National Trends in Child and Adult Medicaid Coverage and Reimbursement for Endodontic Procedures

Medicaid is the largest source of health coverage in the United States and provides dental benefits to eligible low-income families. Federal policies establish minimum dental service requirements for children, while states have flexibility regarding the coverage of dental services for adults in any capacity. The objective of this study was to evaluate endodontic procedure coverage, reimbursement, and dentist participation for Medicaid beneficiaries.

This retrospective, cross-sectional study evaluated child and adult dental Medicaid benefits in 2021. For children, 18 endodontic procedure codes were evaluated; 16 were evaluated for adults. Mapping was used to depict state-level coverage of procedures. Logistic regression analyses were conducted to evaluate the odds of procedural coverage.

For children and adults, initial root canal therapy was the most routinely covered endodontic procedure category; and molar teeth were the least likely tooth type to be covered. States were more likely to have established payment policies for vital pulp therapy procedures for children than for adults. For children and adults, geographic region was significantly associated with Medicaid coverage of endodontic procedures. Endodontic procedure reimbursement rates ranged from $7.00 to $1113.87 (median, $251.00). Overall, adult procedures tended to have lower reimbursement rates than child procedures at the category level but had a higher overall median reimbursement rate. Median endodontist participation for child dental services was 24%.

Gaps in endodontic coverage exist for Medicaid beneficiaries. Endodontic treatments for molar teeth, vital pulp therapy, and regenerative endodontic procedures are the least consistently covered.