Adult Dental Coverage

Challenges
Tooth decay and advanced gum diseases ultimately lead to loss of some or all teeth. In adults aged 55-64 years, about 43% have lost six or more teeth due to dental decay or gum disease. Furthermore, oral cancers are constant contributors to premature death.

Disparities in oral health observed in national surveys are also apparent in West Virginia. For example, among persons 65 years and older, the percent of the population who have lost all their natural teeth varied from a low of 11% among college graduates to a high of 61% among those without a high school degree.

Inadequate access to oral health care is due to a variety of complex factors including a shortage of dental providers, especially in rural areas; not enough providers willing to accept people on medical assistance due to low reimbursement rates; and a gap in affordable insurance options. The need for more accessible and affordable dental care has led people to seek oral health care in emergency departments and hospitals, resulting in exorbitant health care costs that could be prevented.

Adults aged 21+ years, are limited to emergent procedures to treat fractures, reduce pain, or eliminate infection.

In FY 2011, about 20% of Medicaid-eligible adults 21+ years and 48% of Medicaid-eligible children utilized dental services. Because Medicaid does not cover preventative care for adult patients, there were a higher number of visits for restorative care than for preventive care; whereas children’s visits were mostly for preventive care.

In 2013, of the 879 dentists (general dentists and specialists) licensed to practice in West Virginia, 611 (69.5%) were active in the state’s Medicaid program (had at least one paid claim). These numbers vary from the previous year. Accounting for the slight increase in the number of dentists licensed and actively working in the state (873 dentists in 2012 to 879 dentists in 2013), WV Medicaid observed a 2.6% decrease in active dentists.

Solutions
By December 2020, increase the proportion of low-income adults who receive an annual dental visit from 45.4% to 49.9%.
Suggested Strategies:
a) Develop and implement a dental resource for services that are available
b) Assess existing systems for adult dental referrals in free clinics, community health centers (CHCs), federally-qualified health centers (FQHCs)

By December 2018, develop coverage plan (Medicaid expansion) for basic adult dental services (preventive, restorative, extraction, and dentures).
Suggested Strategies:
a) Research successful adult oral health coverage plans including states with similar population demographics as West Virginia
b) Determine possibility of expanding or piloting the WV Pre-Employment Program model of limited services, annual financial cap and nominal Client co-pay for
special adult populations (includes pregnant women, seniors, persons with disabilities/special needs and those deemed medically necessary)
c) Conduct cost analysis for basic adult plan
d) Identify potential financial resources to cover initial or partial estimated costs of basic adult dental benefit
e) Educate (health professionals, administrators, family, and patients) in use of IME for payment of dental services

By December 2020, increase the proportion of dentists actively participating in Medicaid from 69.5% to 76.5%.
Suggested Strategies:
a) Work with CMS and WV Medicaid on comparable reimbursement rates and a standard reimbursement rate review
b) Work with WV Medicaid on streamlining enrollment and billing process
c) Inform dental providers on benefits of treating Medicaid patients
d) Identify programs that have successfully reduced “no show” rates in dental offices and dental clinics and disseminate information about these programs
e) Educate providers on the use of Non-Emergency Medical Transportation

Progress

  • Community based programs and free clinics in West Virginia are attempting to address the overwhelming needs of low income adults in West Virginia with little or no state support.
  • WVU School of Dentistry Rural Rotation Program allowing students to serve in rural and community based programs.
  • HRSA Workforce Grant to provide loan reimbursement to dentists serving in shortage areas.
  • Very little progress has been made to improve the oral health of adults in West Virginia.

Initiatives