Policy Options for Improving Dental Coverage for People on Medicare

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; 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; 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; 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; 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; 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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  2. Some examples of these policy options are: S.97, “Medicare Dental Benefit Act of 2021,”117th Congress (2021) https://www.congress.gov/117/bills/s97/BILLS-117s97is.pdf; S.1423, “Medicare and Medicaid Dental, Vision, and Hearing Benefit Act of 2019,” 116th Congress (2019) https://www.congress.gov/116/bills/s1423/BILLS-116s1423is.pdf; H.R. 1393, “Medicare Dental, Vision, and Hearing Benefit Act of 2019,” 116th Congress (2019) https://www.congress.gov/116/bills/hr1393/BILLS-116hr1393ih.pdf; H.R. 576, Seniors Have Ears, Eyes, and Teeth Act,” 116th Congress (2019) https://www.congress.gov/116/bills/hr576/BILLS-116hr576ih.pdf; S.1129, “Medicare for All Act of 2019,” 116th Congress (2019) https://www.congress.gov/116/bills/s1129/BILLS-116s1129is.pdf; H.R. 1384, “Medicare for All Act of 2019,” H.R.1384, 116th Congress (2019) https://www.congress.gov/116/bills/hr1384/BILLS-116hr1384ih.pdf; H.R. 2452, “Medicare for America Act of 2019,” 116th Congress (2019) https://www.congress.gov/116/bills/hr2452/BILLS-116hr2452ih.pdf

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  3. See Section 1862(a)(12) of the Social Security Act.

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  4. Centers for Medicare and Medicaid Services Publication 100-02, Chapter 15, Section 150. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

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  5. The original National Coverage Determination for renal transplant issued in 1979 provided for oral health examination. (Medicare National Coverage Determination Manual, 100-03, Section 260.6) However, subsequent Medicare coverage decisions for other organ transplantation procedures did not specify coverage of an oral examination prior to the procedure.

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  6. Ibid.

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  7. Centers for Medicare and Medicaid Services Publication 100-02, Chapter 15, Section 150. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

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  8. Ibid.

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  9. Medicare law requires that to be covered, items and services must be reasonable and necessary. This means that if a dental benefit were added to Medicare, dental services would need to be medically necessary to be covered. Preventive services are only covered when specified by law.

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  10. Medicare enrollment data available at https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/CMSProgramStatistics/2016/2016_Enrollment.html#%20Fee-For-Service%20Medicare%20Enrollment

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  11. An example of legislation that has no cost sharing for preventive services is S.97, “Medicare Dental Benefit Act of 2021,” 117th Congress (2021) https://www.congress.gov/117/bills/s97/BILLS-117s97is.pdf

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  12. 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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  13. See National Association of Dental Plans. Dental Benefits Basics: What do dental plans normally cover? $1,500 is median annual limit in 2016 for dental preferred provider organization (PPO) plans. https://www.nadp.org/Dental_Benefits_Basics/Dental_BB_2.aspx

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  14. Meredith Freed, Nancy Ochieng, Nolan Sroczynski, Anthony Damico, and Krutika Amin, “Medicare and Dental Coverage: A Closer Look,” KFF, July 2021. https://www.kff.org/medicare/issue-brief/medicare-and-dental-coverage-a-closer-look/

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  15. Ibid.

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  16. An example of legislation that has frequency limits is S.1423, “Medicare and Medicaid Dental, Vision, and Hearing Benefit Act of 2019,” 116th Congress (2019) https://www.congress.gov/116/bills/s1423/BILLS-116s1423is.pdf

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  17. From the definition of physician at section 1861(r) of the Social Security Act: “… (2) a doctor of dental surgery or of dental medicine who is legally authorized to practice dentistry by the State in which he performs such function and who is acting within the scope of his license when he performs such functions…”

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  18. If Medicare created a new dental benefit that followed existing law, in order for dentists to provide Medicare-covered dental services to Medicare beneficiaries, dentists would either have to 1) enroll in Medicare and submit claims on a beneficiary’s behalf for those services 2) opt-out of Medicare and enter into a private contract with the beneficiary for those services or 3) furnish Medicare-covered services for free. For more information, please see Christina Boccuti, “Paying a Visit to the Doctor: Current Financial Protections for Medicare Patients When Receiving Physician Services,” Kaiser Family Foundation, November 2016. https://www.kff.org/medicare/issue-brief/paying-a-visit-to-the-doctor-current-financial-protections-for-medicare-patients-when-receiving-physician-services/

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  19. Centers for Medicare and Medicaid Services Publication 100-02, Chapter 15, Section 150. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

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  20. Meredith Freed, Nancy Ochieng, Nolan Sroczynski, Anthony Damico, and Krutika Amin, “Medicare and Dental Coverage: A Closer Look,” KFF, July 2021. https://www.kff.org/medicare/issue-brief/medicare-and-dental-coverage-a-closer-look/

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  21. 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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  22. 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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  23. A small number of individuals who are eligible for Medicare Part A only if they pay a monthly premium are not eligible to enroll in Part B. More common are beneficiaries who become eligible for Part A at age 65 but delay enrollment in Part B at that time because they are working and have health insurance coverage through an employer plan.

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  24. 2019 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds.

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  25. Gretchen Jacobson, Christina Swoope, Michael Perry, and Mary C. Slosar, “How are Seniors Choosing and Changing Health Insurance Plans?” Kaiser Family Foundation, May 2014. https://www.kff.org/medicare/report/how-are-seniors-choosing-and-changing-health-insurance-plans/

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  26. The Medicare Payment Advisory Commission, “The Medicare prescription drug program (Part D): Status report.” March 2021. http://www.medpac.gov/docs/default-source/reports/mar21_medpac_report_ch13_sec.pdf?sfvrsn=0

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  27. The Medicare Payment Advisory Commission, “Medicare Payment Policy.” March 2021. See chapter 4: Physician and other health professional services, page 118. http://www.medpac.gov/docs/default-source/reports/mar19_medpac_ch4_sec.pdf?sfvrsn=0

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  28. 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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  29. Institute of Medicine. 2000. Extending Medicare Coverage for Preventive and Other Services. Washington, DC: The National Academies Press. https://doi.org/10.17226/9740

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

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  31. The 2000 IOM report also concluded that given limited evidence, “the severe consequences of radiation-induced osteoradionecrosis, and Medicare's investment in treating patients with head and neck cancer, it is reasonable for Medicare to cover both tooth-preserving care and extractions, which may be medically appropriate for certain patients. The report further concluded that given limited evidence, “the severe consequences of septicemia and other complications of chemotherapy, and Medicare's investment in treating leukemia patients, it is reasonable for Medicare to cover a dental examination, cleaning of teeth, and treatment of acute infections of the teeth or gums for a leukemia patient prior to chemotherapy.”

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  32. Institute of Medicine. 2000. Extending Medicare Coverage for Preventive and Other Services. Washington, DC: The National Academies Press. APPENDIX C: Medically Necessary Dental Services. https://doi.org/10.17226/9740

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  33. Centers for Medicare and Medicaid Services. Fact Sheet: Medicare Prescription Drug Discount Card and Transitional Assistance Program. 2004. https://www.cms.gov/newsroom/fact-sheets/medicare-prescription-drug-discount-card-and-transitional-assistance-program

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  34. See for example: 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; 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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  35. 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; 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; 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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