More Medically-Necessary Coverage Might Cut New Dental Benefit Costs

Inside Health Policy

July 16, 2021 11:02 am

The Biden administration is looking at the idea of expanding Medicare’s definition of medically-necessary dental coverage, according to a senator’s office, and such a move potentially could bring down the cost of congressional Democrats’ plan to add a new dental benefit to Medicare as part of a broad budget reconciliation package later this year. However, the administration has not committed to any action and whether the move would bring down costs depends on several factors, stakeholders said.

A spokesperson for Sen. Ben Cardin (D-MD), a long-standing Medicare dental coverage advocate, said the senator has supported expanding the medically-necessary dental services definition to cover additional medically necessary conditions, and continues to encourage the administration to make this change. The spokesperson said the request is on the administration’s radar.

CMS and the White House did not respond to a request for comment.

Medicare Part A currently covers a narrow set of medically-necessary dental services received in a hospital, and some Medicare Advantage plans offer dental benefits. Medicare statute prohibits coverage of routine dental care and dental prostheses.

Consumer advocates and progressive lawmakers have led a push for expanding Medicare benefits to include dental care, along with hearing and vision, and they hope to accomplish this through the budget reconciliation package. Senate Majority Leader Chuck Schumer (D-NY) announced Tuesday night that he intends to fully fund Medicare dental, hearing and vision care through the $3.5 trillion Senate budget resolution that budget committee Democrats agreed to earlier this week.

Schumer didn’t say how much money could be devoted to the new benefits. But draft Senate budget documents circulating in June put the cost at $299.6 billion over 10 years, with $233.6 billion of that to pay for dental care.

The Congressional Budget Office score of a new Medicare dental benefit might be driven down if CMS expanded the definition of medically-necessary dental coverage, said Meredith Freed, a policy analyst at Kaiser Family Foundation.However, the impact would depend on what services CMS moved to consider medically-necessary and which would be covered under a new law, among other things, Freed added.

Melissa Burroughs, associate director for strategic partnerships at Families USA, said it’s unclear how much an expanded definition of medically-necessary dental coverage would bring down the CBO score for a dental benefit, but she said research shows covering dental services would bring down other health care costs.

A community statement from over 150 medical and beneficiary organizations — including Families USA, the Center for Medicare Advocacy, AARP and the American Medical Association — points out that untreated oral infections are linked to many chronic conditions, which disproportionately affect Medicare beneficiaries and thus pose significant costs to the program. The statement implores Congress and the administration to look at options for extending dental coverage to Medicare beneficiaries.

Consumer advocates have called on CMS to expand the medically-necessary dental coverage definition for years and across administrations, saying the agency already has the authority to do so, but no action has been taken by CMS in the past. Then-CMS Administrator Seema Verma said in early 2019 that the agency was looking closely at medically-necessary dental benefits but worried the agency didn’t have the authority to cover expanded care.

The Center for Medicare Advocacy believes the statutory exclusion of dental care in Medicare doesn’t apply when the dental care is primarily for the purpose of preventing risks from other medical conditions or treatment, like when oral infections need to be addressed before heart surgery or chemotherapy, said Center for Medicare Advocacy Policy Attorney Kata Kertesz.

“Authorizing dental coverage in such circumstances does not require legislation, but could be accomplished by CMS more quickly, through a national coverage determination or policy guidance,” Kertesz said in an email.

The Biden administration hasn’t made any commitment towards expanding medically-necessary dental coverage, Kertesz said. But she added the Center for Medicare Advocacy has sensed some administration interest in and an understanding of the benefits of expanding the definition. CMA remains hopeful the issue will be addressed, Kertesz added. — Maya Goldman