Improving Dental Hygiene for Medicaid Enrollees: 10 Recommendations for Reform

By Jon Warner, February 2025

Access to quality dental care is essential for overall health and well-being. However, millions of Americans on Medicaid face significant barriers to receiving adequate dental services. This article examines challenges to dental care access for Medicaid enrollees. It proposes a set of targeted policy recommendations to strengthen dental benefits and introduce best practices across state Medicaid programs.

The Medicaid Program and Oral Health

Medicaid is a joint federal-state health insurance program that provides coverage to almost 75 million low-income and disabled Americans. It is a critical source of dental coverage, insuring over 37 million children and paying for over 40% of all children's dental visits in the US. However, Medicaid policies around dental benefits for adults vary considerably between states.

While pediatric dental benefits are mandatory for states under federal law, coverage for adults is optional. As of 2023, only 25 states offer comprehensive adult dental benefits through Medicaid. The remaining states provide limited emergency dental services or no dental coverage at all for non-pregnant adults. This patchwork of state policies has led to disparities in access to routine and preventive dental care across the country.

Research shows oral health problems disproportionately impact low-income populations and communities of color that are over-represented in Medicaid. Nearly a quarter of children below the federal poverty level have untreated dental caries (cavities) compared to 10% of higher-income children. Low-income adults are also more likely to have untreated dental disease and report unmet dental needs. Without access to regular dental care, these conditions often progress and require more complex, and costly treatment interventions over time.

The Impact of the COVID-19 Pandemic

The COVID-19 pandemic further exacerbated existing barriers to dental care for Medicaid enrollees. From 2019 to 2020, dental service utilization rates among children and adults on Medicaid/CHIP declined by 8 and 5 percentage points respectively according to Medicaid claims data. While utilization began rebounding in 2021, it remained below pre-pandemic levels indicating the pandemic may have long-term effects on oral health outcomes.

Telehealth played a limited role in maintaining access to dental services during lockdowns and physical distancing requirements. Unlike medical visits that can be conducted virtually, the hands-on nature of dental exams and procedures requires in-person care. This underscores the need for policies that strengthen the Medicaid dental workforce and increase service capacity post-pandemic.

Recommendation #1: Expand Adult Dental Benefits as an Essential Health Benefit

To promote equitable access, all state Medicaid programs could be required to cover comprehensive dental benefits for non-pregnant adults as an Essential Health Benefit. Currently, optional adult dental benefits result in a "dental desert" in nearly half of the states. Expanding adult dental coverage nationwide would insure over 15 million low-income adults who currently lack routine dental care access.

Research shows that expanded adult dental Medicaid benefits increase the utilization of preventive dental services and reduce costly emergency department visits for non-traumatic dental conditions. A recent study estimated that expanding adult dental benefits in all states could generate over $900 million in net savings for Medicaid over 5 years by avoiding expensive treatments resulting from untreated dental disease.

Recommendation #2: Increase Medicaid Reimbursement Rates for Dental Providers

Low Medicaid reimbursement rates are a primary reason many dentists limit the number of Medicaid patients they treat or refuse to accept Medicaid altogether. A 2019 ADA study found over 60% of dentists do not accept new Medicaid patients due to low fees. Increasing fee-for-service Medicaid dental rates to at least the national average commercial dental insurance rate would make participating in Medicaid financially viable for more providers.

States could also implement pay-for-performance programs that provide bonuses or supplemental payments to dentists who meet certain quality metrics like increasing preventive care utilization or reducing emergency visits. Higher reimbursements would expand Medicaid enrollees' access to the general dental provider pool rather than relying on overburdened safety net clinics.

Recommendation #3: Leverage Dental Therapists to Expand the Dental Workforce

All states should adopt licensure and reimbursement policies to integrate dental therapists—mid-level oral health providers—into the Medicaid dental delivery system. Currently, only 10 states license therapists despite research showing they can increase access to basic services, especially in underserved areas. Therapists perform procedures like fillings, extractions, and preventive care under a dentist's supervision—tasks that account for the majority of Medicaid-covered services.

Deploying therapists would allow dentists to focus on more complex cases while therapists address routine care needs. States could reimburse therapists at 85% of the dentist's rate to incentivize participation. Integrating this cost-effective provider model could help address dental workforce shortages exacerbated by an aging dentist population.

Recommendation #4: Expand School-Based Sealant and Fluoride Programs

School-based programs applying dental sealants and fluoride varnishes are highly effective at preventing tooth decay, especially in low-income communities. However, the availability of these programs varies significantly between states and districts. All states should implement statewide school sealant/fluoride programs targeting low-income schools as recommended by the Community Preventive Services Task Force.

Strategies could include bundling school-based reimbursement into Medicaid-managed care contracts or providing grants to local health departments. Expanding proven prevention programs will help reduce oral health disparities and future treatment needs in the Medicaid population.

Recommendation #5: Incentivize Continuous Eligibility for Children

To promote continuity of care, states should adopt 12-month continuous eligibility policies for children covered by Medicaid/CHIP as recommended by the American Academy of Pediatrics. Under continuous eligibility, children maintain coverage for a full year regardless of changes in family income that may occur within that period.

Research shows continuous eligibility significantly increases preventive dental visit rates and reduces costly treatment resulting from untreated cavities. It eliminates gaps and churn on and off Medicaid when families experience temporary income fluctuations around eligibility limits. This provides stability critical for managing children's oral health.

Recommendation #6: Leverage Medical-Dental Integration Initiatives

Integrating dental care into primary medical care settings has the potential to streamline access, especially for vulnerable groups. States should support initiatives co-locating dental professionals in primary care clinics, hospitals, schools, WIC offices, and other sites serving Medicaid populations. Examples include:

• Allowing Medicaid reimbursement for medical providers to apply fluoride varnishes and refer patients to dentists.

• Integrating dental records into electronic health records to facilitate care coordination between medical and dental teams.

• Training primary care clinicians to perform basic oral exams and risk assessments to identify early signs of disease.

Medical-dental integration strategies can help address barriers like transportation limitations and connect more Medicaid enrollees to ongoing oral health services and education.

Recommendation #7: Expand the Use of Mobile and Portable Dental Clinics

Mobile dental clinics equipped to provide preventive, restorative, and surgical procedures have demonstrated success in improving access in underserved rural and urban communities. States should support the expanded use of mobile clinics as a strategy to reach Medicaid enrollees with transportation or geographic barriers to accessing stationary dental offices.

Strategies could include reimbursing mobile clinics through Medicaid-managed care plans or providing grants for clinics to expand service areas. Mobile clinics could also partner with community health centers, schools, WIC programs, and homeless shelters to regularly bring dental services on-site. This innovative model warrants further investment to fill critical access gaps. As an additional step, family teeth brushing programs could be introduced with children in elementary school in which the whole family works together to follow best oral practices (such as brushing teeth for 2 minutes, using quality fluoride toothpaste, and not swilling the mouth after brushing, especially before bedtime.

Recommendation #8: Increase Medicaid Managed Care Plan Oversight of Dental Benefits

Most Medicaid enrollees receive dental coverage through managed care rather than fee-for-service. However, dental networks and quality metrics often receive less scrutiny than medical services. States should strengthen managed care contract requirements and oversight related to:

• Adequate provider networks with timely appointment availability standards.

• Performance incentive programs to increase utilization of services like sealants and preventive visits.

• Withhold pools to fund network adequacy or other access improvement initiatives.

• External quality review of utilization management, claims adjudication, and network sufficiency.

Stricter accountability around dental benefits administration will help ensure Medicaid enrollees receive high value, coordinated oral health services through their managed care plans.

Recommendation #9: Invest in Community Water Fluoridation

Community water fluoridation remains one of the most equitable and cost-effective public health measures for improving oral health, especially in low-income communities. However, some localities have reduced fluoridation efforts in recent years. States should support the expansion of water systems with optimal fluoride levels and counter anti-fluoridation campaigns that are not grounded in scientific evidence.

Investing in water fluoridation infrastructure will help prevent tooth decay across the general population—including Medicaid enrollees who are disproportionately impacted. It is a wise long-term investment compared to the costs of restorative dental treatment resulting from preventable cavities.

Recommendation #10: Conduct Statewide Oral Health Surveys and Needs Assessments

To best target resources, all states should regularly collect data on the oral health status, treatment needs and barriers to care faced by Medicaid enrollees. Comprehensive needs assessments and surveillance involving both clinical exams and consumer surveys can identify underserved regions and populations most in need of expanded services.

Results should guide state quality improvement plans, provider recruitment initiatives, and decisions around benefits design. Robust data collection will allow states to monitor progress in reducing oral health disparities over time and return on investment from access improvement strategies. It is a necessary first step to developing equitable, evidence-based dental policies.

Conclusion

By implementing targeted reforms in coverage, workforce, prevention, and data-driven policy, states can significantly enhance oral health for millions of Medicaid enrollees. A modernized, high-performing Medicaid dental benefit—aligned with best practices—can reduce health inequities and ease the burden of oral diseases that disproportionately affect low-income communities and communities of color. With political commitment and sufficient funding, states can build dental programs that improve health outcomes, generate cost savings, and promote well-being among vulnerable populations.

This article was written by Jon Warner, Executive Chair of Citizen Health Strategies (CHS). Citizen Health Strategies (CHS) specializes in building innovative products and solutions where and when health citizens need them - eliminating care gaps and bottlenecks to create operational efficiencies and outcome effectiveness.