Dental Care for Medicaid and CHIP Enrollees
Dental health is an important part of people's overall health. States are required to provide dental benefits to children covered by Medicaid and the Children's Health Insurance Program (CHIP), but states choose whether to provide dental benefits for adults. See the 2010 Medicaid/CHIP Oral Health Services fact sheet for information on children's access to dental services and opportunities and challenges to obtaining care.
Dental Benefits for Children in Medicaid
Medicaid covers dental services for all child enrollees as part of a comprehensive set of benefits, referred to as the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. Though oral screening may be part of a physical exam, it does not substitute for a dental examination performed by a dentist. A referral to a dentist is required for every child in accordance with the periodicity schedule set by a state.
Dental services for children must minimally include:
- Relief of pain and infections
- Restoration of teeth
- Maintenance of dental health
The Early Periodic Screening, Diagnostic and Testing (EPSDT) benefit requires that all services must be provided if determined medically necessary. States determine medical necessity. If a condition requiring treatment is discovered during a screening, the state must provide the necessary services to treat that condition, whether or not such services are included in a state's Medicaid plan.
Each state is required to develop a dental periodicity schedule in consultation with recognized dental organizations involved in child health care. Dental services may not be limited to emergency services for children entitled to EPSDT.
Dental services must be provided at intervals that meet reasonable standards of dental practice, and at such other intervals, as indicated by medical necessity, to determine the existence of a suspected illness or condition. States must consult with recognized dental organizations involved in child health care to establish those intervals. A referral to a dentist is required for every child in accordance with each State's periodicity schedule and at other intervals as medically necessary. The periodicity schedule for other EPSDT services may not govern the schedule for dental services.
Dental Benefits for Children in CHIP
States that provide CHIP coverage to children through a Medicaid expansion program are required to provide the EPSDT benefit. Dental coverage in separate CHIP programs is required to include coverage for dental services "necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions." For more information see CHIP Dental Care Goals.
States with a separate CHIP program may choose from two options for providing dental coverage: a package of dental benefits that meets the CHIP requirements, or a benchmark dental benefit package. The benchmark dental package must be substantially equal to the (1) the most popular federal employee dental plan for dependents, (2) the most popular plan selected for dependants in the state's employee dental plan, or (3) dental coverage offered through the most popular commercial insurer in the state.
States are also required to post a listing of all participating Medicaid and CHIP dental providers and benefit packages on www.insurekidsnow.gov.
Dental Benefits for Adults in Medicaid
States have flexibility to determine what dental benefits are provided to adult Medicaid enrollees. While most states provide at least emergency dental services for adults, less than half of the states currently provide comprehensive dental care. There are no minimum requirements for adult dental coverage.
Children's Oral Health Initiative
CMS is committed to improving access to dental and oral health services for children enrolled in Medicaid and CHIP. We have been making considerable progress in our efforts to ensure that low-income children have access to oral health care. From 2007 to 2011, almost half of all states (24) achieved at least a ten percentage point increase in the proportion of children enrolled in Medicaid and CHIP that received a preventive dental service during the reporting year. Yet, tooth decay remains one of the most common chronic childhood diseases.
To support continued progress, in 2010 CMS launched the Children's Oral Health Initiative and set goals for improvement by FFY 2015. To achieve those goals, we have adopted a national oral health strategy through which we are working diligently with states and federal partners, as well as the dental provider community, children's advocates and other stakeholders to improve children's access to dental care.
To support state Medicaid and CHIP programs in achieving their improvement goals, we developed Keep Kids Smiling: Promoting Oral Health Through the Medicaid Benefit for Children and Adolescents. It provides an overview of the children's dental benefit in Medicaid, support for evidence-based policies at the state level, and details of successful strategies with state examples.
We are also ramping up our efforts to educate consumers, health care providers and the public about positive oral health practices. Three oral health education materials, with messaging targeted to parents of young children and to pregnant women, are available for download or bulk order. Also available are tips for using the materials.
Tools to Help States Improve the Delivery of Dental and Oral Health Services
Guidance for Reporting the Dental Sealant Measure in the Child Core Set
- Technical Assistance Webinar on the Dental Sealant Measure in the Child Core Set - November 12, 2015
Reporting Dental Data on the Form CMS-416
- Learn how to improve the quality of the dental data reported on the Form CMS-416, the annual report of services provided to children receiving the Medicaid Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit using web-based training modules.
- How to Improve Your State's Reporting of Medicaid Dental Data on the Form CMS-416 - October 27, 2015
Oral Health Performance Improvement Projects
- Medicaid Oral Health Performance Improvement Projects: A How-To-Manual for States
- Medicaid Oral Health Performance Improvement Projects: A How-To-Manual for Health Plans
- Medicaid Oral Health Performance Improvement Projects: A Template
Medicaid Policy Tools for Reducing Early Childhood Tooth Decay
- Reducing Early Childhood Tooth Decay: An Overview for State Policymakers
- Reducing Early Childhood Tooth Decay: Leading Steps for State Policymakers
- Reducing Early Childhood Tooth Decay: Strategies for State Medicaid and CHIP Program Managers
State Oral Health Action Plans
To support the Oral health Initiative, CMS invited state Medicaid agencies to develop State Oral Health Action Plans (SOHAPs) as a roadmap to achieving in their goals.
CMS has received SOHAPs from the following 25 states: Alabama, Alaska, Arizona, California, Connecticut, District of Columbia, Delaware, Florida, Maine, Maryland, Massachusetts, Michigan, Missouri, Nebraska, New Hampshire, New Jersey, North Dakota, Oklahoma, Pennsylvania, Tennessee, Utah, Vermont, Virginia, Washington and Wyoming. CMS encourages the remaining 29 states to develop and submit their SOHAPs, and CMS stands ready to provide technical assistance to any state that requests it.
SOHAPs may be submitted using either a CMS-developed Oral Health Action Plan Template or a user-friendly template developed by the Medicaid-CHIP State Dental Association. Completed SOHAPs may be submitted to Laurie Norris, Senior Policy Advisor via email to Laurie.Norris@cms.hhs.gov with a copy to your CMS Regional Office contact. Any questions about the SOHAPs may also be directed to Ms. Norris.
CMS Learning Lab: Improving Oral Health Through Access
The Center for Medicaid and CHIP Services at the Centers for Medicare & Medicaid Services is hosting a series of webinars to support States and their collaborative partners to improve access to dental services for children enrolled in Medicaid and CHIP. The webinar materials are available below. For more information about the CMS Oral Health Initiative and the CMS Learning Lab webinars, see the June 2012 Informational Bulletin.
Reducing Early Childhood Tooth Decay: Approaches in Medicaid – May 27, 2015
Performance Improvement Projects (PIP) for States and Health Plans - Implementation Considerations – May 20, 2015
Performance Improvement Projects (PIP) for States and Health Plans - Planning Considerations – May 6, 2015
Advancing Program Integrity for Medicaid Dental Programs: Federal, State, and Stakeholder Efforts – January 28, 2015
Improving Oral Health Through Access: Building a Partnership between Medicaid and Head Start – September 16, 2014
State Medicaid and CHIP Program Support of Sustainable Oral Health Care Delivery Models in Schools and Community-Based Settings – May 14, 2014
Keep Kids Smiling: Promoting Oral Health Through the Medicaid Benefit for Children & Adolescents - January 30, 2014
Dental Sealants: An Effective State Strategy to Prevent Dental Caries in Children - September 19, 2013
Engaging More General Dentists to Care for Young Children: Access to Baby and Child Dentistry (ABCD) in Washington and South Dakota - May 8, 2013
Quality Improvement Processes: An Introduction for Medicaid and CHIP Dental Programs - January 23, 2013
Successful Beneficiary Outreach Strategies - September 26, 2012
Developing State Oral Health Action Plan Using State Data - June 19, 2012