelines require states to provide some level of dental care for children, states are not required to provide dental benefits to adults². Each state decides whether to provide dental care to adults and, if so, which dental services they will cover. As of 2020, there are 35 states along with the District of Columbia that have expanded their Medicaid coverage to include some limited dental coverage for adults.³
What is Medicaid?
Medicaid is a state-driven program that provides health coverage for low-income adults, children, pregnant women, the elderly people with disabilities.⁴ It varies from state to state and its typically run by state and local governments within federal guidelines. People who are eligible for Medicaid typically can go to doctors, hospitals, dentists, and other health care providers and Medicaid, rather than the patient, pays the bill. Nearly 16% of the U.S. population⁵ receives health care through Medicaid.
The federal and state governments fund Medicaid jointly; the states run the programs and decide what benefits they will pay for while the federal government provides funding and guidelines. Please visit Medicaid.gov for more information.
Dental health and your overall health
Dental health has a significant impact on your overall health. Problems in your mouth can affect the rest of your body.⁶ The bacteria in your mouth can enter your digestive tract and other parts of your body if that bacteria isn’t kept under control by good oral hygiene and regular dental care and cleanings. Not being able to see a dentist is typically related to a range of health problems and there are many health problems that can be caught and treated early when a person is receiving regular dental exams. Periodontal disease (gum infection) is associated with an increased risk of cancer and cardiovascular diseases. Some of the health conditions that are linked to oral health are:
Cardiovascular disease - There is research that shows that there is a link between a healthy mouth and a healthy heart. Plaque buildup and infection in your mouth can be linked to development of heart disease and clogged arteries and increase your risk of stroke⁷.
Endocarditis - Endocarditis is an infection in your heart, specifically either in the chambers of your heart or the valves of your heart. It occurs when bacteria, like the bacteria in your mouth, is spread throughout the body by your bloodstream. If you have a dental infection or abscess caused by tooth decay and plaque that bacteria can be transported to your heart through your bloodstream⁸.
Pneumonia - Just like bacteria from your mouth can end up causing infection in your heart after traveling through your bloodstream bacteria from your mouth can end up in your lungs and cause massive problems with your lungs by causing pneumonia⁹.
Low-income adults suffer a disproportionate share of dental disease and are nearly 40% less likely to have a dental visit in the past 12 months, compared to those with higher incomes. Forty-four percent of low-income adults ages 20 to 64 have untreated tooth decay. Adults who are disabled, homebound, or institutionalized have an even greater risk of dental disease.¹-
Location also is a factor in access to dental care. Low-income people living in rural areas are even more likely to go without dental care and have worse oral problems because the areas where they live don’t have as many dentists, the dentists who are there don’t take Medicaid, and they lack access to fluoridated water because they rely on well water not city water¹¹.
What dental procedures does Medicaid cover?
Medicaid typically covers some dental services for children, no such requirement exists for adult coverage. States decide what dental services they will cover for adults, so the benefits vary widely from state to state. Medicaid expansion in some states means that adults who previously weren’t eligible for any dental coverage through Medicaid may now get routine exams, cleanings, and some other basic services covered by Medicaid in their state. To find out if your state covers services like braces, dentures, root canals, wisdom teeth removal, or veneers, contact your local Medicaid office.
Many states limit coverage to only tooth extractions or to specific demographics, such as pregnant women. With the wide flexibility given to the states, many provide only emergency dental services for adult patients. Medicaid does not set a minimum requirement for the dental coverage states provide to adults like they do for children.¹²
As of September 2019, less than half of state Medicaid programs offered comprehensive adult dental benefits. But nearly all 47 states and the District of Columbia offered at least emergency services to their adult Medicaid patients. Emergency services include uncontrolled bleeding and traumatic injuries.¹³
Will Medicaid cover dental for my kids?
The Affordable Care Act expanded Medicaid eligibility so that the program could cover more low-income Americans.¹⁴ In addition to making more people eligible for coverage, this expansion provided funds that many states used to improve their dental coverage. Some states increased the Medicaid reimbursements for children’s dentistry as well as expanded the number of services covered¹⁵.
Medicaid covers dental services for children, but covered dental services for children may vary from state to state.
At a minimum, states must provide dental services for children through the Medicaid program that covers the following¹⁶:
Pain relief and infections (such as extractions and treatments for infections)
Teeth restorations (such as fillings and some types of crowns
Dental services for Medicaid-eligible children cannot be limited to only emergency services. Medically necessary care must be provided. Each state determines its own definition of which dental services fall into the “medically necessary” category.
Making Medicaid work for you and your child
If your child needs dental services, it is best to first check with your local Medicaid office to determine the services that are covered and the dental offices that work with Medicaid insurance.¹⁸
If you or another adult living in your home needs dental treatment, the same advice applies. Because of the wide variety of coverage levels, your local Medicaid office is the best place to start to get a list of offices that accept Medicaid payment as well as a list of covered services.
If you find that you are not eligible for dental treatment under Medicaid, you could purchase dental insurance for you or your family.
The benefits of dental insurance
Gaps in your Medicaid coverage , especially for adults, might be filled with dental insurance. Individual dental insurance isn’t as expensive as you might think and there are some low-priced plan options that may make sense for a family. Cost is a concern for many parents and adults and dental insurance can make it more affordable to get routine care that can help prevent more serious problems in the future. Dental insurance is also an option if you live in a rural area or in an area where dentists don’t accept Medicaid. If you are worried about the cost of dental insurance take a look at the options available and you’ll likely see that there’s a dental insurance option to may fit every budget.
This is not dental care advice and should not be substituted for regular consultation with your dentist. If you have any concerns about your dental health, please contact your dentist's office.
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https://www.medicaid.gov/medicaid/index.html, accessed September 2020
https://www.healthinsurance.org/glossary/medicaid-expansion, accessed September 2020
https://www.medicaid.gov/medicaid/benefits/dental-care/index.html, accessed September 2020
https://www.medicaid.gov/medicaid/benefits/dental-care/index.html, accessed September 2020
https://www.medicaid.gov/about-us/contact-us/contact-state-page.html, accessed September 2020
Brought to you by The Guardian Life Insurance Company of America (Guardian), New York, NY. Material discussed is meant for general illustration and/or informational purposes only and it is not to be construed as tax, legal, investment or medical advice.(exp.09/22)