Drilling Down on Dental Coverage and Costs for Medicare Beneficiaries

Issue Brief
  1. U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General.
    Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.

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  2. Ibid.

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  3. Ibid.

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  4. Dental utilization rates are not consistent across nationally representative datasets and may vary depending on populations of interest and how utilization is measured.

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  5. U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General.

    Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial

    Research, National Institutes of Health, 2000.

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  6. IOM (Institute of Medicine) and NRC (National Research Council). 2011. Improving access to oral health care for vulnerable and underserved populations. Washington, DC: The National Academies Press.

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  7. U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General.

    Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial

    Research, National Institutes of Health, 2000.

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  8. Ibid.

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  9. IOM (Institute of Medicine) and NRC (National Research Council). 2011. Improving access to oral health care for vulnerable and underserved populations. Washington, DC: The National Academies Press.

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  10. Schenkein HA, Loos BG. Inflammatory mechanisms linking periodontal diseases to cardiovascular diseases. J Clin Periodontol 2013;40 (Suppl. 14):S51–S69 https://onlinelibrary.wiley.com/doi/epdf/10.1111/jcpe.12060

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  11. Tonetti MS, Van Dyke TE. Periodontitis and atherosclerotic cardiovascular disease: consensus report of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases. J Clin Periodontol 2013;40 (Suppl. 14):S24–S29. https://onlinelibrary.wiley.com/doi/epdf/10.1111/jcpe.12089

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  12. Dietrich T, Sharma P, Walter C, Weston P, Beck J. The epidemiological evidence behind the association between periodontitis and incident atherosclerotic cardiovascular disease. J Clin Periodontol 2013;40 (Suppl. 14):S70–S84. https://onlinelibrary.wiley.com/doi/10.1111/jcpe.12062

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  13. Sharma P, Dietrich T, Ferro CJ, Cockwell P, Chapple ILC. Association between periodontitis and mortality in stages 3–5 chronic kidney disease: NHANES III and linked mortality study. J Clin Periodontol 2016;43:104–113. https://onlinelibrary.wiley.com/doi/10.1111/jcpe.12502

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  14. This may impact women who are under 65 with disabilities on Medicare.

    Madianos PM, Bobetsis YA, Offenbacher S. Adverse pregnancy outcomes (APOs) and periodontal disease: pathogenic mechanisms. J Clin Periodontol 2013;40(Suppl. 14):S170–S180. https://onlinelibrary.wiley.com/doi/epdf/10.1111/jcpe.12082.

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  15. Nwizu NN, Marshall JR, Moysich K, et al. Periodontal Disease and Incident Cancer Risk among Postmenopausal Women: Results from the Women's Health Initiative Observational Cohort. Cancer Epidemiol Biomarkers Prev 2017;26(8):1255–65. http://cebp.aacrjournals.org/content/26/8/1255#ref-1

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  16. Michaud DS, Kelsey KT, Papathanasiou E, Genco CA, Giovannucci E. Periodontal disease and risk of all cancers among male never smokers: an updated analysis of the Health Professionals Follow-up Study. Ann Oncol. 2016;27(5):941-7. https://www.ncbi.nlm.nih.gov/pubmed/26811350

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  17. Teeuw WJ, Gerdes VE, Loos BG. Effect of periodontal treatment on glycemic control of diabetic patients: a systematic review and meta-analysis. Diabetes Care 2010;33(2):421-7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2809296/pdf/zdc421.pdf

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  18. Preshaw PM, Alba AL, Herrera D, et al. Periodontitis and diabetes: a two-way relationship. Diabetologia 2011;55(1):21-31. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3228943/#CR7

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  19. Hajishengallis G. Periodontitis: from microbial immune subversion to systemic inflammation. Nat Rev Immunol. 2015;15(1):30-44. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4276050/

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  20. Michaud DS, Kelsey KT, Papathanasiou E, Genco CA, Giovannucci E. Periodontal disease and risk of all cancers among male never smokers: an updated analysis of the Health Professionals Follow-up Study. Ann Oncol. 2016;27(5):941-7.

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  21. Teeuw WJ, Gerdes VE, Loos BG. Effect of periodontal treatment on glycemic control of diabetic patients: a systematic review and meta-analysis. Diabetes Care 2010;33(2):421-7.

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  22. Plemons JM, Al-Hashimi I, Marek CL. Managing xerostomia and salivary gland hypofunction: Executive summary of a report from the American Dental Association Council on Scientific Affairs. JADA 2014:145(8):867-873. https://jada.ada.org/article/S0002-8177(14)60200-2/fulltext

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  23. Ibid.

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  24. Han P, Suarez-Durall P, Mulligan R. Dry mouth: A critical topic for older adult patients. J Prosthodont Res 2015: 59(1):6-19. https://www.journalofprosthodonticresearch.com/article/S1883-1958(14)00113-3/pdf

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  25. Kirzinger, A, Lopes, L, Wu, B, Brodie, M. KFF Health Tracking Poll – February 2019: Prescription Drugs. March 2019. https://www.kff.org/health-costs/poll-finding/kff-health-tracking-poll-february-2019-prescription-drugs/

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  26. Edentulous was defined as no permanent tooth present and no dental root fragments present. Molars and dental implants were excluded from the analysis (see data and methods for details).

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  27. Dye BA, Weatherspoon DJ, Mitnik GL. Tooth loss among older adults according to poverty status in the United States from 1999 through 2004 and 2009 through 2014. JADA 2019; 150(1):9-23.

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  28. Kaiser Family Foundation analysis of National Health and Nutrition Examination Survey (NHANES), 2013-2016; unpublished estimates.

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  29. Kaiser Family Foundation, State Health Facts: Percentage of Adults 65+ Who Have Had All of Their Natural Teeth Extracted. 2016. https://www.kff.org/other/state-indicator/percent-who-had-all-teeth-extracted/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

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  30. Health Policy Institute. Oral Health and Well-Being in the United States. September 2016. https://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIgraphic_0916_2.pdf?la=en

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  31. Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey (MCBS), 2016; unpublished estimates.

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  32. Centers for Disease Control and Prevention. Oral Health for Older Americans: Facts About Older Adults Oral Health. May 2, 2018. https://www.cdc.gov/oralhealth/basics/adult-oral-health/adult_older.htm

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  33. Griffin SO, Jones JA, Brunson D, Griffin PM, Bailey WD. Burden of oral disease among older adults and implications for public health priorities. Am J Public Health 2012;102(3):411-8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3487659/#bib7

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  34. Kaiser Family Foundation analysis of National Health and Nutrition Examination Survey (NHANES), 2015-2016; unpublished estimates.

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  35. Eke PI, Dye BA, Wei L, et al. Update on Prevalence of Periodontitis in Adults in the United States: NHANES 2009 to 2012. J Periodontol 2015;86(5):611-22. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4460825/

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  36. Griffin SO, Jones JA, Brunson D, Griffin PM, Bailey WD. Burden of oral disease among older adults and implications for public health priorities. Am J Public Health 2012;102(3):411-8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3487659/#bib7

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  37. Kaiser Family Foundation analysis of National Health and Nutrition Examination Survey (NHANES), 2013-2016; unpublished estimates.

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  38. Rui P, Kang K. National Hospital Ambulatory Medical Care Survey: 2015 Emergency Department Summary Tables. https://www.cdc.gov/nchs/data/nhamcs/web_tables/2015_ed_web_tables.pdf

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  39. Allareddy V, Rampa S, Lee MK, et al. Hospital-based emergency department visits involving dental conditions. The Journal of the American Dental Association 2014;45(4):331–337. https://jada.ada.org/article/S0002-8177(14)60010-6/fulltext

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  40. Okunseri C, Okunseri E, Thorpe JM, Xiang Q, Szabo A. Patient characteristics and trends in nontraumatic dental condition visits to emergency departments in the United States. Clin Cosmet Investig Dent 2012;4:1-7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3652363/

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  41. American Dental Association. American Dental Association Statement on Regular Dental Visits. June 10, 2013. https://www.ada.org/en/press-room/news-releases/2013-archive/june/american-dental-association-statement-on-regular-dental-visits

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  42. Vujicic M, Buchmueller T, Klein R. Dental Care Presents The Highest Level Of Financial Barriers, Compared To Other Types Of Health Care Services. Health Affairs 2016; 35(12): 2176–2182. https://www.healthaffairs.org/doi/10.1377/hlthaff.2016.0800

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  43. Health Resources and Services Administration. National and State-Level Projections of Dentists and Dental Hygienists in the U.S., 2012-2025. February 2015. https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/projections/nationalstatelevelprojectionsdentists.pdf

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  44. Nelson J, Thatcher J, Williams J. National Rural Oral Health Association. Improving Rural Oral Healthcare Access. May 2018. https://www.ruralhealthweb.org/NRHA/media/Emerge_NRHA/Advocacy/Policy%20documents/05-11-18-NRHA-Policy-Improving-Rural-Oral-Health-Access.pdf

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  45. Syed ST, Gerger BS, Sharp LK. Traveling Towards Disease: Transportation Barriers to Health Care Access. J Community Health 2013;38(5):976-93. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4265215/

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  46. IOM (Institute of Medicine). 2011. Advancing Oral Health in America. Washington, DC: The National Academies Press.

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  47. Jacobson G, Griffin S, Neuman T, Smith K. Kaiser Family Foundation. Income and Assets of Medicare Beneficiaries, 2016-2035. April 2017. http://files.kff.org/attachment/Issue-Brief-Income-and-Assets-of-Medicare-Beneficiaries-2016-2035

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  48. Centers for Medicare and Medicaid Services. Medicare Dental Coverage. November 19, 2013. https://www.cms.gov/Medicare/Coverage/MedicareDentalCoverage/index.html

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  49. Ibid.

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  50. Institute of Medicine. 2000. Extending Medicare Coverage for Preventive and Other Services. Washington, DC: The National Academies Press.

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  51. Inside Health Policy. Advocates Seek Medically Necessary Oral Health Care, CMS Eyes Issue. January 29, 2019.

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  52. Manski RJ, Goodman HS, Reid BC, Macek MD. Dental insurance visits and expenditures among older adults. Am J Public Health 2004;94(5):759-64. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1448334/

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  53. Manski RJ, Moeller JF, Chen H, Schimmel J, Pepper JV, St Clair PA. Dental use and expenditures for older uninsured Americans: the simulated impact of expanded coverage. Health Serv Res 2014;50(1):117-35. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4295003/

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  54. National Association of Dental Plans. Dental Benefits Basics: What do dental plans normally cover? https://www.nadp.org/Dental_Benefits_Basics/Dental_BB_2.aspx

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  55. Ibid.

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  56. Many Medicare Advantage plans outsource the management of the dental benefits to large dental insurers.

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  57. Kaiser Family Foundation analysis of Medicare Advantage Enrollment File, 2016; unpublished estimates.

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  58. Kaiser Family Foundation analysis of Medicare Advantage Enrollment File, 2016; unpublished estimates. Less than 1% had access to extensive dental coverage only

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  59. To examine the scope of dental coverage offered by Medicare Advantage plans in greater detail, we reviewed 2019 Medicare Advantage plans with the highest enrollment in 6 large metropolitan counties: San Diego, California; Harris, Texas; Cook County, Illinois; Miami-Dade, Florida; Philadelphia, Pennsylvania; Charleston, South Carolina; and 2 rural counties: Jefferson, Oregon and Wayne, Ohio. Coinsurance estimates are illustrative (see data and methods for details).

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  60. Kaiser Family Foundation analysis of Medicare Advantage Enrollment File, 2016; unpublished estimates.

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  61. Kaiser Family Foundation analysis of 5% Sample, 2016; unpublished estimates.

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  62. 2016 is the most recent year of data available for the 5% Sample of Medicare claims and was used to estimate Medicaid dental coverage, based on 2018 dental benefits in each state.

    Kaiser Family Foundation analysis of 5% Sample of Medicare claims, 2016; unpublished estimates. Kaiser Family Foundation. State Health Facts – Medicaid: Dental Benefits. 2018. https://www.kff.org/medicaid/state-indicator/dental-services/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D; The Center for Health Care Strategies. Medicaid Adult Dental Benefits: An Overview. Updated November 2018. https://www.chcs.org/media/Adult-Oral-Health-Fact-Sheet_112118.pdf

    For states that listed “NR” (No Response) in the Kaiser Family Foundation database, the Center for Health Care Strategies Data was used to determine whether the state had some Medicaid dental benefits.

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  63. California Dental Association. New benefits for Denti-Cal adults in 2018. November 2, 2017. https://www.cda.org/news-events/new-benefits-for-denti-cal-adults-in-2018

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  64. California Department of Health Care Services. What are the Medi-Cal Benefits? Accessed December 18, 2018. https://www.dhcs.ca.gov/services/medi-cal/Pages/Medi-Cal_EHB_Benefits.aspx

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  65. Kaiser Family Foundation and Health Management Associates. States Focus on Quality and Outcomes Amid Waiver Changes: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2018 and 2019. October 2018. http://files.kff.org/attachment/Report-States-Focus-on-Quality-and-Outcomes-Amid-Waiver-Changes-Results-from-a-50-State-Medicaid-Budget-Survey-for-State-Fiscal-Years-2018-and-2019

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  66. Kaiser Family Foundation analysis of 5% Sample, 2016; unpublished estimates.

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  67. Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey (MCBS), 2016; unpublished estimates.

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  68. Cubanski J, Damico A, Neuman T, Jacobson G. Kaiser Family Foundation. Sources of Supplemental Coverage Among Medicare Beneficiaries in 2016. November 2018. http://files.kff.org/attachment/Data-Note-Sources-of-Supplemental-Coverage-Among-Medicare-Beneficiaries-in-2016

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  69. Kaiser Family Foundation analysis of Medicare Advantage Enrollment File, 2016; unpublished estimates.

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  70. Coinsurance estimates are illustrative, based on our analysis of 2019 Medicare Advantage plans with the highest enrollment in 6 large metropolitan counties and 2 rural counties (see data and methods for details).

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  71. The implant procedure and treatment plan would be subject to dentist and patient preference; not all implant cost codes are available. An example scenario: intraoral - periapical first radiographic image (D0220): $100 ($50x2); Surgical placement of implant body - endosteal implant (D6010): $4,460 ($2,230x2); second stage implant surgery (D6011): $826 ($413x2) (procedures D6010 and D6011 may be performed by a periodontist or oral surgeon); prefabricated abutment – includes modification and placement (D6056): $1,432 ($716x2); implant/abutment supported removable denture for partially edentulous arch – maxillary (D6112); semi-precision attachment abutment (D6052) for 2 implants; fees were not available for the final restorations: D6112 and D6052 in the 2018 ADA Survey of Dental Fees, so the total cost of implant procedure is under-estimated. Total costs with available fee schedule: $6,818.

    Total out-of-pocket costs were calculated by including all services under Table 4 - scenario 3, as well as the total cost of implants, minus the cost of the partial maxillary denture (D5211) for a total of $10,292.

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  72. The Center for Medicare Advocacy. Legal Memorandum: Statutory Authority Exists for Medicare to Cover Medically Necessary Oral Health Care. January 3, 2019. https://www.medicareadvocacy.org/medicare-info/dental-coverage-under-medicare/

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  73. Letter to Seema Verma and Alex Azar by members of Congress. September 17, 2018. https://familiesusa.org/sites/default/files/Letter%20on%20Medicare%20Coverage%20of%20Oral%20Health%20-%20September%2017%202018.pdf

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  74. Medicare Dental Benefit Act of 2019; S.22, 116th Congress (2019). https://www.congress.gov/bill/116th-congress/senate-bill/22/text; Seniors Have Ears, Eyes, and Teeth Act; H.R. 576, 116th Congress (2019). https://www.congress.gov/bill/116th-congress/house-bill/576/text; Medicare Dental, Vision, and Hearing Benefit Act of 2017; H.R.3111, 115th Congress (2017). https://www.congress.gov/bill/115th-congress/house-bill/3111/text; Medicare for All Act of 2017; S.1804, 115th Congress (2017). https://www.congress.gov/bill/115th-congress/senate-bill/1804/text

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  75. Willink A, Schoen C, Davis K. How Medicare Could Provide Dental, Vision, and Hearing Care for Beneficiaries. The Commonwealth Fund, January 2018. https://www.commonwealthfund.org/sites/default/files/documents/
    ___media_files_publications_issue_brief_2018_jan_willink_medicare_dental_vision_hearing_ib.pdf

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