Dentists report that Medicaid is a complicated and frustrating system; therefore, only a small percentage of dentists are enrolled providers.1 Very few dentists treat more than a small handful of patients with Medicaid per year. For Medicaid patients, a significant gap exists between their dental care needs and availability of care, but through persistent advocacy, dentists can influence Medicaid to perform successfully in their states.
What is Medicaid?
Medicaid and Medicare are separate, publicly funded health insurance programs that were both created in 1965. Medicaid is a state-run health insurance program for low-income individuals and other specific vulnerable populations, whereas Medicare is federally managed health insurance for older adults (65+) regardless of income. Dental care is a required Medicaid benefit for enrolled children and an optional benefit for enrolled adults; Medicare does not have a dental component.2
What is the relationship between the government and health care?
The government provides health insurance for one in three Americans, which amounts to more than 100 million people. Twenty percent of the population in the United States is covered by Medicaid, 15% by Medicare. Half of all births in this country are covered by Medicaid.3
Medicaid and Medicare came to exist as amendments to the Social Security Act, which was first passed in 1935 following the Great Depression.4 These national health-care programs now make up the largest part of the federal budget, ahead of Social Security and the Department of Defense.5
Medicaid funding is a shared responsibility of state and federal governments. The federal government pays for more than half of each state’s Medicaid costs, ranging from 50% for the wealthiest states to 78% for the poorest states. Health care is an increasing part of the US budget, currently 27% of federal spending. At the state level, health-care spending exceeds public education as the largest and fastest-growing portion of state budgets.2
How does Medicaid work?
Every state runs its own Medicaid program based on ground rules set by the federal government, which means that eligibility criteria, reimbursement levels, and dentist participation vary from state to state. Eligibility is based on modified adjusted gross income, yet income limits vary as well. Income is compared to a specific percentage of the federal poverty level, which is set annually by the US Department of Health and Human Services.3 For example, in Wisconsin, a single adult without children qualifies for Medicaid if the person’s annual income is at or below the federal poverty level—$12,760 in 2020. However, the exact same adult is ineligible for Medicaid in Texas, Florida, Kansas, and 11 other states.6
There are also nonfinancial factors that may qualify someone for Medicaid regardless of household income. In the 1980s, two laws passed giving uniquely vulnerable children access to Medicaid regardless of family income: 1) children with special health-care needs (CSHCN) and 2) children in foster care. Half of the CSHCN (13 million in the US) carry Medicaid coverage.2,3 It is estimated that many families of CSHCN may not know they are eligible for Medicaid if they aren’t low-income. Over a half million youth experience foster care each year in the US and are eligible and likely enrolled in Medicaid.3,7
Controversy and complaints
There is a wide body of literature demonstrating financial and nonfinancial barriers to dentists participating in Medicaid. Reimbursement is often much lower than commercial insurance plans and may not cover overhead. Payments can be inconsistent based on state budget shortfalls or inefficient administration.
Third-party companies called managed care organizations (MCOs) are often contracted by states to administer medical and dental Medicaid benefits. They must cover the minimum state benefits, but they can require additional prior authorizations, complex claims processing, and adjudication regarding whether care is medically necessary. Some areas have multiple active MCOs, each with different expectations.
Many states have benefited from advocacy efforts to improve Medicaid for dental patients and providers. For example, dozens of lawsuits have been filed with many successfully establishing that state Medicaid programs have failed to meet the minimum federal requirements for providing care to enrollees. Lawsuits can be initiated by health-care advocacy groups, state dental associations, or even individual stakeholders. There are legislative solutions as well, such as introducing a law that increases reimbursement for dental services in specific counties, then incrementally rolling this enhancement out statewide.
Call to action
Because Medicaid budgets are set at the state level, it’s the constituents’ responsibility to appeal to their legislators, regardless of political ideology. Since 2020 is an election year, there’s no better time to engage candidates for elected office about the opportunities to improve Medicaid for dental patients who are also constituents and voters.
Your state or specialty dental association is likely engaged in ongoing Medicaid reform advocacy. Educate yourself on current efforts. Sign up for your professional associations’ electronic action alerts to easily communicate the importance of adequate funding and efficient administration of Medicaid.
Remember that you can choose which Medicaid HMOs to contract with if they operate in your area. There are outcome measures available to you through the state to help you compare and evaluate plans.
Your practice can be the door that opens for patients who may have extreme dental care needs but few resources for treatment. A large percentage of Americans are covered through Medicaid, but dentist participation in the program is limited for a variety of reasons, many of which can be changed. I challenge you to be a consistent voice committed to educating and urging lawmakers to fulfill their responsibility to the most vulnerable in your community. Successful reform is only possible if motivated stakeholders such as dentists are willing to take the lead.
- Dental benefits and Medicaid. American Dental Association. 2020. https://www.ada.org/en/science-research/health-policy-institute/dental-statistics/dental-benefits-and-medicaid
- Garfield R, Hinton E, Rudowitz R. 10 things to know about Medicaid: Setting the facts straight. Kaiser Family Foundation. March 6, 2019. Accessed May 27, 2020. https://www.kff.org/medicaid
- Curtis CA, Eckstein ET II, Klees BS. Brief summaries of Medicaid and Medicare. Centers for Medicare and Medicaid Services. November 15, 2019. Accessed May 27, 2020. https://www.cms.gov/files/document/brief-summaries-medicare-medicaid-november-15-2019.pdf
- Social Security Act. Encyclopedia Britannica. https://www.britannica.com/topic/Social-Security-Act-United-States-1935
- Policy basics: Where do our federal tax dollars go? Center on Budget and Policy Priorities. Updated April 9, 2020. https://www.cbpp.org/research/federal-budget/policy-basics-where-do-our-federal-tax-dollars-go
- Damico A, Garfield R, Orgera K. The coverage gap: Uninsured poor adults in states that do not expand Medicaid. Kaiser Family Foundation. January 14, 2020. Accessed June 25, 2020. https://www.kff.org/medicaid/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/
- Health care coverage for youth in foster care—and after. Child Welfare Information Gateway. U.S. Department of Health and Human Services, Children’s Bureau. May 2015. Accessed June 25, 2020. https://www.childwelfare.gov/pubPDFs/health_care_foster.pdf