Medicare Should Pay for Oral Health Care That Is Necessary to Manage Serious Illnesses

Oral health is an important part of overall health for everyone – but it can be crucially important to someone who is fighting a serious condition, such as kidney failure, an autoimmune disease, cancer or a heart problem. Unfortunately, Medicare covers almost no dental/oral health care, and imposes ill-considered restrictions on the limited care it will cover.

Families USA is joining with other health care advocates and medical specialists asking the Centers for Medicare and Medicaid Services (CMS) to cover medically necessary oral and dental treatment under Medicare. One of the primary arguments in favor of lifting restrictions on oral health coverage is that there are many cases where not doing so would complicate or preclude treatment of another Medicare-covered condition.

Medicare now pays for exams–but not treatment–when an oral health condition would interfere with other care

Here’s an example of a restriction on oral health coverage that doesn’t make sense: Medicare will pay for an inpatient dental exam that takes place before a kidney transplant because an oral infection would add to the surgery’s risk. Oral infection would also add to post-surgical risks since immune-suppressing drugs used after a transplant would contribute to systemic spread of the dental infection.

However, if the exam reveals an oral infection, Medicare won’t pay for the dental problem to be treated!

This nonsensical rule might leave someone on expensive kidney dialysis because their oral health condition is too risky for surgery, when treating their gums and teeth and then paying for a transplant would be a far better course of care.

Oral health treatment can be critical to effective management of many conditions

Medical specialists name a variety of conditions in which oral health treatment plays a vital role. To name just a few:

• Dental infections can increase the risk of cardiovascular disease.
• Neurologists note that bacterial infections can worsen stroke outcomes.
• Patients taking immunosuppressant drugs – such as people with multiple sclerosis, rheumatological disease, and transplant patients – can face “deadly” risks from dental disease.
• Patients may need dental care before they can safely undergo treatment for gastrointestinal diseases.
• Dental problems put people with joint replacement and other prostheses at serious risk.
• Untreated periodontal disease interferes with the control of diabetes and adds to risks of diabetes complications.
• Patients who are about to undergo chemotherapy are at risk of sepsis if they have untreated dental disease – so dental treatment should precede chemotherapy.

Dental Lifeline Network (DLN), a national nonprofit organization, knows these problems all too well. It operates a volunteer network to provide comprehensive dental treatment to medically compromised people, or who are elderly or have a disability.

Many patients suffer worsened health problems because they lack Medicare oral health coverage. For example:  A heart patient with mitral valve regurgitation required surgery, but it could not be scheduled due to the risk of complications posed by his dental infections. While this patient waited for charitable treatment, he developed extreme symptoms of congestive heart failure and had to be hospitalized (at further danger and Medicare expense).

CMS applies a very narrow interpretation of Medicare rules

So what is up with the Medicare rules? In 1965, when Congress enacted Medicare, it explained that routine dental checkups and treatment were not covered, and so the Medicare statute excludes services that are for “the care, treatment, filling, removal, or replacement of teeth….” (Social Security Act §1862 (a)(12)). However, the statute also defines “doctors of dental care” as a profession that can be reimbursed (Social Security Act §1861).

CMS currently interprets this narrowly to only permit reimbursement for a dental procedure that is incident and integral to a primary covered procedure (such as reconstruction of a jaw), but only if both procedures are performed at the same time and by the same dentist. Lawyers, medical specialists, and consumer organizations are now asking CMS to broaden its interpretation. They believe there is good reason to cover oral health care when there is a risk that not doing so would complicate or preclude treatment of another Medicare-covered condition.

Some Medicare Advantage plans already offer dental benefits that are not available in the traditional Medicare program. In some areas, there may also be Medicare Advantage Special Needs Plans (MA-SNP) available to patients with certain chronic conditions, such as diabetes, which may include or offer dental benefits.

What Medicare beneficiaries should know about dental care

If you are a Medicare beneficiary trying to figure out if your dental care can be covered now, most likely the answer is yes only if you are in one of the minority of Medicare Advantage (“Medicare Part C”) plans that cover dental services.

If you are in a Medicare Advantage plan, talk to the plan and your provider about what is and is not covered. Many MA plans only cover a cleaning, exam, and x-rays.

If you are in the traditional Medicare program, dental care is generally not covered. Talk to your oral health care provider or a Medicare counseling program (SHIP) about whether there are any exceptions that might apply to a medically necessary oral exam you might need, such as an exam for oral cancer.

Help us make the case for the need for better coverage of oral health care. Tell us how lack of oral health coverage has affected your life.