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Addressing the problem of Medicare’s lack of meaningful oral health coverage has long been a focus of the Center for Medicare Advocacy.  Over the decades, the Center has assisted beneficiaries who require access to medically necessary oral health care, challenged Medicare’s restrictive coverage policy in litigation, and worked with broad coalitions to expand Medicare oral health coverage administratively and legislatively. Read on for updates on some of our recent work in this area:

Comprehensive Oral Health Benefit in Part B

As part of the Center’s continued commitment to improving oral health for older adults and people with disabilities, and expanding Part B to include a comprehensive oral health benefit, the Center supported, and urged passage of, H.R. 3, the The Elijah Cummings Lower Drug Costs Now Act, which reinvests savings from changes to drug pricing into filling gaps in Medicare coverage, like oral health. The legislation passed in the House on December 12, 2019.

The Center expressed support for the legislation both as an organization, and collectively with our fellow oral health advocates. While this historic legislation is an important step toward providing comprehensive oral health coverage for all Medicare beneficiaries, the Center continues to advocate for the oral health benefit to align beneficiary coinsurance with all other services covered under Part B.

The Center was pleased to recently share the results of new polling conducted by Morning Consult, which found that a large majority of respondents support including oral and dental health services as part of the traditional Medicare program. The widespread support for an oral health benefit, combined with the momentum from the passage in the House of this historic legislation, continue to propel the Center’s efforts for a comprehensive oral health benefit.

Case Study: MA Enrollee Wins Coverage for Oral Procedures

Recently, the Center assisted “Mrs. S”, a Medicare Advantage (MA) enrollee in Oregon, who had a rapidly growing cyst in her mouth.  Upon the MA plan’s advice, she got a referral from her network physician to see a Medicare-participating oral surgeon, who promptly removed and biopsied the cyst. One of her teeth had to be extracted to remove the cyst. The surgeon billed her for the total procedure, stating it was not Medicare-covered. A claim was submitted to the MA plan, only because her son requested it. The plan denied the claim despite its earlier representation that treatment would be covered.

On appeal, the Center sent a letter to the plan explaining that excision of an oral tumor or lesion is a covered procedure that does not fall within Medicare’s exclusion of payment for services “in connection with the care, treatment, filling, removal, or replacement of teeth or structures supporting teeth.” 42 U.S.C. 1395y(a)(12). The letter also explained that the extraction of Mrs. S’ tooth is also covered, as it was performed “incident to and as an integral part of a covered procedure[.]” Medicare Benefits Policy Manual, Ch. 15, § 150.  The plan reversed its decision and reimbursed Mrs. S for the treatment.

Unfortunately, this is not an isolated case. The Center knows that beneficiaries continue to be denied access to, or payment for, covered oral procedures because MA plans and participating dentists misunderstand Medicare’s oral health coverage policy.

TAKE ACTION to Support Medically Necessary Oral Health Coverage

For the past few years, a coalition of beneficiary advocates, disease organizations, industry groups, oral health and medical health professionals has been advocating for Medicare coverage of medically necessary oral health care, which is authorized under current law. The coalition recently launched a web-based platform for members of the public to express their support and urge the Administration to provide critical coverage for medically necessary oral health services.  Please consider participating and spreading the word. The platform is:

February 6, 2020 – K. Kertesz, W. Kwok

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