Medicare assesses limited benefit expansion as Congress fails to add dental care

Proposed changes to Medicare rules could soon pave the way for a significant expansion of Medicare-covered dental services, while falling short of the full benefits that many Democratic lawmakers have advocated.

That’s because under current law, Medicare can only pay for limited dental care if it’s medically necessary to safely treat another covered medical condition. In July, the officials proposed adding conditions that qualify and solicited public comment. Any changes could be announced in November and take effect as early as January.

The review by the Centers for Medicare & Medicaid Services follows an unsuccessful effort by congressional Democrats to pass full Medicare dental coverage for all beneficiaries, a move that would require changes to federal law. Sen. Bernie Sanders (I-Vt.) unsuccessfully sought to add that to the Democrats’ last major bill, the Cut Inflation Act, which passed in August. As defeat seemed imminent, consumer and seniors’ advocacy groups and dozens of lawmakers urged CMS to take independent action.

Dr Biana Roykh, senior associate dean for clinical affairs at Columbia University’s College of Dental Medicine, calls CMS’s proposal “a step in the right direction.” But she warned that this still did not meet the full scope of older people’s dental needs. “We don’t fix the problems up front” by addressing the causes of tooth decay, including lack of routine care, she says.

Among the dental procedures already covered by Medicare are the wiring of teeth to repair a fractured jawbone, a dental exam before a kidney transplant, and the extraction of infected teeth before radiation therapy for certain neck and head cancers.

But if a patient needs another type of organ transplant, health insurance will not cover the eradication of a dental infection so that the transplant can take place. Or, if a breast cancer patient has an infected tooth, Medicare will cover chemotherapy and radiation therapy, but not the tooth extraction needed before treatment can be given.

CMS hints at dental services that might be covered by asking for comment on whether additional organ transplants and replacement or repair of heart valves should be eligible for related dental examinations and treatments. It also asks for examples of “other types of clinical scenarios” in which dental services would be “essentially related to and essential to the clinical success” of other covered medical treatments.

If CMS receives sufficient medical evidence, officials say, dental services could be covered to detect and eradicate infections prior to total hip or knee replacement surgeries.

One possibility that CMS pointedly does not mention is dental care for diabetic patients, says Dr. Judith A. Jones, adjunct professor at the University of Detroit Mercy School of Dentistry. Medicare pays for insulin and other diabetic care supplies, but not related dental care. “The data is really very clear if you improve periodontal disease, for example, blood sugar control is improved,” she says. More than a quarter of people age 65 and older had diabetes — or about 16 million — in 2019, according to the Centers for Disease Control and Prevention.

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

The proposed changes would be particularly important for patients undergoing treatments that weaken the immune system, giving any dental infection a chance to spread, Jones says. “So if you have an infection anywhere in the body, it can become endemic when you suppress the immune system,” she says.

CMS plans to extend coverage to dental services that are “inextricably linked” to the success of other covered medical procedures, Dr Meena Seshamani, deputy administrator of CMS and director of the Center for Medicare, said in a statement. If the proposal is finalized, Medicare Advantage plans are also expected to expand coverage, she says. And Medicare or Medigap supplemental policies should pay the patient’s share of the cost.

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

Major dental, patient, and senior citizen advocacy organizations, plus congressional Democrats largely support Proposal. But at the same time, they criticized its shortcomings.

“This new rule only expands coverage to align with the most recent medical literature and accepted standards of care,” says Rep. Lloyd Doggett (D-Texas), who chairs the Ways Health Subcommittee. and Means and who argued for full coverage. a statement to KHN. “It’s not a panacea.”

In June, Doggett led a letter signed by over 100 colleagues urging CMS to expand dental services for certain medical conditions. In July, 22 Democratic senators also urges CMS to extend dental coverage.

Related: More Employers Transferring Retirees to Private Medicare Advantage Plans

The proposal has been criticized for omitting follow-up dental care. Extracting infected teeth has consequences, even when necessary to clear an infection that would otherwise compromise potentially life-saving treatment. “If you take the teeth out, patients can’t chew and continue to eat properly,” says Dr. Dave Preble, director of strategy at the American Dental Association. “You have created another medical problem for the patient.” Full or partial dentures are not covered by Medicare. Overall, the ADA supports the proposal, although it has asked CMS for more information.

Additional details to iron out include a big issue: “How do you properly reimburse things that haven’t been covered before?” asks Preble. He asked how CMS would calculate dentist payments and whether they would cover incidental expenses such as supplies, utilities and equipment. The ADA’s concerns about Medicare payments and funding for additional benefits are among the reasons it has not supported legislation for more comprehensive coverage.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. Along with policy analysis and polling, KHN is one of the three main operating programs of KFF (Kaiser Family Foundation). KFF is an endowed non-profit organization providing information on health issues to the nation.

About Michael S. Montanez

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