Unlocking Dental Care: What Traditional Medicare Really Covers!

NOTE: This analysis has been refreshed as of November 2024 to incorporate the latest developments in the Physician Fee Schedule Final Rule.

While traditional Medicare has historically kept a tight lid on dental service coverage, recent moves by the Biden Administration signal a shift towards broader access. Recent changes in the Medicare Physician Fee Schedule have opened new doors, expanding the range of dental services that might be covered. The 2023 rule brought clarity to what counts as medically necessary dental care, defining specific circumstances when Medicare will foot the bill. And looking ahead, the 2024 and 2025 regulations promise to continue this trend, setting the stage for new opportunities for coverage. This summary will walk you through the current landscape of Medicare dental service coverage, the rationale behind these changes, and their potential impact on beneficiaries.

As outlined below, the latest rules do open up some exciting possibilities for Medicare beneficiaries. Starting in 2023, Medicare will now cover dental examinations that are absolutely necessary prior to organ transplants or cardiac procedures. In 2024, we see further advancements with coverage for dental screenings related to head and neck cancer treatments. And eyeing 2025, Medicare will also cover oral exams and treatments aimed at tackling dental infections for patients undergoing dialysis for end-stage renal disease. While these expansions are noteworthy, they still fall short of a sweeping overhaul of dental coverage under Medicare.

Current Dental Coverage Under Medicare: A Tight Squeeze

Since its inception in 1965, Medicare has placed significant restrictions on dental services, allowing coverage only in very specific cases. This limited scope has contributed to a troubling trend: many Medicare beneficiaries skip routine dental care. A staggering 47% of beneficiaries did not visit a dentist in 2018, largely due to cost barriers. Among those who sought dental services, average out-of-pocket expenses soared to $874. Neglecting dental health can worsen chronic conditions like diabetes and heart disease, leading to more severe health challenges down the line. While traditional Medicare isn’t designed to cover routine dental care, many beneficiaries turn to Medicare Advantage plans to fill the gaps—almost all of which provide some form of dental benefits. However, the extent of those benefits varies greatly from plan to plan.

According to Section 1862(a)(12) of the Social Security Act, Medicare explicitly denies payment for most dental services. Exceptions exist, particularly when hospitalization is required due to severe dental procedures. Current interpretations by CMS allow for coverage of medically necessary dental services if they are interconnected with broader medical treatments. For instance, Medicare does cover:

• ridge reconstruction performed alongside tumor removal;
• extractions necessary to prepare for radiation treatments;
• oral exams required prior to renal transplants.

Various stakeholders—including patient advocates, healthcare providers, and legislators—are urging CMS to further expand coverage for necessary dental care. There’s a growing consensus that the current interpretation is too restrictive, leading to disparities in care, especially among older adults who are already at higher risk for oral health issues.

In light of these discussions, the 2023 final rule from CMS aims to clarify existing coverage and potentially broaden the spectrum of services covered under Medicare, paving the way for future improvements.

Breaking Down the 2023 Final Rule: A New Era for Dental Services

The 2023 final rule from CMS is a game-changer. It allows Medicare to cover dental services that are “inextricably linked” to other covered medical services, regardless of whether they’re delivered in a hospital or outpatient setting. This means exciting new possibilities for dental coverage, as the rules clarify that:

• Dental exams prior to organ transplant surgery are now covered.
• Necessary dental treatment performed during tumor removal is eligible for coverage.
• Wiring or immobilization of teeth for jaw fractures can be covered.
• Dental extractions needed before radiation therapy are now part of the coverage.
• Dental splints can be covered when they are part of a medically necessary treatment.

These coverage expansions require coordination between medical and dental professionals, ensuring that patient care is integrated. CMS also confirmed that ancillary services—like X-rays and anesthesia—are eligible for reimbursement when they are essential to the success of dental procedures.

In the current framework, Medicare payments for dental services generally align with the physician fee schedule. For any services not explicitly covered, local Medicare contractors will determine the payment amount.

New Clinical Scenarios for Coverage

CMS is not just stopping at clarifying existing coverage; they are actively evaluating new dental services for potential inclusion. The findings so far indicate that payment can now be made for:

2023 Updates

• Dental exams performed before any organ transplants or cardiac valve procedures (starting in 2023).
• Dental evaluations tied to head and neck cancer treatments, either inpatient or outpatient (starting in 2024).

2024 Updates

• Dental treatments to address complications following radiation, chemotherapy, or surgery for head and neck cancer (starting in 2024).
• Oral exams related to chemotherapy and CAR T-cell therapy (starting in 2024).

2025 Updates

• Dental exams prior to or during dialysis for end-stage renal disease (starting in 2025).
• Treatment for oral infections related to dialysis services (starting in 2025).

Through this annual rulemaking, CMS will determine whether more dental services should be covered, basing decisions on solid scientific evidence and clinical guidelines.

The Bottom Line: What This Means for Medicare Beneficiaries

Despite these exciting changes, CMS projects that the overall impact on Medicare spending and the number of beneficiaries receiving dental coverage will be modest.

• Estimates show around 190,000 dental procedures could be covered prior to transplant or cardiac surgeries in 2023, costing Medicare an additional $200,000 to $2.55 million annually, depending on usage.
• Approximately 155,000 beneficiaries might benefit from dental coverage related to cancer treatments starting in 2024, with costs estimated between $130,000 and $2 million annually.
• For patients requiring dialysis, anticipated costs for dental services could be less than $1 million annually, even at various levels of utilization.