Dentists balk at Medicaid coverage Virginia expanded dental coverage under Medicaid – but not enough dentists accept it

Lillian Hamilton, a Virginia Medicaid enrollee and 21-year-old tattoo shop manager from Hampton Roads, is still trying to get her wisdom teeth removed after years of living with a constantly swollen jaw, the pain from which has resulted in multiple visits to the emergency room.

Hamilton said every time she tries to schedule an appointment with a dentist who can give her a referral for an oral surgeon, she's denied because providers either aren't accepting new patients or don't take Medicaid.

"I have probably called over a hundred dentists," said Hamilton. "And every time I've called, multiple times, they've always been like, 'No, we don't accept this. No, we can't take you.'"

A shortage of Virginia dentists who accept adults on Medicaid is the main factor why enrollees like Hamilton are struggling to find care, said Justin Gist, dental program manager for the Virginia Department of Medical Assistance Services, the agency tasked with overseeing the state's Medicaid program.

Virginia Medicaid enrollees aged 21 and older have had access to comprehensive dental care benefits since July 2021 through a state budget amendment. The numerous services covered, including X-rays, cleanings and fillings, focus on preventing problems and restoring damaged teeth. Prior to this, adults were eligible only for limited care, which mainly just included extractions.

"My office, we get over 200 calls a week. That's since it started - it has not ceased," said Virginia Dental Association President Dr. Cynthia Southern, who has also been a practicing dentist for 23 years and primarily treats patients on Medicaid. "There is an absolute need out there."

Despite this need, the shortage persists. Experts say that's due to several factors, including a low state reimbursement rate that ends up costing dentists to treat enrollees, a lack of awareness among enrollees and providers of the new benefits and challenges that come with treating adults.

The need for dentists

Children enrolled in Medicaid or Family Access to Medical Insurance first gained comprehensive dental service benefits, a program rebranded as Smiles For Children, in 2005. Pregnant Medicaid members gained these benefits in 2015. Then, in 2021, all enrollees in Virginia were granted access to comprehensive dental services.

But a recent DMAS report to the Virginia General Assembly and Department of Planning and Budget on dental access found approximately 73% of Virginia's dentistry workforce did not treat any Medicaid or FAMIS patients in 2022. That number was up 1.5% since 2018.

The same report also showed a statewide ratio of 1,014 Medicaid and FAMIS members to each dentist participating in Smiles for Children in 2021. Southwest Virginia had the highest ratio, with 1,812 members per dentist.

"A lot of areas in our sector are underserved with dentists," Southern said. "The dentists are struggling with seeing the patients that want to be seen."

A lack of dental services can have critical consequences. Gist pointed to the 2007 case of 12-year-old Deamonte Driver, who died from complications initially stemming from an infected tooth in Maryland after circumstances left him unable to get care before it was too late.

"There are so many connections the oral health or the oral cavity has to the rest of the body," Gist said. "Please don't delay."

Paying to treat patients

Numerous studies have shown low reimbursement rates for services through Medicaid are the primary reason why dentists don't participate in the program, according to the 2022 DMAS report.

Virginia and other states reimburse health care providers who treat Medicaid patients for a portion of their treatment costs. The General Assembly passed a budget amendment last July that increased the dental reimbursement rate from the initial 5% established in 2005 to 30%. Since the increase, Gist said 23 new dentists are participating in Smiles for Children each month on average, up from 15 new signups a month prior to the increase.

"We are increasing the number of dentists that we're adding to the network," Gist said. "I think it's a direct result of the fee increase."

However, while Southern said she's hopeful the increase will incentivize more dentists to accept Medicaid, she still loses money the majority of times she treats a member. The higher rate for Medicaid is "not what commercial insurance companies are [offering], but it's much more competitive" than what it was prior to the increase, she said.

Not only do commercial insurance companies reimburse dentists for a procedure at a higher rate than Medicaid, they also require patients to pay a portion themselves, Southern said.

For example, she said, if a filling costs $100, commercial insurance might pay $60 and the patient a $20 copay. The remaining $20 would be written off by the insurance company.

Medicaid, she said, would pay maybe $50, and the patient nothing.

"You can't run your whole practice just doing Medicaid," Southern said. "You just have to use other things to help make ends meet."

Some providers who volunteer in free clinics or offices that primarily accept Medicaid said as long as more than a quarter of their patients aren't on Medicaid, they can make it work, Southern said.

Not all dentists are opposed to accepting Medicaid, she said, but a lot don't even know the state expanded dental coverage two years ago.

Awareness shortfalls

The adult comprehensive dental service benefits added in 2021 "just rolled out and people didn't really know what it meant," said Southern.

Providers were unsure if they were able to accept adult Medicaid or thought they might have to go through credentialing again, which she said doesn't have to happen.

Some enrollees also aren't aware comprehensive dental services are now covered. Hamilton found out about the expansion during an interview with the Mercury this week and said she was never contacted by anyone from the state to inform her.

"I think there was just not a lot of good communication to start with," Southern said. "We're really working hard at getting the word out now."

DMAS is currently working with other organizations like the Virginia Dental Association to increase awareness, Gist said. Efforts include calling members and providers and sending outreach coordinators into communities across the state to educate them about the benefit.

Members can also sign up with Virginia Medicaid to get email and text updates, including information about their benefits and how to use them.

Outreach coordinators are "calling credentialed providers and non-credentialed providers both and letting them know, 'Hey, you can see adults now, right?'" Gist said. "Not to mention, we have a 30% increase and now they can have preventative work done. They can have restorative work done."

A Virginia Dental Association slogan urges providers to "see at least three in 2023" and to "strive for five," Southern said.

Another source of confusion is the Smiles for Children name attached to the comprehensive dental benefit, even though adults can use it, Gist said. DMAS is planning to rebrand the benefit to Cardinal Care Smiles within the coming months. y

Southern did caution that programs don't usually see huge increases in usage right after being introduced. That was the case when comprehensive dental care for pregnant members was added in 2015: A study from Virginia Commonwealth University's School of Dentistry and Business found pregnant members who self-reported having dental insurance rose approximately 27% three years after the benefit was introduced. However, the report showed those using the benefit increased by only 14% over the same period.

Challenges to treating adults

Even providers who are aware of the benefit may have additional hesitancy in accepting it because of challenges associated with treating adults, said Gist.

Children on Medicaid don't have the same level of difficulty finding dental care as adults do, said Southern, which mostly has to do with the newness of the adult program.

Some providers can be hesitant to treat adults because of stigmas surrounding the types of people using Medicaid - associations that Gist said have been a topic of conversation among providers and are mentioned in the DMAS report.

Outreach efforts also aim to change this thought process "of who our Medicaid members are, what they look like and what they embody," Gist said. "You know, these are your cashiers at Wegmans, at Target, who work 32 to 36 hours and you know that they don't have those benefits afforded to them by their employer."

Some providers are apprehensive to treat adults in general regardless of insurance status because they can be difficult, said Gist. Doing a filling on an adult, he said, is a lot different than doing one on a 9- or 10-year-old.

Adults "have an opinion, as opposed to a 6- or 7-year-old that comes in for a feeling," said Gist. "They don't have much of an opinion, they just don't want to hurt."

Broken appointments are also a major concern among providers, because they create gaps in dental practice schedules that result in lost revenue. A higher rate of "no-shows" among Medicaid members than private insurance patients disincentivizes dentists from participating in Medicaid dental programs, DMAS has noted. And some procedures don't have to get pre-approved for children but do for adults.

Challenges also stem from a lack of communication between providers who accept Medicaid but aren't taking new patients and DentaQuest, the state's dental benefits administrator, which can add to the frustration of adult members trying to get care.

When members call DentaQuest, "100% of the time they will receive a list of providers who have indicated they are accepting new patients and can schedule an appointment for treatment," said DMAS communications director Rebecca Dooley in an email.

Despite getting this information from DentaQuest, Hamilton said she was still unable to find a dentist accepting new patients.

This could happen as a result of dental offices changing their new patient status more frequently, sometimes daily due to ongoing labor shortages, high turnover and other issues impacting providers, Dooley said. DentaQuest cannot update their system, Dooley said, if providers don't communicate these changes.

Future of dental benefits

Despite these challenges, Gist and Southern are optimistic that even more members will be able to access dental services in the years to come.

DMAS is already planning a range of actions to address these concerns and make dental services even more accessible. They include developing a statewide provider recruitment campaign, analyzing dental fees every three years to determine if reimbursement rates need to be increased and conducting a thorough review of the state's dental network every two years.

The gap between the number of members and number of providers could narrow as enrollees who are no longer eligible for Medicaid lose coverage over the next year due to the end of the federal public health emergency, Gist said. Provisions from the PHE allowed for continuous coverage, meaning enrollees during the past three years could stay on Medicaid regardless of whether they were still eligible or not.

"The members that will fall off will help our network capacity and our network adequacy as well," Gist said.

Being a Medicaid provider for her entire 23-year-long career has shown Southern just how impactful and important the program can be.

The wife of a patient Southern had treated since he was a child once told her "he has all of his teeth because of you."

Special moments like these, she said, reinforce her passion for providing care for those in need.

"I might not have made a whole lot off of Medicaid," she said, "but that kind of reward to me is worth more than any financial reward I could get."

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