By Tony Pugh
The Biden administration, spurred by House and Senate Democrats, is moving to expand the “medically necessary” circumstances under which Medicare will cover dental services.
While federal law excludes Medicare coverage of routine dental services, the proposal, if finalized, would allow reimbursement for oral and dental care needed to treat more types of Medicare-covered ailments, injuries, and chronic diseases, like diabetes and heart disease.
It would also provide a meaningful consolation prize for lawmakers and patient advocates whose bid for a comprehensive Medicare dental benefit died last year with the Democrats’ unsuccessful Build Back Better Act.
Heartened by passage this month of long-sought legislation that allows Medicare to negotiate some prescription drug prices, supporters of Medicare dental coverage say an incremental advance of their pet policy initiative could eventually spur similar breakthrough legislation to improve the oral health of America’s seniors.
Georgia Burke, director of Medicare advocacy at Justice in Aging, said the drug negotiation provisions in the Inflation Reduction Act of 2022 are a “hopeful sign that Congress is really willing to tackle some of the big gaps that still exist in the Medicare program.”
In 2019, the Congressional Budget Office estimated that Medicare would pay $238 billion for full dental coverage over 10 years. The proposal was included in the nearly $2 trillion Build Back Better Act that passed the House but failed in the narrowly divided Senate.
“It was incredible to get as far as it went,” said Michael Monopoli, vice president of grant strategy at the CareQuest Institute for Oral Health. The discourse around the proposal, which stressed the impact of dental health on overall health, “got the attention of policy makers,” Monopoli said, and “got them to think about this as a possibility.”
With midterm elections later this year, and the Democrats’ control of Congress at stake, the window for passing a full Medicare dental package may be closing quickly.
It’s unclear what the proposed coverage changes might cost. But Monopoli, Burke, and others said the costs might well be offset by savings from fewer complications and hospitalizations due to oral health problems. A 2016 study by Avalere Health estimated that Medicare could save $63.5 billion over 10 years by covering gum disease treatments for heart disease, stroke, and diabetes patients.
The Santa Fe Group, a think tank that advocates for improved dental services, agreed to support the proposed changes from the Centers for Medicare & Medicaid Services after debating whether to hold out for a full Medicare dental coverage package, said group President Terri Dolan.
Dolan, a dentist, knows firsthand the need for Medicare dental coverage. She said her 86-year-old mother, who’s legally blind and on a fixed retirement income, fractured two teeth last year and had to go into her savings to have them fixed.
“She would be a beneficiary if we had a comprehensive dental benefit,” Dolan said. “And there are lots of people who are in even more dire circumstances, so yes, it was terribly disappointing,” when the 2021 legislative measure failed.
If the current proposal is implemented, “hopefully, we’ll do more research, we’ll assess the outcomes, we can do economic studies of the impact, the cost and benefits, and I think it will lay a stronger foundation for further expansion of the services,” Dolan said.
The CMS proposal would amend federal regulations to allow payment under Medicare hospital and outpatient coverage “for dental services that are inextricably linked to, and substantially related and integral to the clinical success of, an otherwise covered medical service,” the proposal said.
The agency also seeks comment on “other types of clinical scenarios where the dental services may be” medically necessary, the “potential establishment of a process to identify” other medically necessary dental services, and input on possible new payment models for dental and oral care services.
Broadening Medicare’s dental coverage through regulatory changes should help advance the Biden administration’s efforts to improve health equity for minorities, rural residents, and those with low incomes. These historically underserved populations make up a disproportionate share of beneficiaries with chronic conditions who would likely qualify for expanded “medically necessary” coverage, Dolan said.
Among Medicare beneficiaries, 68% of Blacks and 61% of Hispanics didn’t visit a dentist in 2020, compared with 42% of whites, according to the Kaiser Family Foundation. For those with low incomes, 73% didn’t see a dentist in 2020.
Medicare administrative contractors determine on a claim-by-claim basis whether dental services should be covered as “medically necessary.”
For example, Medicare will pay for dental splints when needed to treat a medical condition, wiring of teeth related to a jaw fracture, tooth extractions to prepare the jaw for radiation treatment due to tumor growth, and reconstruction of a dental ridge related to the removal of a tumor, according to the CMS.
“Generally, you had to be hospitalized in order for the exception to apply,” Burke said.
But lawmakers and patient advocates say those determinations—and the statutory interpretations that guide them—have been “unnecessarily restrictive, which may contribute to inequitable distribution of dental services for Medicare beneficiaries,” the proposed rule said.
If finalized, the changes outlined in the proposed Medicare physician fee schedule rule would clarify what constitutes medical necessity and expand the types of medical circumstances that meet that threshold.
House and Senate Democrats have suggested Medicare cover dental services in a number of new circumstances, including when they:
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