The 2023 Medicare Physician Fee Schedule Final Rule, published November 2022, incorporates changes to Medicare payment policies for certain dental services, in addition to other payment and policy changes. This brief describes current law related to coverage and payment for dental services under Medicare and the rationale for changes to current policy, explains changes to dental payment and coverage included in the final rule, and discusses the impact on Medicare and beneficiaries.
This rule modestly expands the types of dental services that are covered under Medicare, including dental or oral examinations prior to any organ transplant surgery, cardiac valve replacement or valvuloplasty procedures, beginning in 2023, and dental or oral examinations prior to treatment for head and neck cancer beginning in 2024. However, it does not represent a broad expansion of Medicare coverage of dental services and will not substantially increase Medicare spending or covered dental services for a large number of Medicare beneficiaries.
Medicare coverage of dental services is generally very limited
Since its establishment in 1965, Medicare has explicitly excluded coverage for dental services, except under limited circumstances. Limited or no dental coverage contributes to Medicare beneficiaries foregoing routine and other dental procedures. For example, in 2018, half of Medicare beneficiaries did not have a dental visit (47%), and cost was a major barrier to care for those who reported they couldn’t get dental care in the past year. Among those who used dental services, average out-of-pocket spending was $874 in 2018. Lack of dental care can exacerbate chronic medical conditions, such as diabetes and cardiovascular disease, and contribute to delayed diagnosis of serious medical conditions. While routine dental services are not covered by Medicare, many Medicare beneficiaries have access to some dental coverage through other sources: nearly half of all Medicare beneficiaries are enrolled in Medicare Advantage plans, almost all of which offer dental coverage as an extra benefit, but the scope of coverage varies by plan.
Under current law, Section 1862(a)(12) of the Social Security Act, Medicare is prohibited from making payments for “…services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth.” However, exceptions to this prohibition can apply in the context of inpatient hospital services “in connection with the provision of such dental services if the individual, because of his underlying medical condition and clinical status or because of the severity of the dental procedure, requires hospitalization in connection with the provision of such services.”
Current CMS policy has interpreted the Medicare statute to cover medically necessary dental services under both Parts A and B if they are “incident to and as an integral part” a covered procedure. For example, Medicare currently covers dental procedures, such as:
- when the reconstruction of a ridge is performed as a result of and at the same time as the surgical removal of a tumor (for other than dental purposes);
- extraction of teeth to prepare the jaw for radiation treatment of neoplastic disease; and
- an oral or dental examination performed on an inpatient basis as part of a comprehensive workup prior to renal transplant surgery.
Interested stakeholders, including patient advocates, providers, and members of Congress have asked CMS to use its authority to expand its coverage of medically necessary dental services. CMS has also received feedback that its interpretation of Section 1862(a)(12) of the Social Security Act has been “unnecessarily restrictive” and may contribute to inequitable care, particularly for older adults who are at high risk of poor oral health, which can exacerbate and complicate the treatment of other medical issues. Further, these stakeholders have asserted there are additional clinical scenarios where dental services are directly related to the clinical success of a covered service under Medicare Parts A and B.
To provide greater clarity on their current dental policies under Medicare and to respond to these stakeholders, in the 2023 physician payment final rule, CMS has clarified its interpretation of the statute, codified certain payment policies, defined new scenarios where payment can be made for dental services, and outlined a process for more medically necessary dental services to potentially be covered under Medicare.
The final rule clarifies CMS’s interpretation of when medically necessary dental services can be covered and codifies certain payment policies
In the final rule, CMS clarifies its interpretation of the statute and permits Medicare to make payment for dental services under Medicare Part A and B “that are inextricably linked to, and substantially related and integral to the clinical success of, certain other covered medical services” regardless of the setting, whether inpatient or outpatient.
With this clarification of the statute, the rule codifies that dental services can continue to be made based on the interpretation that these services “are inextricably linked to, and substantially related and integral to the clinical success of, an otherwise covered medical service”, including:
- dental or oral examination as part of a comprehensive workup prior to a renal organ transplant surgery;
- reconstruction of a dental ridge performed as a result of and at the same time as the surgical removal of a tumor;
- wiring or immobilization of teeth in connection with the reduction of a jaw fracture;
- extraction of teeth to prepare the jaw for radiation treatment of neoplastic disease; and
- dental splints only when used in conjunction with medically necessary treatment of a medical condition.
The final rule clarifies that Medicare Parts A and B payment for dental services can occur only when dental and medical services are integrated, meaning medical and dental professionals must coordinate care. The rule also finalizes a policy whereby Medicare can pay for ancillary services that are critical to the success of dental services, such as X-rays, administration of anesthesia, and use of an operating room.
Currently, for the limited circumstances under which Medicare pays for some dental services, Medicare payments to dentists are generally based on the physician fee schedule. For services that are not included on the fee schedule, regional Medicare Administrative Contractors (MACs), which are responsible for administering Medicare claims, determine the amount to be paid. The final rule continues this policy, allowing MACs to determine that payment can be made for dental services and the payment amount itself in other circumstances not specifically addressed in the rule.
The final rule defines new clinical scenarios for which Medicare payment can be made for dental services
CMS evaluated clinical evidence for additional dental services to determine whether they are substantially related and integral to the clinical success of other covered services. Based on this evidence, payment can now be made under Medicare Parts A and B for:
- dental or oral examinations, including necessary treatment, performed as part of a comprehensive workup prior to any organ transplant surgery (rather than only renal organ transplant surgery), or prior to cardiac valve replacement or valvuloplasty procedures (beginning in 2023).
- dental or oral examination performed as part of a comprehensive workup in either the inpatient or outpatient setting prior to or at the same time as Medicare-covered treatments for head and neck cancer (beginning in 2024).
Although CMS had indicated in the proposed rule additional circumstances where payment for dental services might be allowed, including prior to the initiation of immunosuppressant therapy, joint replacement surgeries, or other surgical procedures, CMS did not finalize payment for dental services in the context of these services.
In future years, CMS will use the Physician Fee Schedule annual rulemaking process to determine whether additional dental services should be considered for payment under Medicare. CMS will make this determination based on evidence from relevant peer-reviewed medical literature and research studies, clinical guidelines, or generally accepted standards of care for the suggested clinical scenario, and other supporting documentation.
Impact on Medicare beneficiaries and payments
CMS estimates that these changes will not result in a significant increase in Medicare spending or covered dental services for a large number of Medicare beneficiaries. Based on the changes to Medicare payment for dental services described above, CMS estimates that approximately 219,000 additional dental services could be covered by Medicare prior to organ transplants, cardiac valve replacement, valvuloplasty procedures, and the treatment for head and neck cancers, beginning in 2024. This is in addition to payments for currently covered dental services, which Medicare covered for about 186 patients during an 18-month period from June 2018-December 2019, mostly for tooth extraction in patients undergoing radiation treatment. CMS estimates that the additional annual total cost, beginning in 2024, will range from $230,000 to $3 million, depending on utilization.
Over the years, beneficiary advocates and other stakeholders have encouraged CMS to clarify its definition of medically necessary dental services. This final rule, in part, seeks to address concerns that the interpretation of allowable Medicare-covered dental services was overly restrictive. The changes finalized in this rule clarify the scope of dental services that can be covered under Medicare and allow for the possibility of additional clinical scenarios where dental services could be covered in the future if inextricably tied to medical care, based on clinical evidence.
While this rule modestly expands the types of dental services that are covered under Medicare, it does not represent a broad expansion of Medicare coverage of dental services, such as coverage of routine preventive services including exams and x-rays, or coverage of more extensive services, including root canals and dentures, for all people on Medicare. In the 116th Congress, legislation to add a dental benefit to Medicare was included in H.R.3 – Elijah E. Cummings Lower Drug Costs Now Act – that passed the House of Representatives in December 2019 at a cost of $238 billion over 10 years, but this bill was not voted on by the Senate. In the current Congress, a provision to add a dental benefit to Medicare was included in earlier versions of the Build Back Better Act, but not included in the version of the BBBA that passed the House in November 2021 nor in the Inflation Reduction Act, signed into law in August 2022, in part due to concerns over the cost of this provision. Absent a broader expansion of dental coverage under Medicare, people on Medicare who do not have another comprehensive source of dental coverage will continue to face relatively high out-of-pocket costs, particularly if they need extensive dental care.