Oral Health America (OHA) and its partners have released a white paper, “An Oral Health Benefit in Medicare Part B: It’s Time to Include Oral Health in Health Care,” that examines the need for oral healthcare to be integrated with and elevated to the same importance as the rest of healthcare in Medicare.
“The lack of a dental benefit in Medicare affects older adults’ overall health, quality of life, and financial stability. To ensure access to care, we must provide coverage to pay for care,” said Beth Truett, OHA president and CEO.
“OHA is focused on finding equitable solutions to increase the overall health and wellness of America’s seniors. We believe that including a publicly funded benefit in Medicare Part B is a solution that values oral health as key to total health,” Truett said.
Medicare supports healthcare for 59 million older people and younger people with disabilities in the United States. However, traditional Medicare does not cover routine oral healthcare such as checkups, cleanings and x-rays, or restorative procedures like fillings or bridges, tooth extractions, and dentures.
“Medicare’s dental exclusion is misguided even given the clear connection between oral health and overall health,” said Wey Wey Kwok, JD, senior attorney at the Center for Medicare Advocacy. “The time has come to include an oral health benefit that covers preventive services, disease management, and necessary procedures for all Medicare beneficiaries.”
The white paper looks at many aspects of adding an oral health benefit to Medicare, OHA reports, including medical necessity, costs, and the need for legislative changes. Among its findings:
- 70% of all Medicare recipients lack or have limited dental insurance, and fewer than half access dental care each year.
- Cost is the primary reason that older adults haven’t gone to the dentist in the past year.
- Integrating dental coverage in Medicare would close disparities in dental use and expense between the uninsured and insured and among older adults with few financial resources and limited oral health education.
- Surveys show that consumers widely support adding oral health coverage to Medicare and prioritize two categories of care: checkups and pain treatment.
- 71.2% of dentists agree that Medicare should include comprehensive dental benefits, and a majority indicated they were willing to comply with typical Medicare practice requirements.
The OHA further notes that the ADA recently commissioned a study analyzing the cost structure for various dental benefit designs within Medicare. This study estimated that a comprehensive benefit without dollar value caps would cost the federal government $31.4 billion in 2016 dollars, or $32.3 billion in 2018. Also, the estimated base premium increase for a Part B benefit would be $14.50 per beneficiary per month.
However, OHA reports that ADA input in this white paper does not constitute endorsement of inclusion of a dental benefit under Medicare at this time. The ADA is currently investigating several options to serve the dental needs of a growing elder population, which OHA says will reach 72.1 million seniors in the United States by 2030.
The white paper recommends adding a comprehensive oral benefit to Medicare Part B as it covers outpatient services. Such a benefit would be amended to include dental services using the medically necessary and reasonable standard that applies to all Part B services, OHA says. Its advantages, OHA says, would include:
- Everyone enrolled in Medicare would receive the oral health benefit.
- The greatest number of beneficiaries would have access to a basic level of oral healthcare, encouraging equitable health solutions and provider participation.
- A potentially confusing program and process would be simplified for providers and beneficiaries.
- Established protections for Medicare beneficiaries and providers would be used, alleviating the need for a new system and bureaucracies.
To add oral health benefits, Congress must pass legislation to remove the statutory exclusion in Section 1862(a)(12) of the Social Security Act. Congress also must establish dental coverage in Part B, permit payment for preventive services prescribed in the dental benefit, and define the dental services in the Medicare statute.
“Millions of older Americans lack the resources to maintain their oral health over their lifetime, which will negatively impact their general health and well-being,” said Elisa Chavez, DDS, scholar of the Santa Fe Group.
“[We are] one of many groups advocating for federal legislation to remove the dental exclusion in Medicate in order to make possible a dental benefit and a more coordinated, cost-effective model of comprehensive healthcare,” Chavez said.