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Lawmakers from the U.S. House of Representatives are asking the Centers for Medicare and Medicaid Services 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, House members estimated that half of Medicare beneficiaries lack access to dental coverage despite about two-thirds of them experiencing some form of periodontal disease. Lack of dental insurance leads to many beneficiaries neglecting their oral health, lawmakers said.
The House members made the case that Medicare could see substantial savings by expanding dental coverage, citing an Avalere study showing that the program could save $63.5 billion over 10 years by providing coverage for those with heart disease, stroke and diabetes.
“Lack of access to medically necessary dental treatment can worsen other health conditions, thereby increasing Medicare’s costs for treating their illnesses,” lawmakers wrote.
Section 1862(a)(12) of the Social Security Act excludes Medicare coverage of routine dental services, but the Representatives pointed to a Senate report confirming that payment can be made when there’s an appropriate medical justification, such as when a service is necessary to treat a disease or injury covered by Medicare.
Currently, CMS’ definition of medically necessary is narrow – encompassing such things as reconstruction of the jaw following an injury, or a tooth extraction done in preparation for radiation treatment.
Lawmakers contended the agency should expand services to “all medically necessary situations,” including emergency department visits and hospitalizations for problems in which oral bacteria is the underlying cause, such as an infected cardiac or orthopedic prosthesis.
Other situations the House members 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 infection; diabetes; arthroplasty of the hip and knee, which could leave a person open to postoperative infection; cancer treatment; organ transplantation; and rheumatologic disease, for which patients take medications that can suppress their immune systems.
WHAT’S THE IMPACT
Research published by the Kaiser Family Foundation shows that nearly half of Medicare patients have not seen a dentist within the past year, and the problem is worse among communities of color, with 68% of Black beneficiaries and 61% of Hispanic patients having foregone coverage. Seventy-three percent of low-income beneficiaries have also skipped the dentist in the past year, and one in five who have used dental services spent more than $1,000 out of pocket for their care.
Meanwhile, Health Affairs researchers have found that nearly 20% of seniors have lost all their teeth and 68% have gum disease, resulting in seniors eating unhealthy foods that are easier to chew, but lead to elevated blood sugar and diabetes.
Other data suggests gum disease is linked 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 swollen gums and mouth ulcers.
THE LARGER TREND
Close to half of all Medicare beneficiaries, totaling around 24 million people, did not have 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.
Average out-of-pocket spending on dental services among Medicare beneficiaries who had any 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 Medicare Advantage enrollees in individual plans are in a plan that offers access to some dental coverage. Among these Medicare Advantage enrollees, 86% are offered both preventive and more extensive dental benefits.
More than three in four Medicare Advantage enrollees who are offered more extensive coverage are in plans with annual dollar limits on dental coverage, with an average limit of $1,300 in 2021. More than half (59%) of these enrollees are in a plan with a maximum dental benefit of $1,000 or less.
Medicare Advantage plans are the leading source of dental coverage for people with Medicare. While the scope of dental coverage varies across Medicare Advantage plans, there are some common features: Virtually all MA enrollees with access to dental coverage as part of their plan have preventive benefits, and most have access to more extensive dental benefits, though cost sharing for more extensive services is typically 50% for in-network care, and subject to an annual cap on plan payments.
About 78% of enrollees with access to more extensive services are subject to annual caps – averaging about $1,300 in 2021.
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