November 26, 2022


Health for a better future

Should Medicare Cover Medically Necessary Dental Care?

Should Medicare Cover Medically Necessary Dental Care?

Members of the U.S. Senate and House of Representatives recently sent letters to the Centers for Medicare and Medicaid Services (CMS) urging the Biden Administration to expand access to medically necessary dental care under the Medicare program.  

The senators and representatives stressed the need to expand coverage of medically necessary oral and dental health services to improve the health of Americans enrolled in Medicare and reduce medical costs for the program. 

The letter from the group of 22 Democratic senators noted that oral health is a critical, but often overlooked, factor in ensuring a healthy life, yet is unaffordable and inaccessible for far too many of the over 64 million Americans enrolled in Medicare. “Therefore, we urge you to use existing statutory authority to expand coverage of medically necessary oral and dental health care for eligible Medicare beneficiaries.”

Nearly half of all Medicare beneficiaries – 24 million people – do not have dental coverage. This lack of coverage has caused low utilization of dental care by Medicare beneficiaries, particularly among communities of color. As a result, two-thirds of seniors have periodontal disease, and one-fifth have lost all of their teeth. Racial and ethnic minorities are the most severely impacted. Black American seniors are 1.7 times more likely and Asian American seniors are 1.4 times more likely than non-Hispanic White seniors to experience complete tooth loss, the senators noted. Furthermore, while 1 in 6 older adults have untreated cavities, older non-Hispanic Black or Mexican American adults have 2 to 3 times the rate of untreated cavities as older non-Hispanic adults.

Lack of dental treatment can cause cancers to go undetected, lead to chronic pain and tooth loss, and even limit the ability of an individual to eat and speak. It is well documented that poor oral health can exacerbate or increase the risk of many chronic conditions that face Medicare beneficiaries already, such as heart disease, kidney disease, cancer, and diabetes.

The negative effects of poor oral health increase costs to the Medicare program, which must pay for complications that may have been averted with proper oral healthcare, they wrote. Private insurance companies have realized significant medical savings, and a retrospective claims analysis report found that dental coverage could achieve net savings for the traditional Medicare program of $63.5 billion over 10 years. Expanded coverage would reduce costs to Medicare by strengthening treatment of some of the most persistent medical conditions covered by the program, including:

• Cardiovascular diseases, including cardiomyopathy, endocarditis, vascular disease, rhythm disorders, deep vein thromboses, and aortic disease, when untreated oral infection exacerbates medical conditions or impedes treatment.

• Diabetes management compromised by periodontal infections, which increases the risk of kidney disease and failure, vascular dementia, visual degradation, podiatric complications, cardiac disease, and stroke.

• Cancer treatment, in which leukopenia from chemotherapy or radiation therapy leads to immunosuppression and increases the risk of dentally sourced bacteria causing sepsis or other serious complications.

• Surgery for transplants, insertion of vascular grafts, stents and heart valves, and replacement or modification of joints, where oral infection increases the risk of rejection or other medical complications.

The senators note that while Section 1862(a)(12) of the Social Security Act excludes Medicare coverage of routine dental services, it does not prohibit CMS from authorizing coverage for medically necessary dental care. “It was Congress’ intent to only exclude Medicare coverage of items and services that beneficiaries may utilize outside of the context of medical illness or injury, not limit services that are necessary for medical reasons. This is clearly shown in Senate Report No. 89-404 (1965), which states that payments can be made for services with an appropriate medical justification, including when the service is needed to diagnose or treat a Medicare-covered illness, disease, or injury.”

Furthermore, they wrote, there is precedent in the Medicare program for such services. For example, podiatry services that are deemed medically necessary are covered, despite routine foot care being ineligible for Medicare payment. CMS has also authorized coverage for tooth extractions to allow for radiation treatment for cancer and dental exams prior to kidney transplants, for example.

In a statement, CareQuest Institute for Oral Health President and CEO Dr. Myechia Minter-Jordan said: “We commend these members of Congress for recognizing that oral health care is essential. Expanding medically necessary dental coverage under Medicare would greatly improve access to oral health coverage for millions of eligible seniors and people with disabilities.”