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Andrew Smith

Andrew Smith

Access to Dental Care in Medicaid

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Introduction

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The importance of good oral health to overall health and well-being cannot be overstated. Preventive care, regular self-care and early identification, treatment and management of problems can help many people attain good oral health. However many people suffer from poor oral health, which often has extra negative impacts on their overall health and quality of life. As a result of a lack of dental coverage and care, dental illness and tooth loss are more prevalent among low-income individuals. Disparities by race and ethnicity are also evident in these assessments.

Oral health screening, diagnosis, and treatment are all included as part of Medicaid, the largest health insurance program for the poor in the United States. Dentists in low-income families are now more likely to receive preventive dental care and primary dental care because to Medicaid and CHIP, which have made significant progress over the past decade. Access to dental doctors and services has remained a major issue, even with a comprehensive benefit package. As compared to children, the situation for low-income adults in Medicaid is more complicated. Medicaid adult dental benefits are not mandated by federal law but are available at the state’s discretion, and most states give only limited coverage — in many cases, primarily for extractions or emergency procedures. Adult dental care under Medicaid have historically been one of the first things to go when states are under financial stress. Another thing to keep in mind is the lack of dental benefits under the Medicare program, which covers the elderly and those with disabilities.

 

As evidence of the significance placed on oral health by legislators, both Medicaid and CHIP include comprehensive dental coverage for children and pediatric dental care is one of the ten EHBs under the Affordable Care Act (ACA). Oral health benefits for low-income persons can now be established in new ways. Expanding Medicaid coverage for non-elderly people, as well as reforming payment and delivery systems, are crucial policy levers for a more comprehensive approach to health care. For the purpose of informing federal and state policy on adult oral health care access, this brief evaluates the oral health status of low-income adults, state Medicaid program dental benefits, and current access to dental care for low-income people.

Why adult oral health is important

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The consequences of untreated oral illness can be dire. An untreated oral health problem can limit one’s ability to eat, as well as cause tooth loss, all of which can have a negative impact on one’s nutrition. Chronic pain can disrupt daily tasks such as speech or sleep if untreated problems go unaddressed. Many other health issues, including poor pregnancy outcomes, have been linked to chronic mouth infections. Employed adults are predicted to lose more than 164 million hours of work each year owing to oral health concerns or dental visits. When it comes to oral health difficulties, adults in lower-paying jobs like customer service lose two to four times as many work hours as adults in professional professions. Adults who are looking for a career may find it difficult to land a job if they have visible dental problems or tooth loss.

Dental disease prevalence in nonelderly adults

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Adults aged 20 to 64 in the United States have untreated dental caries, although the disease burden is not fairly distributed. 9 Adults with annual incomes less than or equal to the federal poverty level (FPL) ($11,880 in 2016) have twice the rate of untreated dental caries (44 percent) as those with annual incomes above or equal to the FPL (200 percent). In addition, minorities were more likely to suffer from oral health issues. Untreated caries were found to be substantially higher in adults of color than in whites, a finding that can be attributed in part to the higher poverty rates among these groups.

Medicaid’s role in covering low-income adults

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Nearly 28 million low-income non-elderly individuals were covered by Medicaid in 2014. Four out of every ten non-elderly adults in poverty are covered by the program. Nearly all persons earning less than $16,394 per year in 2016 are eligible for Medicaid in 31 states and the District of Columbia that have adopted the Medicaid expansion under the Affordable Care Act (ACA). In contrast, 19 states have not adopted the Medicaid expansion. Low-income adults continue to have a high uninsured rate, particularly in states that did not participate in the expansion. Adults without dependent children, with the exception of pregnant women and individuals with disabilities, are not eligible for Medicaid in non-expansion states since the median Medicaid income eligibility for parents is 44 percent of the federal poverty level. There are an estimated 2.9 million uninsured persons in non-expansion states who do not have access to Medicaid and do not qualify for subsidies in the Marketplace.

Medicaid dental benefits for adults

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Medicaid adult dental coverage are voluntary, not mandated, under federal Medicaid law, therefore states have wide latitude in selecting what these services should cover for their residents. Adult dental coverage is a state option for all Medicaid-eligible adults, regardless of when they became eligible for Medicaid before or after the Affordable Care Act (ACA). As part of the Medicaid expansion, states are required to provide Medicaid expansion individuals alternative benefit plans (ABPs) based on one of four “benchmark” alternatives, including one option approved by the HHS Secretary. As mandated by the Affordable Care Act (ACA), all ABPs must cover the 10 essential health benefits (EHBs). The EHBs include dental coverage for children, but not for adults. Many states have adopted the Secretary-approved coverage option to align their expansion Medicaid benefits with their standard Medicaid benefits for adults, making the appropriate modifications to meet EHB requirements as a result of this alignment. Medicaid expansion adults in all but two states receive the same dental benefits as Medicaid’s regular adult Medicaid population in 31 states and the District of Columbia. Montana and North Dakota are the only two exceptions. Dental coverage for Medicaid expansion adults is nonexistent in Montana, while significant coverage is available in North Dakota for standard Medicaid recipients but not for expansion recipients.

Medicaid dental benefits are currently available in 46 states and the District of Columbia. Many state Medicaid programs, like commercial dental plans, put spending restrictions on adult dental benefits or restrict the amount of services that are covered. Medicaid adult dental coverage varies greatly from state to state. Some 15 states already offer comprehensive adult dental insurance, which include more than 100 diagnostic and preventive, as well as minor and major restorative operations, as well as an annual expenditure cap of $1,000 or more for each person. Dental benefits were available in 19 states with a $1,000-a-year limits on per-person costs for procedures involving less than 100 patients. As far as the remaining states with adult dental insurance go, they only covered pain treatment or emergency care for injuries or trauma. There were four states that did not provide dental care at all. The expense of dental care can be prohibitive even in states that give some dental benefits to Medicaid participants, making it difficult or impossible for them to get it.

Adult dental benefits are also at risk of being slashed as an optional Medicaid service. It’s common for governments to alter their benefits each year. Medicaid’s adult dental benefits have historically been reduced in times of fiscal stress; but, as the economy recovers, states are more likely to restore them. Non-emergency dental care for adults were terminated in California in 2009, for example. Dentures and periodontal care were among the several benefits that the state reinstated in 2014 for those who had previously lost access to them. Non-emergency dental care for adults were suspended in Illinois in 2012, but were reinstated in 2014 to include limited fillings, root canals and dentures. Unmet dental care needs rise, preventative treatment use falls, and emergency department use for dental disorders increases when states restrict or remove adult dental benefits.

Adult access to dental care

Several factors influence whether or not low-income persons can afford and use dental care. Whether or whether Medicaid-eligible low-income individuals receive dental care depends on a variety of factors, including their ability to pay, the availability of dental care providers, and their own and the clinicians’ understanding of the necessity of preventative dental treatment. A major obstacle for those without dental insurance is the high expense of dental care. Their tight budgets make paying for services out-of-pocket difficult, if not impossible. Low-income persons may have lower expectations for their oral health as a result of a lack of access to dental treatment or connections to dental providers, which can exacerbate already-existing inequities. Customers may wait until they suffer pain in their mouths before seeking treatment if they are unaware of the importance of frequent dental examinations or cannot afford them.

Utilization of Dentists’ Services and Unmet Needs
Maintaining good oral health requires regular dental visits. Low-income persons are less likely than higher-income adults to have seen a dentist in the recent year. One in five adults earning less than $200 per month had a dental visit in the last year, compared to one in three adults earning $200 to $399 per month, and one in two adults earning more than $400 per month. Additionally, those who had access to private dental insurance were more than twice as likely to have seen a dentist in the previous year as those with Medicaid/CHIP or no dental insurance at all. “Uninsured” refers to people without private dental benefits (or Medicaid), as well as non-elderly Medicare-only adults who don’t have private supplemental dental plans.” A dental appointment was made last year by 49% of adults with private insurance, compared to 20% of adults on Medicaid/CHIP and 17% of uninsured adults in 2013. Dentist visits were far more common among Medicaid children than among Medicaid adults, perhaps due to the fact that children on Medicaid/CHIP are required to have dental coverage (42 percent ). Adult Medicaid/CHIP patients had a lower rate of dental visits than both Medicaid/CHIP children and adults with private insurance. This is due in part to Medicaid’s restricted coverage of adult dental benefits.

A new study found that dental care was the most commonly reported service for which insured persons reported having an unmet demand due to the high cost. Most of these individuals were uninsured or underinsured. In comparison to the 11% of full-year insured individuals with incomes above 400% FPL, 31% of nonelderly adults with incomes below 138 percent FPL, and 24% of those between 139 percent and 399 percent FPL claimed that they could not afford dental care. More than twice as many non-elderly adults with public insurance (35 percent vs. 16 percent) reported having an unmet need for dental care due to the cost as adults with employer-sponsored insurance, another indication that Medicaid adult dental benefits are limited in many states.

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PROVIDER AVAILABILITY AND THE ROLE OF HEALTH CENTERS

Over 5,000 dental health professional shortage areas (HPSAs) were identified in the United States as of January 1, 2016. HPSAs are largely characterized in terms of the population’s ratio of dental professionals. A national shortage of dentists is debatable, but the majority of experts agree that dentists are geographically dispersed and lacking in office-based dentists who can serve patients with particular needs such as those in nursing homes and other institutions. The number of dentists who take Medicaid is also limited, as many of those who do accept private insurance do not accept Medicaid patients. Finding a dentist who accepts Medicaid is a common problem for those on the program. Low payment rates, administrative burden, and a high no-show percentage among Medicaid patients are the most common excuses given by dentists for not accepting Medicaid patients.

It’s possible to get Medicaid dental care through fee for service or a dental-only managed care plan that contracts with the state, depending on your needs. In 2015, 29 states with Medicaid managed care covered adult dental treatment, out of the 39 states with such coverage. The Medicaid fee-for-service or prepaid health programs in 10 of these states have carved out adult dental benefits.

In spite of the fact that the vast majority of dental services are supplied by one-person or small dental offices, community health centers are a significant resource for Medicaid recipients and those in medically underserved areas who require dental care. Approximately 22.5 million people were treated in health centers across the US in 2014, with the bulk of those receiving care being Medicaid recipients (46%), as well as patients without insurance (28 percent ). A five-year $11 billion Health Center Trust Fund (which has subsequently been extended through 2017) was established by the ACA, as well as an additional $1.5 billion in financing for the National Health Service Corps, which provides many of the medical and dental providers that work in health centers. Dental care for health center patients can also be contracted out to private dental offices. A recent survey of health centers found that those in Medicaid expansion states were significantly more likely than those in non-expansion states to have expanded their dental and mental services capacity since the start of 2014, thanks in part to money from the ACA trust fund and an increase in patient revenues as a result of expanded coverage for low-income people under the ACA. Approximately 15% of all health center visits in 2014 were for dental treatments, with dental care being provided by nearly three-quarters of all health centers.

Minority dentists are more likely to work in low-income communities and give care to the underprivileged if the dental workforce is more diversified. Participating dental schools have seen an increase in the number of underrepresented minority students because to initiatives like the National Dental Pipeline Program. As a result, the accreditation rules for dentistry schools have been amended to increase the diversity of faculty and students.

The Scope-Of-Practice and New Provider Types: Increasing Access to Dental Care
Preventative dentistry is an important element of the dental profession, and dental hygienists are an important part of the dental team. Many states need dental hygienists to work under the supervision of a dentist because of the wide range of dental practice statutes and laws in each state (e.g. private practices, schools, nursing homes). Dental hygienists can now provide treatments without the direct supervision of a dentist in several states in order to increase access to dental care. In order to allow dental hygienists to charge Medicaid directly for services given to Medicaid enrollees, adjustments may be required to Medicaid reimbursement policies and procedures.

New forms of midlevel dental providers have been introduced in some states, thus broadening the dental workforce. Mid-level dental providers, like nurse practitioners and physician assistants in the medical field, fulfill a similar role conceptually. In addition to providing preventative and restorative services, they are members of the dental team and work in a variety of settings. For the first time in American history, three states, Alaska, Minnesota, and Maine, have recognized and credentialed the new midlevel provider known as a dental therapist. It’s important to note that midlevel dental providers’ educational requirements, duties, and supervision needs differ by state. In Minnesota, for example, dental therapists and advanced dental therapists are required to treat at least 50% of their patients as Medicaid beneficiaries or members of underprivileged communities. According to recently published studies on midlevel dental professionals, they deliver high-quality service at an affordable price.

Other approaches to increasing the current capacity of dental treatment are also being developed. Teledentistry is a method in which dental hygienists work with remote dentists in order to provide dental care to patients in California’s Medicaid program. For years, the state was testing a “virtual dental home” concept to enhance access in dental shortage areas through a pilot initiative called the Virtual Dental Home Demonstration Project. For example, in this paradigm, certified dental hygienists, registered dental assistants, and a variety of other allied dental professionals operating in the community are connected to dentists in dental offices or clinics using telehealth technology. Patients’ medical histories and x-ray pictures are collected by community-based clinicians and provided to the collaborating dentist. As part of the treatment plan, patients are referred to a local dentist for more advanced services, which are provided by the community-based provider.

system for the delivery of dental care
The delivery of dental treatment is about to undergo significant changes as a result of developments in two main areas. The first one has to do with the way service delivery is organized. Healthcare professionals that haven’t previously collaborated to plan patients’ care are now doing so as a result of the movement toward more integrated, “whole-person” care and accountable systems of care (e.g., Accountable Care Organizations). Dental care is beginning to be integrated into some systems, but states and delivery systems (such as managed care plans) are now focusing primarily on the integration of mental health treatment with general healthcare. However, preliminary findings suggest that health plans that include a dental clinic and have Medicaid contracts are more likely to be accountable care organizations (ACOs).

There is also a major shift taking place in the field of clinical treatment. The old fee-for-service, procedure-driven model of today’s oral health care is being replaced with a model that involves care planning based on individual patient characteristics and risk factors, with reimbursement connected to quality and results rather than volume. Preventive care, early intervention, careful monitoring, and chronic care management are aimed to those at high risk for disease under this model of prevention and care management. The goal is to enhance oral health outcomes by delivering services tailored to each patient’s specific risk and needs. Improving access to and use of dental services, along with Medicaid spending on them, may be possible if systems of care and health system accountability are reexamined.

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