The CMS is considering a new rule proposal for Medicare after leading dental and medical organizations called for action. But what impact could this have on millions of Americans' access to dental care (and the reimbursement)?
By Genni Burkhart
Currently, the Centers for Medicare & Medicaid Services (CMS) interprets Medicare law as not allowing for the payment of comprehensive dental care, which leaves millions of people without adequate dental coverage.
While some Medicare Advantage plans include dental coverage it’s constrained, and beneficiaries often have high out-of-pocket costs. For example, the Kaiser Family Foundation (KFF) recently reported that half of the Medicare population (approx. 24 million people) lacked dental coverage in 2019.
Earlier this year, three leading dental groups wrote to the CMS specifying “significant concerns” about hospital access to dental procedures. Those three organizations include the American Academy of Pediatric Dentistry (AAPD), the American Association of Oral and the Maxillofacial Surgeons (AAOMS), and the American Dental Association (ADA).
Officials from these organizations wrote in their letter that “The lack of (operating room) access for needed and covered dental procedures often results in wait times of 6-12 months for these patients, many of whom are children whose daily activities and school performance are often significantly affected in the interim.” The letter continues to address “this access challenge to the lack of a sustainable billing mechanism for hospitals and ASCs to report dental surgical services in both Medicare and Medicaid.” (1)
Growing Calls for Action
On September 6, the Medicare Rights Center submitted comments in response to a proposed rule extending Medicare coverage to dental and mental health services. If finalized, these policies would broaden the availability of medically necessary dental coverage and expand the number of providers for Medicare mental health and substance abuse.
The Consortium for Citizens with Disabilities (CCD), the American Academy of Pediatrics (AAP), and some members of Congress have also formally addressed similar concerns directly to the CMS.
The Big Problem
In their letter to the CMS, officials wrote that the issue with treating Medicare patients in hospitals and similar clinical settings was due to existing billing codes hospitals use for dental patients requiring an operating room. Currently, Medicare only provides $203.64 for these procedures, significantly less than the average cost of $2,334.87. As a result, hospitals are reluctant to schedule Medicare dental surgeries, leaving patients without the care they desperately need.
Additionally, Medicare regulations do not provide coverage for dental surgeries at ambulatory surgery centers, which officials have stated would help increase patient access and alleviate pressure on hospital operating rooms.
This letter continues to explain how widespread this issue is, as Medicaid rates are modeled on Medicare rates, and private insurance often looks to Medicare to determine what is and isn’t covered.
Finally, Progress?
On August 31, the CMS responded to the growing call for action on this issue with a new rule proposal, allowing them to update the Medicare code used by hospitals in billing dental procedures performed in operating rooms. Under the new proposal, Medicare would provide payment for these procedures at an increased rate of $1,958.92. In addition, the CMS proposal would also make it easier for people to obtain and maintain coverage under Medicaid and the Children’s Health Insurance Program (CHIP).
As reported at disabilityscoop.com, the senior director of the Council on Advocacy for Access and Prevention at the ADA is quoted as stating that if the CMS proposal is approved, it “would take a significant first step forward toward improving access to needed dental surgeries for children and adults with disabilities.” In addition, she states that “the dental community is continuing to advocate for reforms that would help to ensure there is sufficient operating room capacity to support dental surgical access for disabled patients served by Medicare and Medicaid.”
The CMS estimates the newly proposed rule would increase coverage, reduce administrative costs, simplify and expand enrollment, and increase the timeliness of state-determined eligibility.
In Conclusion
By 2040, the number of people aged 65 and older will reach nearly 81 million in the United States. That means dental care and coverage are increasingly less likely to be seen as an exception but as a requirement. And given the overwhelming call to action from leading dental, medical, and advocacy organizations and the response by the CMS – are we now witnessing a shift? Hopefully. Given the ripple effect Medicare has on Medicaid and private insurance, millions of children, disabled, low-income, and retired patients stand to gain the most from this.
If finalized, the CMS proposal would take effect on January 1, 2023.
References:
- June 30, 2022, Meena Seshamani, MD, Ph.D. Deputy Administrator and .... https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/advocacy/220630_coaltionletter_meetingrequest_aapdadaaaomsjune30_d1008594.pdf?rev=409e49baea204a66b7071182001506b5&hash=B44D679739677C4A4A90F67B1F719A7F.
Author: With over 12 years as a published journalist, editor, and writer Genni Burkhart’s career has spanned politics, healthcare, law, business finance, technology, and news. She resides on the western shores of the idyllic Puget Sound where she works as the Editor in Chief for the Incisor at DOCS Education out of Seattle, WA.
