Dental Benefits: “Because Medicaid Has, How Do You Call It? A Limit”

Follow up on: Neeley M, Jones JA, Rich S, Gutierrez LS, Mehra P. Effects of cuts in Medicaid on dental-related visits and costs at a safety-net hospital. Am J Public Health. 2014;104(6):e13–e16.

During the current US presidential campaign season, Senator Bernie Sanders has argued for a single-payer health care plan that he refers to as “Medicare for all.” Recently, the Democratic nominee Hillary Clinton has suggested that Americans younger than 65 years, perhaps “people 55 or 50 and up,” could voluntarily pay to join the program.¹ While Medicare covers most health services for adults aged 65 years and older as well as for younger adults with disabilities, it provides no benefits for routine dental care.² Medicaid, the major health coverage program for low-income Americans, provides a comprehensive mandatory benefit package for children that includes oral health screening, diagnosis, and treatment services, but allows states to determine whether to offer dental benefits for adults.²

MEDICAID CUTS AND DENTAL-RELATED VISITS AND COSTS

In an AJPH report published two years ago, Neely et al. found that dental-related emergency department (ED) visits and costs increased at Boston Medical Center in Massachusetts when Medicaid coverage for adult dental care was reduced in July 2010.³ By age group, the greatest percentage increases in ED visits for dental reasons were in persons aged 55 to 65 years (50%), followed by persons aged 65 years and older (45%).³

These findings are consistent with other evidence that when states have faced budgetary pressures—as Massachusetts did during and following the US Great Recession that began in December 2007 and lasted through June 2009—adult dental services in Medicaid have typically been among their first cutbacks.^2,3 For instance, California removed all but emergency adult benefits in 2009 and restored a subset of these benefits in 2014.⁴ Glassman argues that the cycle of removing and restoring benefits has been among the deterrents to dentists providing dental care to low-income adults covered by Medicaid.⁴

VARIATION IN ADULT DENTAL BENEFITS BY STATE

Nearly all states (46) and Washington, DC, currently provide adult dental benefits, with 15 states providing extensive dental benefits (including more than 100 diagnostic, preventive, and minor and major restorative procedures), 19 states providing limited dental benefits (including fewer than 100 dental procedures), and 13 states providing emergency-only dental benefits (including pain relief and extractions).² Furthermore, many state Medicaid programs set a maximum on per-person spending for adult dental benefits or impose caps on the number of certain services covered.

The Affordable Care Act (ACA; Pub L No. 111–148), signed by President Obama in 2010, requires states to provide Alternative Benefit Plans for Medicaid expansion adults, modeled on one of four benchmark options specified in the law, including an option for coverage approved by the US Secretary of Health and Human Services.^2,4 Of the 31 states and Washington, DC, that have adopted Medicaid expansion, all but two have used the Secretary-approved coverage option to conform the benefits provided for expansion adults with the benefits for adults in traditional Medicaid, modifying them as necessary to comply with the 10 Essential Health Benefits established by the ACA.²

Even in New York State, where Medicaid enrollees are covered for essential dental services, locating dentists who accept Medicaid can be problematic. Reimbursements for dentists by Medicaid are often lower than those paid by private insurers, the program places restrictions on the scope and timing of services covered (e.g., no dental implants, fixed bridgework, immediate full or partial dentures, or molar root canal therapy for adult beneficiaries except in narrowly defined medical situations), and the policies and procedures for participation in Medicaid are often onerous.⁵

CHALLENGES FOR OLDER ADULTS ON MEDICAID

Beyond the effects of cuts in Medicaid and the scope and timing of services covered, we asked 194 racial/ethnic minority adults aged 50 years and older who participated in 24 focus groups in New York City from 2013 to 2015 about their experiences in seeking and receiving dental care. A hierarchical coding scheme was developed for data analysis that included Financial and Insurance as a core code, with Medicaid as a subcode. Preliminary findings regarding Medicaid are presented here.

Participants reported stigma in dental settings related to their Medicaid coverage, for themselves and others.

“When you walk in [neighborhood clinics] the first thing they ask you is what kind of insurance you have, when you come in is Medicaid or Medicare, they turn up their nose at you.”

“The ones from Medicaid are left sitting there and the ones who pay cash, they come to the front.”

Furthermore, the distinctions among which, if any, dental services are covered under Medicaid, Medicare, and other insurance plans is not always straightforward.

“I have Medicare, which you know I pay forever more, I have Medicaid, and I have Health First. So, when one don't take over, the other one take over. They send me a book every year explaining to me what Medicaid pays, Medicare pays, and health insurance pays…if I had to pay that out of my pocket, I'd have been dead and never got it.”

“What Medicaid tells you when you look in your provisions, if you got Medicare and you got Medicaid it’s supposed to be a full service coverage, but in reality when it comes to dental, it’s not. Then they compound their arrogance by making you get another card, United or Metro and you still don’t get full coverage, somebody need to do something about that.”

While participants may not have been as explicit as the official Dental Policy and Procedure Code Manual about the essential services covered by Medicaid in New York State,⁵ they appreciated both the limited scope and the changes over time of the dental services covered by the program.

“Yeah, Medicaid, they real, they only go for the minimum like if you need extensive dental work done they are going to deny you, every time.”

“Well, I remember when Medicaid used to pay for root canal. And that would save the tooth. But now they have discarded that. And they want to pull the teeth now.”

Finally, participants on Medicaid reported needing to pay out-of-pocket for part of the dental services they received.

“I am on Medicaid and there is a loophole when it comes to dental that you still got to pay.”

“Because Medicaid has, how do you call it? A limit… I tell you because of my own case. I have to pay a certain amount because I went beyond the limit. They go up to $820…”

PROGRESS AND PROMISE

Since the Neely et al. findings³ were published two years ago, Massachusetts has gradually added back Medicaid coverage on a service-by-service basis through the state budget process.⁶ For instance, in January 2013, coverage was added for fillings on front teeth, which are important for employability; in May 2014, coverage for all fillings was restored; and in May 2015, coverage for dentures was restored.⁶

During this election season, there has been a palpable lack of optimism, not only among the presidential contenders, but among Americans overall.⁷ Past reforms—notably the ACA—fail to receive the credit they deserve, especially for enhancing children’s use of preventive dental care services.² As a society, we need to fulfill the promise of health care for all, and develop integrated and humane models of care that include the mouth in the rest of the body for adults, too.