Dental coverage under Medicare could soon start expanding for seniors under a new proposal from the U.S. Centers for Medicare and Medicaid Services (CMS).
Still, the proposed rules would not provide full coverage for regular dental care, which has been explicitly excluded from Medicare since the program’s founding in 1965.
“Traditional Medicare doesn’t cover routine preventive dental services, such as exams, cleanings, X-rays, nor more expensive services such as fillings, crowns or dentures,” said Meredith Freed, a Medicare expert with the Kaiser Family Foundation.
However, the new proposal would effectively open the door to Medicare potentially covering a wider array of dental services if medical science can demonstrate that oral health substantially improves the outcomes of different diseases and treatments.
Under the proposal, rule makers and bureaucrats would have greater flexibility to approve whole new areas of dental coverage as well as to pay for specific procedures on a case-by-case basis, experts say.
Currently, nearly half of all Medicare beneficiaries—about 24 million people—don’t have dental insurance, even though two-thirds suffer from periodontal disease, according to a letter from U.S. Senators urging the CMS to expand coverage.
Rotting teeth and inflamed gums can have a tremendous impact on a person’s overall health, contributing to heart disease, diabetes, pneumonia and a host of other illnesses, research has shown.
Despite this, existing law allows Medicare to cover dental procedures only under very narrow circumstances, if dentistry can be proven “an integral part of a covered procedure,” Freed explained.
For example, Medicare will pay dentists to help reconstruct a jaw following a traumatic injury, or to perform an oral exam prior to a kidney transplant, said Wey-Wey Kwok, senior attorney for the Center for Medicare Advocacy.
But if the dentist finds a decayed tooth that needs to be pulled, Medicare won’t cover the cost of the extraction, Kwok added.
The new CMS proposal would require Medicare to pay outright for dental exams and all procedures necessary to eradicate oral infections prior to any organ transplant surgery or cardiac valve procedure, Kwok and Freed said.
Preliminary dental care is incredibly important to the success of any procedure like organ transplant that weakens the immune system, the experts said.
Existing infections can run rampant in the body if a person is on immune-suppressing drugs, potentially risking the success of the transplant and the health of the patient.
It’s self-evident “that infection or inflammation anywhere in the body can complicate or compromise certain major medical procedures or treatments,” Kwok explained.
Even more significantly, the new rules would also create an annual review process under which the CMS would evaluate expanding dental coverage to more clinical scenarios, Freed said.
“This is one way of expanding dental coverage without adding a dedicated dental benefit to Medicare,” Freed said. “By requesting comment on clinical scenarios, I think they are looking for enough evidence of a clear connection to include additional kinds of diseases.”
Seniors with diabetes could be one group that would benefit from expanded dental services, the American Dental Association (ADA) noted in its comments on the proposed rule.
Medical evidence has shown that better oral hygiene can improve the control of blood sugar levels in people with diabetes, the ADA noted.
“To achieve these outcomes for people with diabetes, comprehensive and continuous dental care must be available. We respectfully request CMS conduct a cost analysis of expanding the benefit to the population of people with diabetes such that patients can receive comprehensive ongoing care,” ADA President Dr. Cesar Sabates and Executive Director Dr. Raymond Cohlmia wrote in the association’s comments to CMS.
The new proposal also provides insurance paper-pushers more leeway in determining whether Medicare will cover specific dental claims, Kwok said.
“In this proposal, CMS is not limiting the ability of its contractors, the ones that process claims, to determine on a case-by-case basis whether a claimant’s dental care falls within the coverage standard of being inextricably linked, substantially related and integral to the clinical success of the covered medical treatment,” Kwok said.
“So even though CMS is proposing to outright pay for these exams and treatments prior to organ transplants and cardiac valve procedures, they’re also saying in this proposal that contractors could more broadly apply the standard and determine whether it applies in other circumstances, not just organ transplants and cardiac valve procedures,” Kwok added.
These two changes could slowly improve Medicare’s dental coverage, Kwok said, in the absence of Congress passing a law to add full dental benefits to the program.
“Last year was the closest we’ve come to having a dental benefit legislated into the Medicare program,” Kwok said. “There was a tremendous effort to add dental, vision and hearing benefits in the Build Back Better legislation,” a Biden administration initiative that failed to pass Congress.
The CMS is expected to announce whether the proposal has been finalized by the first week in November, Kwok said.