Rethinking Medicare’s “medically necessary” dental coverage

Since its inception in 1965, Medicare has provided virtually no coverage for dental care. In November 2022, the Centers for Medicare and Medicaid Services (CMS) released its final medical fee schedule rules for calendar year 2023, which included a new guarantee to cover dental services “when such service is an integral part of the treatment of medical conditions of a beneficiary”. While CMS has set some guidelines for what will be included in the first few years, this non-specific deadline also sets a precedent for expanding who is eligible and what care is covered in the future.

Newly expanded Medicare dental coverage

Medicare Parts A and B will begin covering dental care to eliminate oral infections before solid organ transplantation and select cardiac procedures in 2023 and before head and neck cancer treatment in 2024. CMS will also generate a review process annually to cover other medically necessary dental care. Other patients for whom dental care may be a key component of clinical outcomes include those at risk of stomatitis (inflammation of the mouth) from chemotherapy, patients starting bisphosphonate therapy for osteoporosis, and even patients with comorbid diabetes and disease periodontal. Currently, traditional Medicare beneficiaries with any of these conditions can expect to pay out-of-pocket for dental care or supplemental dental insurance.

Expanding dental reimbursement for these and other disease entities benefits medically complex beneficiaries and potentially increases equity in health outcomes by reducing the patient’s cost burden to receive life-saving care. However, these provisions are also an overly narrow interpretation of what makes a health service “necessary”.

Oral health inequalities among Medicare beneficiaries

Across the lifespan, cost remains the most commonly reported barrier to dental access in the United States. Older adults have the lowest dental insurance rates of any demographic group. Medicare beneficiaries with a dental visit spend an average of more than $800 each year on their dental care, and only 53 percent see a dentist. Some Medicare Advantage plans, which provide coverage to nearly half of Medicare enrollees, may offer more robust dental coverage, but out-of-pocket dental costs and low utilization rates are comparable to those with traditional Medicare. Although Medicare likewise excludes vision and hearing services from coverage, these services represent substantially lower cost burdens than dental care for beneficiaries, a cost that is likely to decrease further under the Inflation Reduction Act provision. recently approved for over-the-counter hearing aid sales.

Medicare’s current lack of dental benefits does not affect all beneficiaries equally. In addition to having more financial resources to pay for dental care or dental insurance out-of-pocket, higher income recipients are more likely to have benefited from employer-sponsored dental benefits while working and accessing care dental care during adulthood, preventing the development of more expensive dental care and painful dental needs as older adults. Low-income beneficiaries, those in rural areas, and beneficiaries of color are more likely to lose all teeth, have untreated dental disease, and be unable to access dental care. The marginal expansion of dental coverage would exclude the millions of beneficiaries who would not qualify for dental care due to a medical diagnosis, but who nevertheless currently cannot afford the necessary dental care.

Additionally, the Medicare program still incurs the costs related to dentistry. Medicare paid for 213,700 emergency department (ED) visits for dental problems in 2018, at a cost of more than $1,100 per visit. Seniors who present to the emergency room with dental pain are also more likely to be subsequently hospitalized, and in 2013, 329 seniors died during hospitalization from dental problems.

Even assuming the widest possible adoption of a medically necessary dental service through the annual review process, this policy will only cover a subset of dental procedures for a small percentage of the overall Medicare population. Requiring an “inextricable link” with medical outcomes places a heavy burden of proof on the merits of any dental service to justify its reimbursement, particularly when the results of clinical trials and quasi-experimental studies on the impact of dental care on health they are still conflicting. The smaller the population of beneficiaries that have been granted the benefit, the less incentive there is for dental providers to accept Medicare reimbursement, especially outside the tertiary care and academic settings. A poor distribution of Medicare-accepting dentists who provide care could worsen, rather than improve, inequity.

Go beyond medical necessity

Medicare coverage of behavioral health services is an instructive parallel. The Medicare Improvements for Patients and Providers Act of 2008 reduced cost sharing for behavioral health care to the same level required for other medical care. Notably, the language of the bill made no mention of “medically necessary” behavioral health treatment, instead calling for an end to “discriminatory rates of compensation … for psychiatric services.” Interestingly, behavioral health cost parity did not lead to an increase in behavioral health visits among Medicare beneficiaries, but it did increase psychiatric drug prescribing rates, suggesting that coverage led to an increase in treatment from part of those who previously could not afford it, but not to excessive use of psychiatric care.

It’s important to note that this iteration of a Medicare dental expansion comes after repeated failed attempts to enact a more comprehensive Medicare dental benefit through Congressional or executive legislation. In both 2019 and 2021, the US House of Representatives passed a Medicare dental benefits bill, although it was never adopted by the US Senate. Last fall, an initial draft of President Joe Biden’s Build Back Better Act included Medicare dental coverage, but it was removed amid pushback from the American Dental Association and budgetary concerns over its estimated $238 billion cost in 10 years.

Expanding medical needs, while affecting a much smaller share of Medicare beneficiaries, presents opportunities for further integration of dentistry into Medicare. The proposal firmly consolidates dental reimbursement under Medicare Parts A and B with other inpatient and outpatient services, which contravenes the American Dental Association’s call for a separate “Part T” for dental care. This will also facilitate the development of the CMS infrastructure to reimburse dental care, including the development of dental quality metrics or the definition of dental services in the resource-based relative value scale through which all outpatient services are funded. Such efforts could be seen as a ramp toward implementing a broader Medicare dental benefit if the political climate becomes more supportive.

While these changes are promising, the current proposal should be seen as an interim measure, not an end to Medicare’s liability to those it covers. To request medically necessary dental care, please contact indeed assumption that dental care itself is not fundamentally medical care.

The separation of medicine and dentistry – in funding structures, delivery systems, and education – has a basis in history, not biological or clinical fact. While worthy of celebration for the new patients who will benefit from it, Medicare’s limited expansion of dental coverage raises difficult questions about the role of dental care and health care in general in the lives of beneficiaries. Is it medically necessary for a person to be able to chew? To smile? To be free from preventable pain? These answers may hinge on what is currently politically feasible, rather than what is right.

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