Adult Access to Medicaid Dental Services (Denti-Cal)

Issue Statement

States are required to cover children's dentistry in their Medicaid programs, but coverage for adults is optional. While the federal government does not require it, California provides dental services to its adult Medicaid population (Medi-Cal Dental Services). However, as this coverage is commonly seen as optional, state budget constraints are consistently met with proposals to eliminate adult dental services, both in California and nationally. As of 2005, 26 states have chosen to either eliminate these services entirely or reduce them to emergency services only. Another 17 states list their services as “limited,” which is often so limited as to provide virtually no real options for care.

Proposals to eliminate adult dental services fail to take into consideration several factors:

  • Dental caries is now known to be an infectious disease caused by the transmission of bacteria from parents and other caregivers to the child. It has been referred to by many experts as "the silent epidemic." The 2000 publication Oral Health in America: A Report of the Surgeon General was a milestone, providing overwhelming evidence of the epidemic. Significantly, the preface to the report states, "Those who suffer the worst oral health are found among the poor of all ages, with poor children and poor older Americans particularly vulnerable." Citing the association between poor oral health and a variety of serious medical conditions such as diabetes, heart disease, and adverse pregnancy outcomes, the report makes it clear that oral health is integral to overall health. The report goes on to state that oral health care should be included in the provision of primary health care and incorporated into the design of community health programs.
  • The problems that people encounter in being unable to access dental health resources have devastating personal consequences, including severe pain; infection that leads to other health problems; impaired eating that contributes to poor diet and nutritional status; speech difficulties, tooth loss; lost work days and more. In fact, oral health needs represent the most frequently reported unmet health need among low-income persons. The Surgeon General reports that more than 164 million hours of work are lost each year due to dental disease or dental visits. Among adults seeking jobs, those with visible caries are less employable than those with healthy smiles. Preventing and treating dental disease fosters greater personal responsibility of Medicaid recipients through increased employment prospects.
  • People with disabilities and the aging population also have special considerations. Elderly and disabled individuals in particular have a far more difficult time accessing dental care than other Medicaid beneficiaries. In addition, these individuals are responsible for only a fraction of total Denti-Cal expenditures, as contrasted with the medical payments for this population which account for a very large percentage of the total Medi-Cal budget.
  • Dental disease, treated early, prevents more expensive services later. According to Medicaid: Good Medicine for State Economies, a report by Families USA released in January 2003, when low-income, uninsured people must find heath care, they go to local public hospitals, health departments, state and county health clinics and other state financed programs and services. “Thus, as states reduce the number of people served by the Medicaid program, the funding demands for other public programs go up and must be met by the state and local communities . . . By paying for that care through Medicaid (instead of other state programs), states can, in essence, buy these services at a 50-76.6% ‘discount’ provided by the federal government through the federal-state matching formula.”
  • There is an unrecognized economic benefit when federal dollars enter the state through the Medicaid program. According to the Families USA report, these funds are a powerful stimulus to state economies “generating new business activity, increasing the output of good and services, creating new jobs and increasing aggregate state income.”

Both ADA and CDA have a long history of advocating for improved access to care, although neither had specifically dealt with the issue of access to dental care for adult Medicaid recipients. In August 2004, CDA’s 13th District Caucus approved a resolution proposing the ADA adopt policy for the inclusion of adult dental benefits in the Federal Medicaid program, and that ADA educate policy makers that oral health is an integral part of overall health, and as such, adult dental coverage should not be “optional.” This effort was successful at the 2004 ADA House of Delegates.

In 2005, Governor Schwarzenegger proposed a redesign of the entire Medi-Cal system. Acknowledging the importance of adult dental care, rather than eliminate the entire program, the administration proposed that cost containment be achieved by placing a cap on services. As a result of the administration’s efforts, in July 2005, AB 131 was passed by the California Legislature, affecting the dental services provided by the California Medi-Cal program as follows:

  • Dental services provided to individuals 21 years or older shall be limited to $1800 per beneficiary in any calendar year, commencing on January 1, 2006.
  • Exclusions to this limit include: emergency dental services; services that are federally mandated under Part 440 (commencing with Section 440.1) of Title 42 of the Code of Federal Regulations, including pregnancy-related services; dentures; maxillofacial and complex oral surgery; maxillofacial services, including dental implants and implant-retained prosthesis; and services provided in long-term care facilities.
  • These changes are due to sunset January 1, 2009.

The battle to retain adult Denti-Cal services in California has been fought repeatedly for more than a decade. The focus on oral health produced by the Surgeon General’s report increased awareness of oral health as an indisputable part of general health and supports CDA’s position that its time to end the “optional” status of adult Medicaid dental services and make these services an integral part of the overall health care Medicaid recipients receive. When this change occurs at the federal level, the assurance of federal matching funds will make it that much easier and smarter for California to continue to offer these services to its adult Denti-Cal population.

Last revised July 2005