Fillings Needed for Gaps in Government Dental Coverage

The connection between oral health and overall well-being is clear: untreated oral diseases can decrease quality of life, worsen health, and create economic burdens for patients and society.¹ In 2019, the US lost more than $78 billion in productivity due to untreated oral disease.² Nearly 70 million US adults lacked dental coverage in 2023, and almost 6 in 10 were unable to visit a dentist, mostly due to cost. The ongoing debate over water fluoridation further underscores the importance of integrated oral health strategies to prevent dental disease.³

The historical separation between dentistry and medicine has long led to a fragmented oral health care system, with inadequate funding and limited access to care. The 3 main government health insurance programs (Medicaid, Medicare, and the Affordable Care Act [ACA] Marketplace) each offer some level of dental coverage, but leave large gaps. As a result, marginalized populations often lack access to necessary dental services.¹

Addressing these gaps requires a bipartisan effort and substantial reform of oral health care financing and delivery. We discuss the current dental coverage available in government health insurance programs and identify opportunities for improvement.

Medicaid

Medicaid, which covers more than 79 million low-income individuals, operates under a joint federal and state structure that has resulted in 51 different Medicaid programs (including Washington, DC) with varying levels of dental coverage. Although dental care is a required benefit for child beneficiaries, adult coverage ranges from comprehensive care in some states to limited or no coverage in others.

Medicaid has achieved significant progress in expanding access to dental care. Since 2010, states offering comprehensive dental benefits for adults have more than tripled, with 34 states now providing such coverage. In states with Medicaid expansion under the ACA, adult dental benefits increased use of dental services, improved oral health outcomes, and reduced emergency dental visits.^4,5 Moreover, all states and Washington, DC, have now expanded dental coverage for pregnant and postpartum Medicaid enrollees. However, the major remaining need is to make adult dental coverage a standard benefit in all states.

In states lacking the political will or budget to cover dental services for all beneficiaries, Medicaid waivers offer an alternative to expand dental coverage to some groups. Waivers can provide coverage to populations with complex needs or fill gaps in existing services, like adding periodontal treatment beyond what state coverage offers.

Medicaid waivers promoting dental access offer a more constructive alternative to improving economic circumstances for beneficiaries than the popular work requirements proposal. Even though research shows Medicaid work requirements do not increase employment and cause coverage loss due to red tape,⁶ other studies show that good dental care is a key enabler of job opportunities,¹ suggesting that Medicaid coverage of adult dental services could promote employment.

In addition, the growing role of managed care organizations (MCOs) in Medicaid has led to additional changes in dental care delivery. Although evidence is limited, early indications show shifting to a managed care plan increased pediatric emergency dental visits, suggesting reduced access to dental care for children.⁷ To improve oversight, the Centers for Medicare & Medicaid Services (CMS) should mandate comprehensive reporting by MCOs on oral health metrics and establish performance standards for oral health. Extending network adequacy standards to adult dental plans, already required for pediatric MCO dental plans, could help address the long-standing issue of limited dentist participation in Medicaid.

Medicare

Medicare covers 68 million individuals, but traditional Medicare excludes dental care except for limited medically necessary services. As of 2019, nearly 24 million Medicare beneficiaries lacked dental coverage, with 47% not visiting the dentist in the prior year.

Many Medicare Advantage (MA) plans partially fill this gap with supplemental dental benefits funded by MA rebate dollars. More than 98% of MA plans offer dental benefits, which may be a draw in enticing new enrollees, but beneficiaries still often face significant out-of-pocket costs due to cost sharing and coverage limits. Research suggests that MA coverage does not sufficiently address the oral health needs of individuals transitioning to Medicare from Medicaid programs that offer dental benefits, nor do MA beneficiaries have better access to dental care on average than those in traditional Medicare (who may have supplemental coverage).⁸ Furthermore, the absence of dental quality and performance measures (eg, star ratings for MA plans) and incomplete encounter data on supplemental benefits limit evaluation of their effectiveness. However, in February 2024, the CMS addressed encounter data concerns by clarifying reporting guidelines and addressing challenges in capturing certain services with procedure codes.

Efforts to add a full dental benefit to traditional Medicare, such as what was proposed in President Biden’s Build Back Better Act, have fallen short, in part due to opposition from dental organizations concerned about reimbursement rates as well as concerns about the effects on budgets. In this void, the CMS has taken modest steps to improve dental coverage in traditional Medicare without legislation. The CMS expanded Medicare in 2023 to include dental services prior to organ transplant, cardiac valve replacement, and valvuloplasty. This coverage expansion was extended in 2024 to include patients undergoing chemotherapy, chimeric antigen receptor T-cell therapy, antiresorptive therapy, and treatment for head and neck cancer and was further extended in 2025 to include patients undergoing dialysis for end-stage kidney disease. Although these changes are important steps toward integrating dental and medical care for select high-risk patients, they do not address the limited dental access faced by most Medicare beneficiaries.

ACA Marketplace

For 2025, 23.6 million people have selected coverage through the ACA Marketplace; however, many enrollees lack dental coverage. Dental plans are available through the ACA Marketplace in 2 ways: embedded within a health insurance plan or as a stand-alone dental plan. Roughly two-thirds of states offer embedded Marketplace dental coverage, and all states offer stand-alone dental plans in the Marketplace.⁹ However, dental insurer participation is limited in counties with a state-based Marketplace, in rural areas, and in counties with dentist shortages.

Under the ACA, children’s dental coverage is an essential health benefit and must be offered in all Marketplace plans, but families are not required to purchase it. In contrast, adult dental benefits are not considered an essential health benefit, resulting in separate deductibles, no annual limits on out-of-pocket cost sharing, and ineligibility for federal premium subsidies for that portion of coverage. However, a new CMS rule (starting in 2025) allowing states to designate adult dental benefits as an essential health benefit is a promising development, potentially improving dental coverage across all Marketplace plans.

Nonetheless, dental coverage through the Marketplace needs improvement. The lack of standardization and the numerous plan offerings in some counties (as high as 88 plans in 1 study⁹) complicate consumer choices. Lack of network adequacy requirements for stand-alone dental plans is another concern, particularly in areas with dentist shortages. Approximately 24.7 million people across the US live in dental care shortage areas, which disproportionately affect rural underserved counties and areas with high proportions of uninsured individuals, exacerbating existing disparities in dental care.¹⁰

Aligning Dental Coverage Policies for Better Oral Health

Strengthening dental coverage across Medicaid, Medicare, and the ACA Marketplace can address existing gaps, and improving data reporting on these issues will enable evidence to inform future reforms. The intersection of these programs offers opportunities for enhanced access, such as aligning dental coverage for dual-eligible individuals, and ensuring seamless transitions when moving from Medicaid to Medicare at 65 years of age. In addition, making plans with dental coverage the default option for individuals enrolling in the Marketplace (as well as a required standard benefit for adults in Medicaid) could improve uptake of available dental benefits and provide continuity even during transitions from one coverage type to another. Because these programs cover roughly half of the US population, policymakers should ensure that recent momentum toward better oral health is not reversed.