Broader Medicare dental coverage pushed by Biden team

The Biden administration, spurred on 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 for routine dental services, the proposal, if finalized, would allow reimbursement for oral care needed to treat more types of illnesses, injuries and chronic conditions covered by Medicare. , such as diabetes and heart disease.

It would also provide a significant consolation prize to lawmakers and patient advocates whose bid for a full Medicare dental benefit died last year with the failure of the Democrats’ Build Back Better Act.

Encouraged by the passage this month of long-awaited legislation that allows Medicare to negotiate certain prescription drug prices, proponents of Medicare dental coverage say a gradual advancement of their pet policy initiative could eventually spur similar groundbreaking legislation to improve the oral health of America’s seniors.

Georgia Burke, Medicare Advocacy Director at Justice in Aging, said the drug bargaining provisions in the Cut Inflation Act of 2022 are a “sign of hope that Congress is really willing to fill 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 comprehensive 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 amazing to get this far,” said Michael Monopoli, vice president of grantmaking strategy at the CareQuest Institute for Oral Health. The discourse around the proposal, which highlighted the impact of dental health on overall health, “got the attention of policymakers,” Monopoli said, and “got them thinking about it as a possibility.”

With the midterm elections later this year and Democrats’ control of Congress on the line, the window for passing a comprehensive Medicare dental package could be closing quickly.

Costs versus Savings

It’s unclear what the proposed coverage changes might cost. But Monopoli, Burke and others said the costs may well be offset by savings from fewer complications and hospitalizations from 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 patients with heart disease, stroke and diabetes.

The Santa Fe Group, a think tank that advocates for improved dental services, agreed to back the changes proposed by the Centers for Medicare & Medicaid Services after debating whether to wait for a comprehensive dental coverage package Medicare, said group president Terri Dolan.

Dolan, a dentist, knows firsthand the need for Medicare dental coverage. She said her 86-year-old mother, who is legally blind and on a fixed retirement income, fractured two teeth last year and had to dip into her savings to get them repaired.

“She would benefit if we had comprehensive dental insurance,” Dolan said. “And there are a lot of people who are in even more difficult circumstances, so yeah, it was terribly disappointing,” when the 2021 legislation failed.

If the current proposal is implemented, “I hope we will do more research, we will evaluate the results, we can do economic studies on the impact, the costs and the benefits, and I think that will lay a foundation more solid for future service expansion,” Dolan said.

Improving health equity

CMS’s proposal would change federal regulations to allow payment under Medicare inpatient and outpatient coverage “for dental services that are inextricably linked, and substantially linked and essential to the clinical success of an otherwise covered medical service,” indicates the proposal.

The agency is also seeking comments on “other types of clinical scenarios where dental services may be ‘medically necessary’, the ‘potential establishment of a process to identify’ other medically necessary dental services, and comments. on possible new models of payment for dental and oral care. services.

Expanding Medicare dental coverage through regulatory changes is expected to help advance the Biden administration’s efforts to improve health equity for minorities, rural residents and low-income people. These historically underserved populations represent a disproportionate share of beneficiaries with chronic conditions who would likely be eligible for expanded “medically necessary” coverage, Dolan said.

Among Medicare beneficiaries, 68% of blacks and 61% of Hispanics did not see a dentist in 2020, compared to 42% of whites, according to the Kaiser Family Foundation. For low-income people, 73% did not see a dentist in 2020.

“Unnecessarily restrictive”

Medicare’s administrative contractors determine, on a case-by-case 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 broken jaw, dental extractions to prepare the jaw for radiation therapy due to tumor growth, and tooth reconstruction. dental ridge linked to tumor removal, says CMS.

“Generally, you had to be hospitalized 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 an inequitable distribution of dental services for Medicare beneficiaries,” the proposed rule says.

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 that Medicare cover dental services in a number of new circumstances, including when they:

  • cause emergency room visits and hospitalizations;
  • can prevent aspiration pneumonia or infected medical devices in recipients with Parkinson’s disease;
  • could avoid delays or interruptions in the treatment of gastrointestinal diseases;
  • help diabetic patients with periodontal infections;
  • and help patients avoid infections after hip and knee reconstruction surgery.

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