America's Benefit Specialist November 2022

MEDICARE MATTERS

AFTER CONGRESS FAILS TO ADD DENTAL COVERAGE, MEDICARE WEIGHS LIMITED BENEFIT EXPANSION

tion anywhere in the body, it can become rampant when you suppress the immune system,” she said. CMS is considering extending coverage to dental services that are “inextricably linked” to the success of other covered med ical procedures, Dr. Meena Seshamani, a CMS deputy administrator and the di rector of the Center for Medicare, said in a statement. If the proposal is finalized, Medi care Advantage plans would be required to expand coverage as well, she said. And Medicare supplemental or Medigap policies would have to pay for the patient’s share of the cost. Officials say the potential changes come after receiving criticism that the current definition of medically necessary dental care is too “restrictive, which may contribute to inequitable distribution of dental services

care won’t cover the eradication of a dental infection so that the transplant can proceed. Or, if a patient with breast cancer has an infected tooth, Medicare will cover chemo therapy and radiation, but not the tooth extraction needed before that treatment can be provided. CMS hinted at what dental services might be covered by asking for comments on whether additional organ transplants and cardiac valve replacement or repairs should be eligible for related dental exams and treatment. It also asked for examples of “other types of clinical scenarios” in which dental services would be “substantially related and integral to the clinical success” of other covered medical treatments. If CMS receives sufficient medical evidence, officials said, dental services could be covered to detect and eradicate infections before total hip or knee-replace ment surgeries. One possibility CMS pointedly does not mention is dental care for diabetes patients, said Dr. Judith A. Jones, an adjunct professor at the University of Detroit Mercy School of Dentistry. Medicare pays for insu lin and other diabetic care supplies but not related dental care. “The data are really quite clear if you improve periodontal disease, for example, blood sugar control is improved,” she said. More than a quarter of people 65 and older had diabetes—or an estimated 16 million—in 2019, according to the Centers for Disease Control and Prevention. CMS is also contemplating the creation of a system to review requests for additional kinds of dental treatment needed to im prove the outcome of other covered medical care. The proposed changes would be par ticularly important for patients undergoing treatments that weaken the immune system, giving any dental infections the opportunity to spread, Jones said. “If you have infec

By Susan Jaffe Proposed changes in Medicare rules could soon pave the way for a significant expan sion in Medicare-covered dental services, while falling short of the comprehensive benefits that many Democratic lawmak ers have advocated. That’s because, under current law, Medicare can pay for limited dental care only if it is medically necessary to safely treat another covered medical condition. In July, officials proposed adding conditions that qualify and sought public comment. Any changes could be announced this month and take effect as soon as January. The review by CMS follows an unsuc cessful effort by Congressional Democrats to pass comprehensive Medicare dental coverage for all beneficiaries, a move that would require changes in federal law. Sena tor Bernie Sanders (I-VT) sought in vain to add that to the Democrats’ last major piece of legislation, the Inflation Reduction Act, which passed in August. As defeat appeared imminent, consumer and seniors’ advocacy groups along with dozens of lawmakers urged CMS to take independent action. Dr. Biana Roykh, senior associate dean for clinical affairs at Columbia University’s College of Dental Medicine, called the CMS proposal “a step in the right direction” but she cautioned that it doesn’t yet address the full extent of dental needs among seniors. “We’re not solving the problems upstream” by tackling the causes of dental decay, in cluding a lack of routine care, she said. Among the dental procedures Medicare already covers are wiring teeth to repair a fractured jaw, a dental exam before a kidney transplant, and extraction of infected teeth before radiation treatment for certain neck and head cancers. But if a patient needs another kind of organ transplant, Medi

OLDER ADULTS HAVE THE HIGHEST OUT-OF-POCKET DENTAL COSTS.

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