After Congress failed to expand dental coverage, Medicare is considering a limited expansion of benefits

After Congress failed to expand dental coverage, Medicare is considering a limited expansion of benefits

Proposed changes to Medicare rules could soon pave the way for a significant expansion of dental services covered by Medicare, but fall short of the sweeping benefits that many Democratic lawmakers have advocated.

That's because under current law, Medicare can only pay for limited dental care if it is medically necessary to safely treat another covered condition. In July, officials suggested Adding qualifying conditions and seeking public comment. Any changes could be announced in November and come into force as early as January.

The review by the Centers for Medicare & Medicaid Services follows an unsuccessful attempt by congressional Democrats to pass comprehensive Medicare dental insurance for all beneficiaries, a move that would require changes to federal law. Sen. Bernie Sanders (I-Vt.) unsuccessfully tried to add this to Democrats' last major bill, the Inflation Reduction Act, which passed in August. With defeat appearing imminent, consumer and seniors groups and dozens of lawmakers called on CMS to take independent action.

Biana Roykh, associate dean for clinical affairs at Columbia University's College of Dental Medicine, called CMS's proposal "a step in the right direction." However, she warned that this does not cover the full extent of older people's dental needs. “We don’t solve the problems up front” by addressing the causes of dental caries, including a lack of routine care, she said.

Dental procedures that Medicare already covers include wiring teeth to repair a broken jaw, a dental exam before a kidney transplant, and the extraction of infected teeth before radiation treatment for certain neck and head cancers.

However, if a patient requires another type of organ transplant, Medicare will not cover removing a dental infection so that the transplant can occur. If a breast cancer patient has an infected tooth, Medicare will cover the cost of chemotherapy and radiation, but not the tooth extraction needed before treatment.

CMS hinted at what dental services might be covered by seeking comments on whether additional organ transplants and heart valve replacements or repairs should be considered for related dental exams and treatment. It also asked for examples of “other types of clinical scenarios” in which dental services would be “substantially related to other covered medical treatments and critical to clinical success.”

If CMS receives sufficient medical evidence, dental services could be covered to detect and eliminate infections before hip or knee replacement surgeries, officials said.

One option CMS specifically does not mention is dental care for diabetes patients, he said Dr. Judith A. Jones, associate professor at the University of Detroit Mercy School of Dentistry. Medicare covers the cost of insulin and other diabetic care supplies, but not related dental care. “The data is really quite clear, if you relieve periodontitis, for example, blood sugar control also improves,” she said. According to the Centers for Disease Control and Prevention, more than a quarter of people age 65 and older had diabetes in 2019 - an estimated 16 million.

CMS is also considering creating a system to review requests for additional types of dental care necessary to improve the outcome of other covered medical care.

The proposed changes would be particularly important for patients undergoing treatments that weaken the immune system and give dental infections a chance to spread, Jones said. “So if you have an infection somewhere in the body, it can spread if you suppress the immune system,” she said.

CMS is considering expanding coverage to include dental services that are “inextricably linked to the success of other covered medical procedures.” Dr. Meena Seshamani said a CMS deputy administrator and director of the Center for Medicare in a statement. If the proposal is finalized, Medicare Advantage plans would also be required to expand coverage, she said. And Medicare supplemental insurance or Medigap insurance would have to cover the patient's share of the costs.

Officials say the potential changes come after they received criticism that the current definition of medically necessary dental care is too "restrictive," "which could result in an unequal distribution of dental benefits for Medicare beneficiaries," the proposal says. It also quotes a Report 2021 on oral health from the National Institutes of Health, which found that nearly three in five older adults have severe periodontitis or gum disease. Older adults also have the highest out-of-pocket dental costs.

Leading dental care, patient and senior advocacy organizations join forces with Democrats in Congress largely support the application. At the same time, they also criticized its shortcomings.

“This new rule simply expands insurance coverage to align with the latest medical literature and accepted standards of care,” Rep. Lloyd Doggett (D-Texas), chairman of the Ways and Means health care subcommittee and who has advocated for comprehensive insurance coverage, said in a statement to KHN. “It’s not a panacea.”

In June, Doggett introduced a letter signed by more than 100 colleagues urging CMS to expand dental services for certain medical conditions. In July, 22 Democrats in the Senate also called on CMS to expand dental coverage.

The proposal has been criticized for neglecting dental follow-up care. Extraction of infected teeth has consequences, even if it is necessary to eliminate an infection that would otherwise jeopardize potentially life-saving treatment. “If you remove the teeth, patients will no longer be able to chew properly and continue to eat properly,” said Dr. Dave Preble, Chief Strategy Officer of the American Dental Association. “You have created another medical problem for the patient.” Full or partial dentures are not covered by Medicare. Overall, the ADA supports the proposal, although it has asked CMS for more information.

Other details that still need to be worked out include a big one: “How do you properly reimburse for things that weren’t previously covered?” Preble asked. He questioned how CMS would calculate dentists' payments and whether they would cover incidental costs such as supplies, utilities and equipment. The ADA's concerns about Medicare payments and funding for additional services are among the reasons it has not supported legislation for more comprehensive coverage.

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