After Congress failed to add dental coverage, Medicare weighed limited benefits

Proposed changes to Medicare rules could soon pave the way for a significant expansion of Medicare-covered dental services, while many Democratic lawmakers tout the comprehensive benefits.

This is because, under current law, Medicare can pay for limited dental care only if it is medically necessary to safely treat another covered medical condition. In July, officials proposed adding conditions that are qualified and sought public comment. Any changes are likely to be announced in November and take effect as soon as January.

The review by the Centers for Medicare and Medicaid Services follows a failed attempt by congressional Democrats to pass comprehensive Medicare dental coverage for all beneficiaries, a move that would require changes to federal law. Sen. Bernie Sanders (I-Vt.) tried in vain to add it to the Democrats’ last major piece of legislation, the De-Inflation Act, which passed in August. As defeat appeared imminent, dozens of lawmakers, along with consumer and seniors advocacy groups, called on CMS to take independent action.

Dr. Biana Reich, senior associate dean for clinical affairs at Columbia University’s College of Dental Medicine, called the CMS proposal “a step in the right direction.” But he cautioned that it still doesn’t fully address dental needs among seniors. By addressing the causes of tooth decay “we’re not solving the problems” that include lack of regular care, he said.

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

But if a patient needs another type of organ transplant, Medicare can’t eliminate dental infections so the transplant can go ahead. Or, if a patient with breast cancer has an infected tooth, Medicare will cover chemotherapy and radiation, but not require the tooth to be extracted before providing that treatment.

CMS indicated what dental services may be covered by asking for comment on whether additional organ transplants and dental examinations and treatments related to cardiac valve replacement or repair should be eligible. It also asked for examples of “other types of clinical situations” where dental services would be “substantially related to and integral to the clinical success” of other covered medical treatments.

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

Adjunct Professor at the University of Detroit Mercy School of Dentistry, Dr. Judith A. CMS doesn’t specifically address dental care for people with diabetes, Jones said. Medicare pays for insulin and other diabetic care supplies but not related to dental care. “The data is really quite clear if you improve periodontal disease, for example, blood sugar control improves,” he said. According to the Centers for Disease Control and Prevention, more than a quarter of people age 65 and older had diabetes in 2019 — or an estimated 16 million.

CMS is also considering creating a system to review requests for additional types of dental treatment needed to improve outcomes for other covered medical care.

Jones said the proposed changes would be especially important for patients receiving treatments that weaken the immune system, giving any dental infections a chance to spread. “So if you have an infection somewhere in your body, it can become widespread when you suppress the immune system,” he said.

CMS is considering expanding coverage to dental services that are “involuntarily linked” to the success of other covered medical procedures, Dr. Meena Seshamani, a CMS deputy administrator and director of the Centers for Medicare, said in a statement. If the proposal is finalized, Medicare Advantage plans would also have to expand coverage, he said. And Medicare Supplement or Medigap policies must pay for the patient’s share of the costs.

Officials say the potential changes come after criticism that the current definition of medically necessary dental care is too “restrictive, which could contribute to the unequal distribution of dental services for Medicare beneficiaries,” according to the proposal. It also cites a 2021 report on oral health from the National Institutes of Health, which found that nearly 3 in 5 older adults have severe periodontal or gum disease. Older adults also have the highest dental costs.

Leading dental care, patient, and seniors advocacy organizations along with congressional Democrats largely support the proposal. But at the same time, they criticized its shortcomings.

“This new rule only expands coverage to align with the latest medical literature and accepted standards of care,” Rep. Lloyd Doggett (D-Texas), who chairs the Ways and Means Health Subcommittee and advocates for comprehensive coverage, told KHN. a statement. “It’s not a cure.”

In June, Doggett spearheaded a letter signed by more than 100 colleagues that pressed CMS to expand dental services for certain medical conditions. In July, 22 Senate Democrats also urged CMS to expand dental coverage.

The proposal has been criticized because it eliminates follow-up dental care. Extracting an infected tooth has consequences, even when it is necessary to remove an infection that would jeopardize otherwise potentially life-saving treatment. “If you remove teeth, patients can’t chew and can’t nourish themselves properly,” said Dr. Dave Preble, chief strategy officer of the American Dental Association. “You just created another medical problem for the patient.” Full or partial dentures are not covered by Medicare. Overall, the ADA supports the proposal, although it asked CMS for more information.

Additional details include a big one: “How do you properly compensate for things that weren’t previously covered?” asked Preble. He questioned how CMS would calculate payments to dentists and whether they would cover incidental costs such as supplies, utilities and equipment. The ADA’s concerns about Medicare payments and additional benefit funding are among the reasons it did not support legislation for more comprehensive coverage.

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