The maternal mortality crisis has driven state and federal leaders to address access to high quality care during the perinatal period. With proposals to extend Medicaid coverage to twelve months postpartum, states are also considering what services are offered to pregnant women through Medicaid. Currently, 29 states and Washington DC offer extensive dental services to pregnant and postpartum women.
Dental care during the perinatal period influences health outcomes for both the parent and child, and can reduce expensive medical care that results from lack of care. With this in mind, Virginia added a pregnancy dental benefit in 2015. With nearly half of pregnancies in the United States financed by Medicaid, Virginia shows how states can play an important role in providing access to dental care for pregnant women through their Medicaid programs.
Access to Perinatal Dental Care and Health Outcomes
Inability to access dental care while pregnant can result in adverse health outcomes. Research indicates that all dental care, including procedures that require dental anesthesia during pregnancy, is safe. Poor oral health is associated with low birthweight, preeclampsia, other pregnancy complications and a lower quality of life. Nationally, 73 percent of women had dental insurance during pregnancy, but only 48 percent received a dental cleaning during pregnancy.
Evidence suggests that prenatal oral health care can improve children’s oral health by reducing the incidence of Early Childhood Caries (ECC). ECC is the presence of decayed, missing or filled tooth surfaces in primary (baby) teeth in a child under the age of 6. ECC can lead to emergency room visits and negatively impact school performance. Dental caries (tooth decay) is the most common chronic disease in US children ages 6 to 19 years. Additionally, children are at a higher risk for tooth decay if their birth parent has untreated tooth decay. Parents’ oral health behaviors and dental care utilization can influence children’s risk of dental caries.
Despite overall oral health improvement in the United States over the past several decades, racial and economic disparities persist. Access to dental clinics, insurance status, financial resources and underrepresentation of people of color in the dental workforce are cited as structural barriers for accessing dental care for people of color. These disparities are evident in children, pregnant women and adult populations:
- Latino children, regardless of insurance type, visit the dentist less frequently than white children and are more likely from age two to five have cavities.
- Black and Hispanic pregnant women are less likely to receive dental care, including teeth cleanings before or during pregnancy, than white women.
- Over 40 percent of low-income and non-Hispanic Black adults experience tooth decay, and low-income adults are three times as likely to have four or more untreated cavities as adults with higher incomes.
Dental Care for Pregnant Women in Medicaid
While state Medicaid programs are required to cover dental services for children under 21 as a part of the Early and Periodic, Screening, Diagnostic and Treatment (EPSDT) benefit, dental services for adults are optional in Medicaid. However, 36 states and Washington, DC provide services beyond emergency dental situations; 22 states and Washington, DC provide extensive services for adults, and 29 states and Washington, DC offer an extensive benefit to pregnant women. State benefit packages vary from state to state and generally fall into the following categories:
- Emergency services only;
- Limited services: a cap of $1,000 annually and fewer than 100 American Dental Association (ADA) identified services; or
- Extensive coverage: a cap greater than $1,000 dollars annually and more than 100 ADA identified services including major restorative procedures.
The American Academy of Pediatric Dentistry and the American College of Obstetricians and Gynecologists recommend diagnostic, preventative, restorative, emergency and periodontal care for pregnant women.
When states face revenue shortfalls, they tend to cut optional services, including dental services for pregnant women. For example, 19 states restricted their dental programs during the great recession and only 8 states restored their dental benefit between state fiscal years 2013 and 2016. Despite these fiscal constraints, Virginia expanded health benefits to pregnant women, citing the importance of good oral health for overall health and impact on child oral health.
Virginia’s Dental Benefit for Pregnant Women
Recognizing the importance of oral health in overall health and its key role in healthy birth outcomes, Virginia added a dental benefit in 2015. It was introduced as part of Gov. McAuliffe’s A Healthy Virginia Plan, which proposed expanding services to over 200,000 Virginians, including dental benefits to 45,000 pregnant women in Virginia. The initial cost for the program was 1.9 million over the 2014-2016 biennium budget.
In Virginia, pregnant women over age 21 with incomes less than 148 percent of the Federal Poverty Line (FPL) are covered by Medicaid, and pregnant women with incomes between 148 and 205 percent FPL are covered by the Family Access to Medical Insurance Security (FAMIS) program, which is Virginia’s Children’s Health Insurance Program (CHIP). Dental services are delivered either by the individual’s selected medical managed care organization (MCO) or through fee-for-service. All pregnant women receive dental services through the state’s Smiles For Children program, provided by a dental benefits manager (DBM). The dental benefit ends at the end of the month following an individual’s 60th day postpartum.
Virginia requires coordination between the Medicaid MCOs and the DBM. The Medicaid managed care request for proposals (RFP) outlines the MCO’s role for coordination with the DBM on outreach for dental service utilization. According to state officials, the Commonwealth has also established relationships between MCOs and the DBM to assist pregnant members in locating dentists and securing appointments.
State officials noted that there is still skepticism about going to the dentist while pregnant. This presents the state with an opportunity to collaborate with MCOs and the DBM to educate enrollees about the safety of services and the new benefit.
A staff member with the DBM is responsible for collaboration efforts including education and training. Virginia Medicaid MCOs work to promote dental services with pedicitricians, family practices and OB/GYNS through the Smiling Stork Program. The Smiling Stork program educates women about the importance of being screened for periodontal disease during pregnancy, the value of establishing good oral health habits for their babies, and how to access covered dental services during pregnancy.
The addition of dental services for pregnant women in Medicaid has yielded positive results for Virginia. Pregnancy Risk Assessment Monitoring System (PRAMS) data show that the number of pregnant women receiving dental services doubled from 2014 to 2019. The Virginia Department of Health created practice guidance for prenatal and dental providers, and it conducts outreach to maternity clinics to promote dental care access.
The expanded dental benefit was initially funded for three years. The Department of Medical Asssistance Services (DMAS), Virginia’s Medicaid program, engaged the Dental Advisory Committee and other stakeholders to maintain the expanded benefit. State officials cite strong internal collaboration among IT staff, health care services, maternal and child health, training and transportation, and executive leadership as key for successful implementation of the benefit.
Recent state Medicaid coverage expansions and a concerted focus on improving maternal health provide opportunities for states to ensure dental services for pregnant women. The expansion of dental services for pregnant women in Virginia was a part of broader coverage expansion introduced by Gov. McAuliffe, with the 2015 dental benefit for pregnant women predating Medicaid expansion in 2019 and an adult Medicaid dental benefit in 2020.
Virginia also recently submitted an amendment to its 1115 demonstration waiver to extend postpartum Medicaid coverage to 12 months. This expansion would include dental benefits, as “full benefit coverage is essential to meeting the needs of the state’s postpartum women.” The demonstration waiver amendment includes an evaluation plan to determine the impact of postpartum coverage on reducing the rate of maternal mortality, morbidity and racial disparities among postpartum women and infants.
As Virginia expands services for pregnant and postpartum women, there is an increased focus on quality care during the perinatal period at the state and federal level. The Mothers and Offspring Mortality and Morbidity Awareness (MOMMA’s) Act introduced in the House of Representatives and Senate would extend Medicaid coverage to 12 months postpartum and require states to cover preventative, diagnostic, periodontal and restorative care during pregnancy and the postpartum period. Additionally, the recently passed American Rescue Plan gives states the option to extend Medicaid coverage to 12 months postpartum through a state plan amendment (SPA). States seeking to expand postpartum coverage through a waiver may select the SPA option.
Another introduced bill, S. 560, the Oral Health for Moms Act, aims to expand dental services for pregnant women. This bill would require Medicaid and CHIP to cover dental services for pregnant and postpartum women and make dental services an essential health benefit for pregnant women who receive health insurance through the federal marketplace or small group markets. The bill would also:
- Provide grants to federally qualified health centers (FQHCs) for dental services;
- Create an oral health initiative through the Indian Health Service to address barriers to oral health for American Indian and Alaskan Native populations;
- Require the Medicaid and CHIP Payment and Access Commission to issue a maternal oral health care report;
- Establish a perinatal oral health outreach and education program to provide information on best oral health practices and connect pregnant and postpartum individuals and children to oral health care; and
- Integrate oral health care into maternal health care settings through grants to state health departments and agencies to develop trainings on oral health for maternal health providers.
With national attention on Medicaid coverage for the postpartum period, states can consider including dental services as a component of perinatal health care. New federal options including the MOMMA’s Act, ARPA, and Senate Bill 560 may allow states to expand dental services to pregnant women and lengthen the duration of services; recently introduced federal legislation might further increase opportunities for states. Experience from Virginia can serve as a case study for states looking to expand access to dental services during the perinatal period and improve maternal health outcomes.
Acknowledgement: This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under grant number U2MOA394670100, National Organizations of State and Local Officials. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the US government. The author would like to thank the Virginia state officials, including Dr. Hairston who helped review and provide feedback on this blog.