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Recently, the Center for Medicare Advocacy laid out our Medicare Platform for the New Congress. One of the core considerations for Medicare, now and in the future, is the need to expand and Improve Medicare for all current and future beneficiaries, not just those in private Medicare plans. One of the key issues faced by beneficiaries in the traditional Medicare program is the lack of coverage for oral health benefits.

As noted in last week’s CMA Alert, one of the Center for Medicare Advocacy’s top priorities is to expand Medicare coverage to include oral and dental care for all beneficiaries.  We have also long advocated for coverage of medically necessary oral health care, which we believe is currently supported by the Medicare statue but is, unfortunately, significantly limited in practice due to Medicare policy.

The Medicare statute specifically excludes payment for services “in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth…” (Section 1862(a)(12) of the Social Security Act [42 U.S.C. § 1395y(a)(12)]).  The provision bars payment when the primary purpose of the dental work is to address the teeth and supporting structures.

Importantly, the plain language of the statutory provision does not prohibit payment for dental services needed “in connection with” treatment of medical issues that extend beyond the teeth and supporting structures. For example, clinical standards and protocols for certain covered medical procedures (e.g., some organ transplants, cardiac surgeries, chemotherapies) require that dental infections be treated to reduce the risk of serious and costly complications.

As we work toward the development of a comprehensive Medicare oral health benefit, the Center for Medicare Advocacy will continue to fight against the over-broad use of the dental exclusion to preclude coverage for dental procedures in all circumstances.  This was not the legislative intent. Appropriate interpretation also aligns with Medicare’s fundamental, remedial purpose to help beneficiaries access and afford treatment for major medical problems.

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