Coverage & Financing
 

 

 

Is dental coverage and financing different from other healthcare coverage and financing in the United States?

Yes, for most health care, only 14 cents of every dollar spent is paid out-of-pocket, with the remainder covered by public or private insurance. In contrast, 45 cents of every dollar is paid out-of-pocket for dental care, about 50 cents is paid for by insurance, and 6 cents is paid by Medicaid and CHIP -- with nothing paid by Medicare.

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How does passage of health reform and other federal legislation affect coverage for children?

The combination of new laws in 2009 (the Children’s Health Insurance Program Reauthorization Act (CHIPRA)) and in 2010 (the Patient Protection and Affordable Care Act (“ACA” or “Health Reform”) have the potential to bring oral health coverage to nearly all children in the United States.

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How does the publicly financed component of dental insurance work?

Medicaid dental care for children is required by federal law and offers comprehensive coverage (involving early screening, diagnosis and treatment and known as “EPSDT”). A state is responsible for treating a patient if screening identifies a problem (even if the service is not in the state’s Medicaid plan). Medicaid costs are shared between federal and state governments (two states also share costs with local governments). However coverage for adults in Medicaid is optional, although a few states have mandated coverage for pregnant women.

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To what extent do private practice dentists treat publicly-insured patients and how is their Medicaid payment determined?

Across the U.S., fewer than one-in-four dentists participate in Medicaid and fewer than one-in-ten treat at least 30% of patients with Medicaid coverage. There are groups of private practitioners who see Medicaid patients almost exclusively. In most states, private providers receive Medicaid payments through discounted “fee-for-service” payments schedules. States have the option to increase fees to reflect market rates and rates range considerably. States that increased their Medicaid participation have also raised fees high enough to engage the market.

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Does public financing of provider services differ if a patient goes to a community health center, school-based health center, hospital or other treatment center?  
States have different mechanisms for Medicaid payments to “safety net” providers. These institutions may bill Medicaid through systems that pay on a “per visit” basis, which guarantees fewer financial risks than experienced by private providers who bill Medicaid. Additional federal funding streams help to sustain safety net providers.

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What about dental Medicaid managed care vendors?
States cannot contract away their legal responsibility to follow federal Medicaid regulations, but can contract with MCO’s to administer their programs. States are permitted to experiment with Medicaid reforms and have undertaken demonstration projects that draw on the experience of MCO’s in increasing utilization. These efforts often target improvement by incentivizing relationships among both providers and beneficiaries.

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What federal programs support coverage and financing that relate to oral health?

Under Medicaid, CHIPRA and ACA (health reform), all US children and adolescents under the age of 21 who now lack dental insurance may gain access to dental coverage as part of the law’s “essential benefits” requirement (e.g., insurance plans through state Exchanges must include oral care for kids and may not charge “out-of-pocket” for preventive services). The ACA law also addresses coverage and financing as it:

  • Creates an option for purchasers to buy pediatric dental coverage directly from stand-alone dental plans or through medical plans
  • Puts payments and access to dental professionals under review by the Medicaid and CHIP Payment and Access Commission (MACPAC)
  • Establishes grants for school-based health centers that include oral health services
  • Establishes standards for accessibility of medical and dental diagnostic equipment for persons of all ages with disabilities
  • Based on CHIPRA, ARRA, and federal Medicaid funding, what state opportunities exist to enroll children and improve coverage overall?
  • States have an opportunity to expand income eligibility levels in CHIP and/or Medicaid programs, simplify steps for enrollment and renewal using technology and enhance outreach, adopt “Express Lane” Eligibility options, adjust waiting periods, and coordinate with CMS to verify citizenship to process Medicaid and CHIP.

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Where can I get more information?

Selected Federal Government news and reports:

Analysis from the Children’s Dental Project (CDHP) and other groups:

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