Medicare’s Proposed Payment Rule Offers Critical “Clarification” and Possible Expansion of Medically Necessary Dental Coverage

Millions of older adults and people with disabilities lack access to affordable, essential dental care. This care is critically important to maintaining overall health, and the lack of coverage in the Medicare program exacerbates underlying racial, geographic, and disability-related health and economic disparities and inequities.

Currently, Medicare Part B only pays for dental services when that service is integral to medically necessary services needed to treat a beneficiary’s primary medical condition, which is extremely narrowly defined. Last week, the Centers for Medicare & Medicaid Services (CMS) issued the Calendar Year 2023 Physician Fee Schedule (PFS), which includes proposals to pay for additional services.

We strongly support these changes. The Medicare statute provides ample flexibility for CMS to use its authority in this area more thoroughly. The current regulatory scheme provides for medically necessary dental care in a very limited way, providing coverage in only specifically listed circumstances. The statute, however, allows for CMS to ensure “medically necessary” care follows the more common usage of that phrase–including needed oral health services for people undergoing organ transplants, treatment for cardiovascular diseases, cancer therapies, and other critically important medical care.

While comprehensive coverage remains the most complete solution, the interim step of providing meaningful coverage of dental services that are more intimately connected to particular health care services covered by Medicare would help mitigate some of the disparities caused by the status quo.

The PFS changes would be an important advancement in ensuring that Medicare beneficiaries who need dental treatment as part of their covered medical care are no longer forced to make impossible financial trade-offs or delay or go without necessary services to access the full scope of care they require. Medicare Rights applauds the advocates, including the Medicare Oral Health Coalition, as well as policymakers and beneficiaries who have worked towards this goal for years.

Medicare Rights will be submitting comments strongly urging CMS and the Biden Administration to use this opportunity to deliver on this critically needed benefit and addressing the proposed rule in more detail.

Learn more about Medically Necessary Dental. Read about the proposed rule.