Related Resources
- Oral Health Initiative Expert Workgroup Report
- Oral Health Quality Improvement Resources
- Dental Excerpt from the 2015 Secretary's Report
- Medicaid Dental Trends Analysis: 2000-2012
- Improving Oral Health Care Delivery in Medicaid and CHIP: A Toolkit for States
- CMS Oral Health Strategy
- Federal Policy Guidance-Dental Coverage in CHIP
- Guide to Children's Dental Care in Medicaid
- Policy Issues in the Delivery of Dental Services
- 2010 Eight-State Medicaid Dental Review Summary Report
- 2010 Individual State Reports
- 2008 National Dental Summary Report
- 2008 Individual State Reports
- ADA Practice Management
- AAPD State EPSDT Dental Periodicity Schedules
- Find a Medicaid/CHIP Dental Provider in your State
- Oral Health Care During Pregnancy: A National Consensus Statement
- Tips for Good Oral Health During Pregnancy
- Keep Kids Smiling Promoting Oral Health Through the Medicaid Benefit for Children and Adolescents
- Rural Oral Health Resources Toolkit
Dental health is an important part of people's overall health. States are required to provide dental benefits to children covered by Medicaid and the Children's Health Insurance Program (CHIP), but states choose whether to provide dental benefits for adults. See the 2010 Medicaid/CHIP Oral Health Services fact sheet for information on children's access to dental services and opportunities and challenges to obtaining care.
Dental Benefits for Children in Medicaid
Medicaid covers dental services for all child enrollees as part of a comprehensive set of benefits, referred to as the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. Though oral screening may be part of a physical exam, it does not substitute for a dental examination performed by a dentist. A referral to a dentist is required for every child in accordance with the periodicity schedule set by a state.
Dental services for children must minimally include:
- Relief of pain and infections
- Restoration of teeth
- Maintenance of dental health
The EPSDT benefit requires that all services must be provided if determined medically necessary. States determine medical necessity. If a condition requiring treatment is discovered during a screening, the state must provide the necessary services to treat that condition, whether or not such services are included in a state's Medicaid plan.
Each state is required to develop a dental periodicity schedule in consultation with recognized dental organizations involved in child health care. Dental services may not be limited to emergency services for children entitled to EPSDT.
Dental services must be provided at intervals that meet reasonable standards of dental practice, and at such other intervals, as indicated by medical necessity, to determine the existence of a suspected illness or condition. States must consult with recognized dental organizations involved in child health care to establish those intervals. A referral to a dentist is required for every child in accordance with each State's periodicity schedule and at other intervals as medically necessary. The periodicity schedule for other EPSDT services may not govern the schedule for dental services.
Dental Benefits for Children in CHIP
States that provide CHIP coverage to children through a Medicaid expansion program are required to provide the EPSDT benefit. Dental coverage in separate CHIP programs is required to include coverage for dental services "necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions."
States with a separate CHIP program may choose from two options for providing dental coverage: a package of dental benefits that meets the CHIP requirements, or a benchmark dental benefit package. The benchmark dental package must be substantially equal to the (1) the most popular federal employee dental plan for dependents, (2) the most popular plan selected for dependents in the state's employee dental plan, or (3) dental coverage offered through the most popular commercial insurer in the state.
States are also required to post a listing of all participating Medicaid and CHIP dental providers and benefit packages on InsureKidsNow.gov.
Dental Benefits for Adults in Medicaid
States have flexibility to determine what dental benefits are provided to adult Medicaid enrollees. There are no minimum requirements for adult dental coverage.
Oral Health Initiative
The Centers for Medicare & Medicaid Services (CMS) is committed to improving access to dental and oral health services for beneficiaries enrolled in Medicaid and CHIP. In 2010, CMS established an Oral Health Initiative (OHI) to improve children’s access to appropriate preventive dental care by working with states, federal partners, the dental provider community, and advocates. A 2020 Center Informational Bulletin describes the history and progress of the OHI.
Since the OHI was established, the landscape for improving oral health care in Medicaid and CHIP has changed in several ways, including increases in Medicaid and CHIP enrollment among children and adults; state expansion of dental benefits for adults enrolled in Medicaid; growth in dental managed care delivery systems; and the growth of dental quality measurement.
In 2023, CMS convened an expert workgroup to provide input on strategic priorities for the next phase of the OHI. The workgroup recommended that CMS broaden the OHI to work on oral health access, quality, and outcomes across the lifespan, with a focus on:
- increasing an emphasis on preventive, minimally invasive, and timely care;
- enhancing managed care plan engagement and accountability; and
- enhancing capacity for quality measurement and data analytics.
Read the full report of the expert workgroup recommendations.
Tools to Help States Improve the Delivery of Dental and Oral Health Services
Medicaid & CHIP Beneficiaries at a Glance: Oral Health
- Infographic released 2023
Medicaid Adult Beneficiaries Emergency Department Visits for Non-Traumatic Dental Conditions
Guidance for Reporting the Dental Sealant Measure in the Child Core Set
- Technical Assistance Webinar on the Dental Sealant Measure in the Child Core Set - November 12, 2015
Oral Health Performance Improvement Projects
- Medicaid Oral Health Performance Improvement Projects: A How-To-Manual for States
- Medicaid Oral Health Performance Improvement Projects: A How-To-Manual for Health Plans
- Medicaid Oral Health Performance Improvement Projects: A Template
Medicaid Policy Tools for Reducing Early Childhood Tooth Decay
- Reducing Early Childhood Tooth Decay: An Overview for State Policymakers
- Reducing Early Childhood Tooth Decay: Leading Steps for State Policymakers
- Reducing Early Childhood Tooth Decay: Strategies for State Medicaid and CHIP Program Managers
Keep Kids Smiling: Promoting Oral Health Through the Medicaid Benefit for Children and Adolescents
Improving Oral Health Care Delivery in Medicaid and CHIP: A Toolkit for States
Innovative State Practices for the Provision of Dental Services in Medicaid
State Oral Health Action Plans
To support the Oral health Initiative, CMS invited state Medicaid agencies to develop State Oral Health Action Plans (SOHAPs) as a roadmap to achieving in their goals.
CMS has received SOHAPs from the following 25 states: Alabama, Alaska, Arizona, California, Connecticut, District of Columbia, Delaware, Florida, Maine, Maryland, Massachusetts, Michigan, Missouri, Nebraska, New Hampshire, New Jersey, North Dakota, Oklahoma, Pennsylvania, Tennessee, Utah, Vermont, Virginia, Washington and Wyoming. CMS encourages the remaining 29 states to develop and submit their SOHAPs, and CMS stands ready to provide technical assistance to any state that requests it.
SOHAPs may be submitted using either a CMS-developed Oral Health Action Plan Template or a user-friendly template developed by the Medicaid-CHIP State Dental Association. Completed SOHAPs may be submitted to the EPSDT mailbox via email to [email protected] with a copy to your CMS Regional Office contact.
CMS Learning Lab: Improving Oral Health Through Access
The Center for Medicaid and CHIP Services at the Centers for Medicare & Medicaid Services is hosting a series of webinars to support States and their collaborative partners to improve access to dental services for children enrolled in Medicaid and CHIP. The webinar materials are available below. For more information about the CMS Oral Health Initiative and the CMS Learning Lab webinars, see the June 2012 Informational Bulletin.
Reducing Early Childhood Tooth Decay: Approaches in Medicaid – May 27, 2015
Performance Improvement Projects (PIP) for States and Health Plans - Implementation Considerations – May 20, 2015
Performance Improvement Projects (PIP) for States and Health Plans - Planning Considerations – May 6, 2015
Linking Children with Special Healthcare Needs to Dental Providers – February 18, 2015
Advancing Program Integrity for Medicaid Dental Programs: Federal, State, and Stakeholder Efforts – January 28, 2015
Improving Oral Health Through Access: Building a Partnership between Medicaid and Head Start – September 16, 2014
State Medicaid and CHIP Program Support of Sustainable Oral Health Care Delivery Models in Schools and Community-Based Settings – May 14, 2014
Keep Kids Smiling: Promoting Oral Health Through the Medicaid Benefit for Children & Adolescents - January 30, 2014
Dental Sealants: An Effective State Strategy to Prevent Dental Caries in Children - September 19, 2013
Engaging More General Dentists to Care for Young Children: Access to Baby and Child Dentistry (ABCD) in Washington and South Dakota - May 8, 2013
- Presentation Slides
- Related Resource: WDSF ABCD Toolkit
Quality Improvement Processes: An Introduction for Medicaid and CHIP Dental Programs - January 23, 2013
Successful Beneficiary Outreach Strategies - September 26, 2012
Developing State Oral Health Action Plan Using State Data - June 19, 2012