Rethinking Medicare’s “Medically Necessary” Dental Coverage

Since its inception in 1965, Medicare has provided essentially no coverage for dental care. In November 2022, the Centers for Medicare and Medicaid Services (CMS) released Calendar Year 2023 Physician Fee Schedule final rules, which included a new guarantee to cover dental services “when that service is integral to treating a beneficiary’s medical condition.” While CMS has set some guidelines for what will be included in initial years, this nonspecific term also sets a precedent for expanding who is eligible and what care is covered in the future.

Newly Expanded Medicare Dental Coverage

Medicare Parts A and B will begin coverage of dental treatment to eliminate oral infection prior to solid organ transplant and select cardiac procedures in 2023, and prior to head and neck cancer treatment in 2024. CMS will also generate an annual review process for coverage of other medically necessary dental treatment. Other patients for whom dental care may be a key component of clinical outcomes include those at risk of stomatitis (inflammation of the mouth) from chemotherapy, patients initiating bisphosphonate therapy for osteoporosis, and even patients with comorbid diabetes and periodontal disease. Currently, traditional Medicare beneficiaries with any of these conditions can expect to pay out of pocket for dental care or supplemental dental insurance.

Expansion of dental reimbursement for these and other disease entities stands to benefit medically complex beneficiaries and potentially increase equity in health outcomes by reducing patient cost burden to receive life-saving care. However, these provisions are also an overly narrow interpretation of what makes a health care service “necessary.”

Oral Health Inequities Among Medicare Beneficiaries

Across the life span, cost remains the most commonly reported barrier to dental access in the United States. Older adults have the lowest rates of dental insurance of any demographic group. Medicare beneficiaries with a dental visit spend an average of more than $800 out of pocket each year for their dental care, and only 53 percent see a dentist at all. Some Medicare Advantage plans, which provide coverage to nearly half of those enrolled in Medicare, may offer more robust dental coverage, but out-of-pocket dental costs and low utilization rates are comparable to those with traditional Medicare. While Medicare similarly excludes vision and hearing services from coverage, these services represent substantially lower cost burdens than dental care for beneficiaries—a cost that is likely to decrease further with the recently passed Inflation Reduction Act’s provision for over-the-counter sale of hearing aids.

Medicare’s current absence of dental benefit does not affect all beneficiaries equally. In addition to having greater financial resources to pay out of pocket for dental care or dental insurance, higher-income beneficiaries are more likely to have had employer-sponsored dental benefits when working and access to dental care throughout adulthood, preventing development of more costly and painful dental needs as older adults. Low-income beneficiaries, those in rural areas, and beneficiaries of color are more likely to be missing all their teeth, have untreated dental disease, and be unable to access dental care. Marginal expansion of dental coverage would exclude the millions of beneficiaries who would not qualify for dental treatment due to a medical diagnosis but nonetheless cannot currently afford needed dental care.

Moreover, the Medicare program still incurs dental-related costs. Medicare paid for 213,700 emergency department (ED) visits for dental problems in 2018, at a cost of more than $1,100 per visit. Older adults presenting to the ED with dental pain are also more likely to be subsequently admitted to the hospital, and in 2013, 329 older adults died while admitted for dental problems.

Even assuming the broadest possible adoption of a medically necessary dental benefit through the annual review process, this policy will cover only a subset of dental procedures for a small proportion of the overall Medicare population. Requiring an “inextricable link” to medical outcomes places a high burden of proof on the merit of any dental service to justify its reimbursement, particularly when the results of clinical trials and quasi-experimental studies of the impact of dental care on health are still mixed. The smaller the population of beneficiaries granted the benefit, the lower the incentive for dental providers to accept reimbursement Medicare, especially outside of tertiary care and academic settings. A maldistribution of Medicare-accepting dentists providing treatment could worsen, rather than improve, inequity.

Reaching Beyond Medical Necessity

Medicare coverage of behavioral health services is an instructive parallel. The Medicare Improvements for Patients and Providers Act of 2008 reduced cost sharing for behavioral health care to the same level required for other medical care. Notably, the bill’s language made no mention of “medically necessary” behavioral health treatment, calling instead for an end to “discriminatory copayment rates … for psychiatric services.” Interestingly, behavioral health cost parity did not result in increased behavioral health visits among Medicare beneficiaries but did increase rates of psychiatric medication prescription, suggesting that coverage led to increased treatment by those previously unable to afford it, but not to overuse of psychiatric care.

It is important to note that this iteration of a Medicare dental expansion comes after repeated failed attempts to enact a more comprehensive Medicare dental benefit through congressional or executive legislation. In both 2019 and 2021, the US House of Representatives passed a Medicare dental benefit bill, although it has never been adopted by the US Senate. Last fall, an initial draft of President Joe Biden’s Build Back Better Act included Medicare dental coverage, but it was removed amid pushback from the American Dental Association and budgetary concerns over its estimated $238 billion 10-year cost.

The medical necessity expansion, while affecting a much smaller share of Medicare beneficiaries, does present opportunities for further integration of dentistry under Medicare. The proposal firmly entrenches dental reimbursement under Medicare Parts A and B with other inpatient and outpatient services, which contravenes the American Dental Association’s request for a separate “Part T” for dental care. This will also facilitate the development of CMS infrastructure to reimburse for dental care, including developing dental quality metrics or defining dental services in the resource-based relative value scale through which all outpatient services are funded. Such efforts could be seen as an on-ramp to implementation of a more expansive Medicare dental benefit if the political climate becomes more favorable.

While these changes are promising, the current proposal must be seen as a stopgap measure, not the conclusion of Medicare’s responsibility to those it covers. For the call for medically necessary dental care makes a de facto assumption that dental care itself is fundamentally not medical care.

The separation between medicine and dentistry—in funding structures, delivery systems, and education—has a basis in history, not biological or clinical fact. While worthy of celebration for the patients who will newly benefit, the limited expansion of Medicare’s dental coverage prompts difficult questions about the role of dental care—and health care in general—in beneficiaries’ lives. Is it medically necessary for a person to be able to chew? To smile? To be free from preventable pain? These answers may depend on what is currently politically feasible, rather than what is just.