Barriers to Care

Medicaid facts

Wisconsin’s dental Medicaid and BadgerCare programs are grossly underfunded which denies patients necessary economic purchasing power. Increasing access depends on additional financial investment by the state, because coverage alone does not equal care.

  • Dental MA is not considered mandatory by the federal government. The state decides: type of dental procedures allowed/covered; who receives coverage; and amount of reimbursement for services provided to MA patients. Once the state decides coverage and reimbursement rates for providers (current rate is about 30-35 cents on the dollar for dentists), the federal government covers 60 percent and the state generally covers 40 percent of its reduced rate.
  • Wisconsin is one of only a few states offering comprehensive dental care coverage to the adult MA population. Adults, rather than children, are most likely to suffer from serious, debilitating dental infections that are costly to treat, contribute to missed work days or unemployment and result in repeated and costly trips to hospital emergency rooms.
  • The state reimburses about 30-35 cents for every $1 of services provided in a private dental practice NOT including the dentist’s salary. The WDA believes the government should reimburse all dental providers the same for services rendered. Unfortunately, the government currently reimburses full costs for services provided in Federally Qualified Health Centers which equates to about double that paid to private dental practices (view data). In addition, FQHC buildings and equipment are frequently paid for by the government – a substantial advantage compared to private practitioners.
  • A Wisconsin work force report released in January 2010 details the tremendous increase in the state’s MA population. About 1 million low-income individuals, or 20 percent of Wisconsin residents, are beneficiaries of MA coverage in a 12-month period. The number of MA individuals who were continuously enrolled in MA for 12 months nearly doubled between 2000 and 2008. MA-certified dentists played a critical role in increasing continuously-enrolled individuals’ utilization rate (at least one dental visit in the 12-month period) from 31 percent in 2000 to 33.6 percent in 2008.
  • That same report indicates some 43 percent of actively-practicing Wisconsin dentists participate in the MA program which, despite low reimbursement rates, is a higher percentage than in other states.
  • In 2007, the state Department of Health Services estimated that providing fair-market rates for dental MA services could be expected to increase utilization by MA patients by 25 percent each year of the biennium. This would result in a 56 percent net increase in the number of MA patients receiving dental care during the first two-year period under fair-market rates. A WDA survey conducted a few years ago indicates 80 percent of dentists would begin seeing MA patients or increase the number of these patients they were seeing with fair-market reimbursement.
  • HMOs have a state contract to provide dental services to MA patients in six counties: Milwaukee, Waukesha, Racine, Kenosha, Washington and Ozaukee. The WDA opposes contracting of dental services to HMOs after a 2008 Legislative Audit Bureau report showed these programs cost the state more money and provide less care than what is provided under the fee-for-service program operating in the other 66 counties.
  • The state’s most current dental MA data shows Wisconsin and federal governments spend just 1 percent, or only $76 million of a $6.6 billion annual MA budget, on oral health programs for children and adults. In comparison, 80 percent of other states spend a greater percentage of their MA budgets on delivering dental care to low-income patients. The American Academy of Pediatrics (physicians) has determined that 20 percent of all health care funds spent on children should be spent on improving and maintaining their oral health.
  • Data from the state’s fee-for-service MA program (data from the six HMO counties not included) shows that as of fiscal year 2010, the state spent $146.6 million in dental care services for the MA population; yet, the state/federal government only paid $58 million (39 percent) of those charges, leaving participating dentists to donate $88 million to the program.
  • The vast majority of dental care provided to MA patients is done in traditional, small, dental office settings. Unlike in the medical model, these stand-alone small businesses are not connected to a nonprofit parent hospital or profitable medical institution where large losses can be shifted (read more about why dentists don’t cost-shift). In addition to donating significant services, MA provider dentists pay out-of-pocket for dental staff and overhead costs, because these are not covered by government funding.
  • Dental patients enrolled in state insurance programs can pay for their own care if they see a dentist who is not a certified MA/BC provider. Dentists who are not MA/BC certified can accept cash from patients enrolled in the state’s insurance programs. Approximately 50 – 60 percent of all dentists in Wisconsin are not MA/BC certified, so MA/BC patients do have the option of seeking care from these dentists and working with the office to make payment arrangements that are outside of the very limited MA/BC fee schedule set by the state.
  • Dental hygienists can provide care to MA patients and receive reimbursement independent from a dentist. Since these changes went into effect in 2007, very few hygienists that have become MA providers or choose to treat MA patients. Furthermore, MA patients have the greatest amount of dental disease making them most in need of the services that only a doctor of oral health can provide.