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CMS might expand Medicare dental coverage

U.S. House lawmakers are calling on Medicare and Medicaid Service Centers to expand the definition of medically necessary dental coverage for Medicare beneficiaries, saying the agency currently has the regulatory authority to do so.

In a letter to CMS administrator Chiquita Brooks-LaSure, members of the House estimated that half of Medicare beneficiaries do not have access to dental coverage despite the fact that approximately two-thirds of them suffer from some type of periodontal disease. Lack of dental insurance causes many beneficiaries to neglect their oral health, lawmakers said.

House members argued that Medicare could see substantial savings by expanding dental coverage, citing a study by Avalere that shows the program could save $ 63.5 billion in 10 years by providing coverage for people with heart disease, stroke and diabetes.

“Lack of access to medically necessary dental treatment can worsen other health conditions, thus increasing Medicare costs to treat their illnesses,” lawmakers wrote.

Section 1862 (a) (12) of the Social Security Act excludes Medicare coverage from routine dental services, but representatives noted a Senate report confirming that payment can be made when there is adequate medical justification. , such as when a service is needed to treat a Medicare-covered illness or injury.

Currently, the definition of medically necessary CMS is limited, which includes things such as reconstructing the jaw after an injury or removing the tooth prepared for radiation treatment.

Lawmakers said the agency should extend services to “all medically necessary situations,” including visits to the emergency department and hospitalizations for problems in which oral bacteria are the underlying cause, such as a prosthesis. infected cardiac or orthopedic.

Other situations that members of the House said should be considered medically necessary include: Parkinson’s disease, which can be complicated by oral bacteria; multiple sclerosis, in which oral bacteria can cause serious infections; diabetes; hip and knee arthroplasty, which could leave a person open to a postoperative infection; cancer treatment; organ transplantation; and rheumatic disease, for which patients take medications that can suppress their immune system.


Research published by the Kaiser Family Foundation shows that nearly half of Medicare patients have not seen a dentist in the past year, and the problem is worse among communities of color, with 68% of beneficiaries black and 61% of Hispanic patients who have lost coverage. Seventy-three percent of low-income recipients have also missed the dentist over the past year, and one in five who has used dental services has spent more than $ 1,000 out of pocket for their care.

Meanwhile, Health Affairs researchers have found that almost 20% of older people have lost all their teeth and 68% have gum disease, which causes older people to eat unhealthy foods that are more easy to chew, but leading to high blood sugar and diabetes.

Other data suggest that gum disease is related to poor cognitive function and an increased risk of developing dementia and Alzheimer’s, while more than 90% of all systemic diseases have oral manifestations, such as inflammation of the gums and gums. mouth ulcers.


Nearly half of all Medicare beneficiaries, with a total of about 24 million people, had no dental coverage in 2019, and the same percentage did not have a dental visit during that year, according to a 2021 analysis published by the Kaiser Family Foundation.

The average out-of-pocket spending on dental services among Medicare beneficiaries who had some dental service was $ 874 in 2018. One in five Medicare beneficiaries who used dental services spent more than $ 1,000 out of pocket on dental care.

Meanwhile, in 2021, 94% of those enrolled in Medicare Advantage on individual plans are on a plan that offers access to some dental coverage. Among those enrolled in Medicare Advantage, 86% offer both preventive and more extensive dental benefits.

More than three in four Medicare Advantage enrollees who are offered broader coverage are in plans with annual limits on dollars in dental coverage, with an average limit of $ 1,300 in 2021. More than half (59%) of those enrolled are in a plan with a maximum dental benefit of $ 1,000 or less.

Medicare Advantage plans are the primary source of dental coverage for people with Medicare. Although the scope of dental coverage varies between Medicare Advantage plans, there are some common features: Virtually everyone enrolled in MA with access to dental coverage as part of their plan has preventative benefits and most have access to more extensive dental benefits, although they share the costs for The widest services are usually 50% for network care and are subject to an annual limit on plan payments. About 78% of those enrolled with access to broader services are subject to annual limits, averaging about $ 1,300 in 2021.

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