Participating in Medicaid

Medicaid provides health coverage to millions of low-income Americans, including eligible adults, children, pregnant women, elderly adults and people with disabilities. As of 2021, there are nearly 76 million individuals enrolled in Medicaid.

Medicaid represents $1 out of every $6 spent on health care in the U.S. and is the primary source of funding for states to address the health needs of low-income residents.

Medicaid is jointly funded by states and the federal government. As the third largest domestic program in the federal budget — right behind Medicare and Social Security — the program plays a unique role in state budgets. As a result of this joint financing structure, Medicaid acts as both an expenditure and the largest source of federal revenue in state budgets.

States are required to balance their budgets on a regular basis, making choices about program spending and how much revenue to collect. Balancing these competing priorities creates an ever-present tension that ultimately affects Medicaid and CHIP.

Learn more at Medicaid.gov

Medicare and Medicaid comparison (PDF)

From the Kaiser Family Foundation: facts about Medicaid financing, access and more

The EPSDT benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid. This benefit is key to ensuring that children and adolescents receive appropriate medical and dental care. Overall goals are:

• To assess and identify problems early
• To check children's health at periodic, age-appropriate intervals
• To provide screening tests to detect potential problems
• To perform diagnostic tests when risks are identified
• To control, correct or reduce health issues uncovered by testing

Yet even with these goals in place, only around 45% of eligible children actually see a dentist. Since we know the value of early, family-centered care in reducing the lifetime incidence of tooth decay, this is a serious concern. The ADA supports ongoing efforts to ensure that EPSDT-eligible patients receive the comprehensive care they need.

Here are helpful resources on children’s dental care from Medicaid.gov, the Centers for Medicare and Medicaid Services (CMS) and other organizations.

Overview: Early and periodic screening, diagnosis and treatment

Medicaid EPSDT benefit keeps children healthy (PDF)

Insure Kids Now: a website devoted to expanding children’s access to care through Medicaid

From the American Academy of Pediatric Dentists: state dental periodicity schedules

EPSDT guide for states: coverage in the Medicaid benefit for children and adolescents

Keep kids smiling: promoting oral health through the Medicaid benefit for children & adolescents

Paving the road to good health: strategies for increasing Medicaid adolescent well-care visits

Making connections: strategies for strengthening care coordination in the Medicaid benefit for children & adolescents

Even though oral health is crucial to overall health, Medicaid programs often treat dental care as an elective option. Allocation of state Medicaid dollars for dental services averages about 2% of the total Medicaid budget. Cutting Medicaid dental benefits may be a symbolic cost-reduction mechanism for many states, yet it clearly harms those who need preventive dental care the most.

According to the ADA Health Policy Institute (HPI), Medicaid-eligible adults represent a growing share of the U.S. population. Many of these individuals urgently need dental care – and with the number of privately insured patients shrinking, some dentists find that treating Medicaid patients isn’t an option, but a necessity to keep their practices going.

Some dental professionals provide care for large numbers of Medicaid-eligible adults. Others accept a modest number of these patients, encouraged by “Take Five” programs that have proven useful in several states.

Success story: Take 5 program in Colorado

Kaiser Family Foundation report: improving access to care for adults in Medicaid

Center for Health Care Strategies report: what’s keeping state oral health leaders up at night

Center for Health Care Strategies report: engaging stakeholders to improve access to care for Medicaid-enrolled adults

Many dentists are reluctant to treat Medicaid patients, citing these concerns:

• Low reimbursement rates
• Administrative burdens
• Worries about complying with Medicaid regulations
• Perception that no-show rates will be high
• Lack of clear information about existing dental benefits
• Transportation challenges that patients may face
• Issues of cultural competency, including language barriers
• Need to educate this patient group about the benefits of regular oral care

Working alongside other stakeholders, the ADA is engaging state dental associations and Medicaid programs to address these concerns. For example, the ADA’s Council on Dental Benefit Programs has developed a sample template for working with states that contract with third-party administrators of managed care plans. By clearly stating expectations, responsibilities and risk-sharing, all parties know what to expect and who will be held accountable within the contract. This is critical, since Medicaid audits are becoming more frequent.

Several states have made real progress in convincing more dental providers to accept Medicaid patients, using incentives such as modest increases in reimbursement rates. Challenges and best practices are gathered and shared with other states to widen the dental safety net nationwide.

Research report: Most important barriers to dental care are financial, not supply-related 

Medicaid: Considerations when working with states to develop an effective RFP/dental contract

The first rule of dental care documentation is that if something isn’t written down, it doesn’t exist. Dentists who see Medicaid patients must be sure to fully document the care they provide.

Dentists are well-trained to document the steps they take, but it’s equally important to establish medical necessity. This means confirming that the appropriate treatment and supplies were chosen in order to evaluate and treat a specific condition, illness or injury. Documentation should confirm the rationale for the procedure in alignment with the Current Dental Terminology (CDT) Code.

Depending on the situation, dentists may need to document that care was necessary to:

• Eliminate or prevent orofacial disease, infection or pain
• Restore form and function to dentition
• Correct facial disfigurement or dysfunction

Here are helpful resources on documentation and fraud awareness.

From the Centers for Medicare and Medicaid Services (CMS): Electronic health records: increasing the quality of care (PDF)

From CMS: There are many types of Medicaid fraud (PDF)

From the American Academy of Pediatric Dentists (AAPD): brochure on medically necessary care and how to document it (PDF)

AAPD policy on medically necessary care (PDF)

From the Centers for Medicare and Medicaid Services (CMS): Medicaid compliance for the dental professional 

Video: Medicaid compliance for the dental professional 

From the HHS Health Care Fraud Prevention and Enforcement Action Team: Cultivate a culture of compliance with health care law (PDF) 

From Dr. Bicuspid: How to get Medicaid dental compliance right

In working with Medicaid patients, you may encounter cultural or language barriers that make it difficult to provide the best possible care. Fortunately, there are resources that can help.

The Department of Health and Human Services Office of Minority Health (HHS OMH) has created a free online education program for oral health professionals. This program will help you build the knowledge, skills and awareness needed to care for all patients, whatever their background.

The course is designed for all dental professionals working with diverse populations. Those who complete the course can earn six CE credits.

View the course 

Georgetown University also offers this resource:

Self-direction of home and community-based services (HCBS) lets patients determine the mix of personal care services and supports that will work best for them. Many states that have implemented managed care programs are offering patients the opportunity to direct their own HCBS. Health plan case managers play a key role in implementing self-direction.

The Integrated Care Resource Center, with support from the former National Resource Center for Participant-Directed Services, has developed a training curriculum for case managers. The webinars and resources in this curriculum offer an overview of self-directed care, considerations for design and implementation of a self-directed program and best practices for self-directed programs in a managed care context.

View the curriculum

Whether your state uses one third-party administrator or several, advocacy efforts can make a difference. Timely action can improve contract terms before new agreements are signed with administrators. This is true whether your state Medicaid plan handles dental benefits through a stand-alone contract or as part of a larger contract covering all health services.

The ADA has developed a toolkit to help state dental associations work with Medicaid program administrators. View the toolkit below, along with other related resources.

ADA toolkit

From Medicaid.gov: Medicaid fee-for-service: access monitoring plans checklist

From Families USA: How Medicaid waivers could limit access to oral health care

Many dentists use silver diamine fluoride (SDF) to treat carious lesions without the need to drill and fill. This strategy may be useful to you in caring for Medicaid-eligible patients. Here are relevant resources on SDF use.

ADA overview on SDF 

ADA video: how to apply SDF 

ADA clinical practice guidelines on non-restorative treatment for carious lesions  

SDF information from the ADA Science and Research Institute (ADASRI) 

From the California Dental Association Journal: Silver diamine fluoride in elder care