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Oral Health Topics

Medicaid Principles

Dental Medicaid Reform Core Principles and Policies

Given that Medicaid beneficiaries are more likely to access care than similarly situated uninsured; Given that the dental services children and adults receive in Medicaid are cost-effective; Given that dental disease is the single most common chronic disease of children; Given that parents consistently cite dental as the number one unmet health need of their children; Given that poor oral health can affect a child's ability to learn and an adult's ability to obtain a job due to appearance; Given that untreated oral disease complicates medical conditions like diabetes and heart disease and may be associated with pre-term low-birth weight babies; Given that oral disease can jeopardize the health of Medicaid-eligible elderly and the disabled, affecting the health and well-being of those living in nursing homes; Given that preventive and routine dental services save overall health care dollars by avoiding costly visits to the emergency room, the dental community agrees to the following principles and recommended policies:

Preserve the Federal Guarantee of Medicaid Coverage, Services and Consumer Protections

  • Maintain a federal requirement for dental services for EPSDT Medicaid-eligible children , and extend medically necessary coverage to adults.
  • Ensure that preventive dental benefits are excluded from cost-sharing requirements.

Preserve the Federal Financing Role in Medicaid

  • Maintain the current federal-state financing arrangement within Medicaid and reject proposals to establish caps on payments to states.
  • Update the federal matching formula to address changes in state economics, and provide an enhanced match for dental services to ensure a state is able to adequately cover these services for Medicaid populations.
  • Allow for flexibility within states without diminishing the existing federal-state partnership, which includes federal requirements and/or incentives to enhance program effectiveness.

Assure and Maintain Access to Care Through Adequate Provider Participation

  • Provide incentives to states to adopt Medicaid models that mirror programs dental providers work with in the private sector, improve access for beneficiaries and facilitate providers' active participation in the Medicaid program.
  • Ensure that dental providers receive fair and market-based compensation for services provided and that compensation is not decreased by cost-sharing requirements.
  • Consider utilizing the private market to provide additional dental coverage options to higher-income Medicaid beneficiaries or populations not currently covered by the Medicaid program (e.g., optional dental health savings accounts), and ensure that any private insurance models offered to Medicaid beneficiaries provide comprehensive dental benefits.
  • Maintain equal access provision in federal law to ensure that beneficiaries within Medicaid have access to dental services in the same way as beneficiaries in the private sector.
  • Support dental targeted case management programs that utilize Medicaid funds to capitalize on disease management.

Use the Medicaid Waiver Process to Foster Improvements and Innovation, Not to Eliminate Federal Protections or Reduce Benefits

  • Ensure that medical necessity criteria does not restrict or eliminate coverage for oral health/dental care that meets professional standards and is clinically appropriate, as determined by a dentist.

Improve the Integrity of Medicaid

  • Eliminate fraud and abuse within the program and ensure necessary oversight to determine adequate access to care is provided to beneficiaries.
  • Ensure that the financing of the Medicaid program is sound and responds to market demands and state economic needs.

Recognize the Interdependence of Medicaid and the Public Health System

  • Facilitate public-private partnerships that improve access for individuals who access oral health care through a safety-net provider. Such a partnership may result in private contracts between safety-net clinics and dental providers and academic dental institution clinics.
  • Facilitate the establishment of school-linked programs.

Encourage programs that value prevention and disease management (to reduce disease burden), are science and evidence-based and invest in strategies with strong potential for long-term savings through preventive care