Why do dentists oppose Medicare for older Americans?
The main opposition comes from dentists. With the Democrats’ large policy ambitions but narrow majority, its passage is not assured. The American Dental Association, which fought to keep dental care out of the original Medicare program in 1965, supports a limited government benefit for older Americans.
Can dental problems worsen Medicare coverage?
There’s growing evidence that dental problems can worsen other health conditions that Medicare does cover. Bernie Sanders, the Vermont independent who is the chairman of the Senate Budget Committee, has played a crucial role in advancing the measure.
Do dentists accept Medicare or Medicaid?
Some dentists worry that a Medicare benefit limited to low-income older adults would be easier to shun, pushing even more newly insured Americans into an already burdened dental safety net. Overall, fewer than half of U.S. dentists accept Medicaid, though more than 60% of NDA members do, according to Fletcher.
How will the Medicare reform proposal affect dentists?
The proposal, part of the large budget bill moving through Congress, would be among the largest changes to Medicare since its creation in 1965 but would require overcoming resistance from dentists themselves, who are worried that it would pay them too little. The impact could be enormous for people like Natalie Hayes, 69.
Key Findings
Nearly half of Medicare beneficiaries (47%), or 24 million people, do not have dental coverage, as of 2019.
Dental Coverage, Utilization and Out-of-Pocket Spending
Nearly 24 million people, or about half of all Medicare beneficiaries (47%), did not have any form of dental coverage in 2019 (Figure 1).
Medicare Advantage Dental Benefits
Medicare Advantage plans may provide extra (“supplemental”) benefits that are not covered under traditional Medicare, such as dental, vision, hearing, and fitness benefits. The cost of these benefits may be covered using rebate dollars. Plans can also charge additional premiums for such benefits.
How Medicare Advantage Dental Coverage Compares to Affordable Care Act (ACA) Marketplace Coverage
As context for assessing the scope of dental benefits offered to Medicare Advantage enrollees, we reviewed dental coverage available to those who purchase dental coverage through the ACA Marketplaces.
How Current Proposals Would Add a Dental Benefit to Medicare
In the 116 th Congress, the House of Representatives passed the Elijah E. Cummings Lower Drug Costs Now Act (H.R.3), which among many provisions, provided for dental coverage under Part B of the Medicare program, starting in 2025 if enacted into law.
Discussion
Since its enactment in 1965, Medicare has not covered routine dental care and half of Medicare beneficiaries (47%) do not have any dental coverage, as of 2019.
What are the items that are excluded from Medicare?
Excluded items and services include routine check-ups, hearing and eye examinations, hearing aids, eyeglasses, orthopedic shoes, and dental treatment.
What level of review is a beneficiary's denial overturned?
A beneficiary may have a better chance of getting a coverage denial overturned at the third level of review, which allows an evidentiary hearing before an Administrative Law Judge (ALJ), who is not bound by CMS policy in rendering coverage determinations.
Does Medicare cover dental cleanings?
Medicare Policy on Dental Services. Traditional Medicare does not cover preventive dental services like exams, cleanings, and x-rays. Nor does it cover basic or major restorative services and items like fillings, extractions, root canals and dentures. When such dental work must be performed in a hospital setting due to the severity ...
Is the same time dentist rule a medical rule?
The rule hinges Medicare coverage on the timing of the dental procedure, who administers it, and the anatomical location of the primary covered procedure, rather than taking into account clinical standards and protocols and whether the procedure is , medically-speaking, incident to and an integral part of a covered medical procedure or course of treatment
Does CMS cover dental services?
In the meantime, CMS should exercise its authority to expand coverage for oral and dental services that are vital to the medical management or treatment of serious underlying diseases, illnesses, and injuries.
Does Medicare require prior authorization for dental?
If the client is enrolled in a private Medicare Advantage plan that includes dental benefits, the plan may require prior authorization before approving coverage of needed dental services. Advise the client to engage the relevant physicians and practitioners to contact the plan directly to advocate for coverage.
Does Medicare cover jaw surgery?
Under CMS’ policy, Medicare will cover extractions needed to prepare the jaw for cancer radiation therapy, and inpatient oral examinations (but not treatment) prior to kidney transplants and, in certain settings, heart valve replacements.
What is the dental exclusion?
Section 1862 (a) (12) of the Social Security Act states, "where such expenses are for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth, except that payment may be made under part A in the case of inpatient hospital services in connection ...
What is the structure that supports the teeth?
Definition. Structures directly supporting the teeth means the periodontium , which includes the gingivae, periodontal membrane, cementum of the teeth, and the alveolar bone (i.e. alveolar process and tooth sockets). Page Last Modified: 11/19/2013 03:03 AM.
Did the dental exclusion include foot care?
In establishing the dental exclusion, Congress did not limit the exclusion to routine dental services, as it did for routine physical checkups or routine foot care, but instead it included a blanket exclusion of dental services.
Does Medicare pay for dental implants?
Currently, Medicare will pay for dental services that are an integral part either of a covered procedure (e.g., reconstruction of the jaw following accidental injury), or for extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw.
A once-in-a-generation opportunity
Health equity advocates see President Biden's Build Back Better agenda as a once-in-a-generation opportunity to provide dental coverage for those on Medicare, nearly half of whom did not visit a dentist in 2018 — well before the pandemic paused dental appointments for many people.
Democrats Hope To Beef Up Medicare With Dental, Vision And Hearing Benefits
Advocates of dental coverage for everyone on Medicare find themselves up against an unlikely adversary: the American Dental Association, which is backing an alternative plan that would give dental benefits only to low-income Medicare recipients.
Dental care and health are intertwined
More recently, however, dentists have stressed the link between oral and overall health. Most infamously, the 2007 death of a 12-year-old boy that might have been prevented by an $80 tooth extraction prompted changes to Maryland's version of Medicaid, the federal-state public insurance program for people with low incomes.
The Lifecycle of a Tooth
The ADA-backed Medicare proposal would cover only seniors who earn up to three times the poverty level. That currently translates to $38,640 a year for an individual and would the number of potential recipients from more than 60 million people to r oughly half that number.
Research finds cost a barrier to dental care
Unlike the ADA, the National Dental Association is pushing for a universal Medicare dental benefit. The group, which "promotes oral health equity among people of color," was formed in 1913, in part, because the ADA did not eliminate discriminatory membership rules for its affiliates until 1965. Dr.
Why some oppose a universal Medicare dental benefit
"It would be tragic if we didn't do something for those low-income seniors," says Michael Graham, senior vice president of government and public affairs for the ADA.
Would most dentists take Medicare patients?
Of course, covering only low-income seniors presents its own questions, the biggest being: Will dentists even accept Medicare if they don't have to? Low-income patients often seek their dental care at safety-net clinics that schedule out months in advance.
Key Findings
- Nearly half of Medicare beneficiaries (47%), or 24 million people, do not have dental coverage, as of 2019.
- Almost half of all Medicare beneficiaries did not have a dental visit within the past year (47%), with higher rates among those who are Black (68%) or Hispanic (61%), have low incomes (73%), or who...
- Nearly half of Medicare beneficiaries (47%), or 24 million people, do not have dental coverage, as of 2019.
- Almost half of all Medicare beneficiaries did not have a dental visit within the past year (47%), with higher rates among those who are Black (68%) or Hispanic (61%), have low incomes (73%), or who...
- 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 (20%) who used dental services spent m...
- In 2021, 94% of Medicare Advantage enrollees in individual plans (plans open for general enrollment), or 16.6 million enrollees, are in a plan that offers access to some dental coverag…
Dental Coverage, Utilization and Out-Of-Pocket Spending
- Nearly 24 million people, or about half of all Medicare beneficiaries (47%), did not have any form of dental coverage in 2019 (Figure 1). The remaining Medicare beneficiaries have access to dental coverage through Medicare Advantage plans, Medicaid, and private plans, including employer-sponsored retiree plans and individually purchased plans. In 2019, 29% of all Medicar…
Medicare Advantage Dental Benefits
- Medicare Advantage plans may provide extra (“supplemental”) benefits that are not covered under traditional Medicare, such as dental, vision, hearing, and fitness benefits. The cost of these benefits may be covered using rebate dollars. Plans can also charge additional premiums for such benefits. In 2021, 94% of Medicare Advantage enrollees in individual plans, have access to som…
How Current Proposals Would Add A Dental Benefit to Medicare
- In the 116th Congress, the House of Representatives passed the Elijah E. Cummings Lower Drug Costs Now Act (H.R.3), which among many provisions, provided for dental coverage under Part B of the Medicare program, starting in 2025 if enacted into law. Medicare would cover 80% of the cost of preventive services and basic treatments, and would phase up coverage for more major t…
Discussion
- Since its enactment in 1965, Medicare has not covered routine dental care and half of Medicare beneficiaries (47%) do not have any dental coverage, as of 2019. Without dental coverage, many people on Medicare forego needed and routine dental care – an issue that disproportionately impacts communities of color – with significantly fewer visits to the dentist in the past year amo…
Statutory Dental Exclusion
Background
- The dental exclusion was included as part of the initial Medicare program. In establishing the dental exclusion, Congress did not limit the exclusion to routine dental services, as it did for routine physical checkups or routine foot care, but instead it included a blanket exclusion of dental services. The Congress has not amended the dental exclusion since 1980 when it made a…
Coverage Principle
- Coverage is not determined by the value or the necessity of the dental care but by the type of service provided and the anatomical structure on which the procedure is performed.
Services Excluded Under Part B
- The following two categories of services are excluded from coverage: A primary service (regardless of cause or complexity) provided for the care, treatment, removal, or replacement of teeth or structures directly supporting teeth, e.g., preparation of the mouth for dentures, removal of diseased teeth in an infected jaw. A secondary service that is ...
Exceptions to Services Excluded
- The extraction of teeth to prepare the jaw for radiation treatment of neoplastic disease. An oral or dental examination performed on an inpatient basis as part of comprehensive workup prior to renal transplant surgery or performed in a RHC/FQHC prior to a heart valve replacement.
Definition
- Structures directly supporting the teeth means the periodontium, which includes the gingivae, periodontal membrane, cementum of the teeth, and the alveolar bone (i.e. alveolar process and tooth sockets).