Update Oct. 28: Medicare dental benefit unlikely
A Congressional spending deal nears, and a Medicare dental benefit is not likely to be included in the final legislation. Read the latest from CDA.
Sept. 20: A significant amount of activity is underway in the U.S. Congress focused on adding dental, vision and hearing benefits to the Medicare program, and the proposals are moving quickly. This communication from CDA supplements what the ADA, media and other sources have shared to give members background and context for the current activity and clarify some common misunderstandings, including:
- What is happening in Congress?
- What is still to be determined?
- What are common misunderstandings?
- What are stakeholder groups saying and doing?
- What is CDA doing?
- Reference Information: How Medicare works now and dental benefits in Medicare
What is happening in Congress?
Both the U.S. House of Representatives and the U.S. Senate in August adopted a $3.5 trillion budget resolution, upon which a reconciliation package called the Build Back Better Act is being developed for a Congressional vote this fall.
This legislation intends to make significant new investments in the social safety net, including health care. The bill may be passed with a simple majority vote in the House and Senate and therefore could pass with only support from Democrats. Negotiations are in progress among progressive and moderate Democrats and the White House over the sources of funding, the overall spending level and various bill provisions.
The addition of supplemental benefits (dental, vision, hearing) in Part B of the Medicare program is one of the high-profile items in the package. (See end of the article for a description of the current Medicare program parts).
What is still to be determined?
The congressional discussions are centered around the following key issues:
- Benefit design (covered services) – While most stakeholders consider a comprehensive dental benefit ideal, managing the overall cost requires discussion about what services should be covered if resources are limited. The design questions are primarily whether the benefit should be narrow (such as coverage only for prevention services) or more comprehensive. The current House version provides for a comprehensive benefit with a high share of cost coverage initially that decreases over time as Medicare picks up more of the costs. However, it is possible that the final benefit included in the package will only include limited services or may be limited at the start and increase in more covered services over time.
- Provider participation and reimbursement – The legislation is not expected to explicitly address a specific provider reimbursement fee schedule and claims billing details. However, it will likely establish a broad framework for reimbursement methodology based on a “fee for service” approach consistent with Medicare Part B. Congress will need to establish a rate methodology that will attract participating dentists and ensure patients have access to a dentist of their choice. Key to this discussion is whether dental reimbursements are embedded in, or separate from, the physician fee schedule and how they address the unique costs of dental services. In the House version of the bill, the dental fee schedule is separate from the physician fee schedule, although few other details are currently included.
- Timing – Due to cost consideration, there is much discussion regarding when the benefit starts and whether covered services will be phased in over time. Currently, the debate is whether the benefits will start in 2025 or 2028 and whether any interim benefits will be offered before then.
- Administrative issues – While discussion about administrative issues is minimal compared to the prior three topics, the final bill will likely provide the secretary of health and human services the authority to set rules for the use of electronic health records for patient information and billing.
Given the complexity of negotiations between the House and Senate, it is unclear when the final bill package will become public — possibly within the next few weeks or, if negotiations stall, as late as November.
What are common misunderstandings?
The lack of final and printed legislative details, especially those likely to change based on stakeholder input and the size of the final package, may be contributing to confusion, concern or, in some cases, misinformation. Some of the questions raised include:
- Provider reimbursements: Some stakeholders have expressed concerns that reimbursements will be inadequate or will be set and controlled by physicians, and that the rules in the Part B physician fee schedule will apply to dentistry unless the benefit is established in a new and separate part. This is not necessarily the case. Part B already includes different fee-setting schedules for a range of outpatient services and can accommodate a distinct and separate process for dentistry that sets adequate reimbursement levels and includes dentists’ input. Congress and policymakers are aware that adequate levels of reimbursement will be needed for a large proportion of dentists to accept Medicare.
- Medicare versus Medi-Cal: There appears to be a widespread misconception that Medicare is akin to Medicaid (Medi-Cal in California). While California has addressed many of the historic program challenges, Medicaid is often associated with low reimbursements, missed patient appointments and other administrative elements that are difficult for dentists. However, the two programs are very different and serve different populations. Medicaid is a program for low-income individuals and is subject to state rules and state budget pressures. Medicare is a federally funded program that applies consistent rules across states and serves seniors and some special-needs populations. Medicare reimbursement rates are usually more akin to commercial rates than Medicaid, and Medicare provider participation is likewise much more equivalent to commercial plan network participation.
While none of the details are final, addressing any confusion now is critical so that if a benefit is adopted, dentists have accurate information and can make an informed decision about whether to enroll as a provider if the benefit has the potential to work in their practice. At the end of this article is a brief reference about how Medicare works today.
What are stakeholder groups saying and doing?
For several years, organized dentistry, patient advocacy organizations and other stakeholders have shared the concern that more than half of aging Americans have no dental coverage and suffer from high levels of untreated disease.
The health care community and public have a growing understanding of the links between chronic conditions, such as diabetes and cardiovascular disease, and untreated dental disease. Also, studies show cost reductions and health improvements when dental care is regularly provided. For these and other reasons, a growing number of voices are advocating to ensure that Medicare provides for this essential care.
ADA proposal
ADA and many organizations within organized dentistry have submitted letters opposing adding a Medicare dental benefit to Part B. Referencing a 2020 ADA policy, which states that benefits should cover seniors with incomes under 300% federal poverty level, ADA’s proposal seeks to limit eligibility to only those low-income seniors. This type of income limitation is similar to how Medicaid works today. However, no other benefit in Medicare is “means tested,” or limited to certain individuals because of their income status. The only component of Medicare that changes due to income is Part B premiums, with some higher-income Medicare recipients pay higher premiums while lower-income Medicare recipients are protected.
ADA’s legislative proposal suggests separating dental benefits from the other outpatient health services seniors receive in Part B by creating a new Medicare “Part T.” However, many of the principles from ADA’s 2020 policy may be achievable in a Part B framework, particularly if income is considered as a cost share consideration rather than an eligibility limitation, consistent with how Medicare works now.
Health insurance companies, dental benefit plans
Health insurance companies and dental benefit plans are also opposing the benefit, arguing that dental coverage available through Medicare Advantage plans is sufficient. In Medicare Advantage, recipients choose to receive services via a managed health care plan rather than through the traditional Medicare fee-for-service network. These plans currently serve about 45% of Medicare beneficiaries in California and about 39% nationally.
The health plans have a vested interest in keeping dental benefits out of Part B, as Medicare Advantage plans currently offer dental benefits on a voluntary basis, which attracts patients to their plans. Current Medicare Advantage plans’ dental benefits are widely variable with some offering extensive benefits and some offering minimal. These plans are not currently required to offer a certain level of benefits.
Consumer advocacy organizations
The addition of a dental benefit is highly popular among seniors and advocacy organizations, including AARP, Families USA, Center for Medicare Advocacy, Justice in Aging, and the American Heart Association, and they are pushing strongly for a robust dental benefit in Medicare Part B.
These groups support several elements that are contained in the legislative framework under consideration. AARP’s letter supporting a Part B dental benefit states that Medicare Advantage dental coverage is “inconsistent, and not nearly robust enough,” adding that, “Medicare should cover the entire person — from head to toe … People want these services and are often surprised when they learn Medicare does not cover them.”
What is CDA doing?
CDA has been closely monitoring this issue and preparing for this legislation to come to fruition for some time.
The CDA House of Delegates in 2019 received a report from the CDA Medicare Task Force, appointed specifically to examine this issue and the impact of adding a dental benefit to Medicare for patients and dentists. Their work seeks to understand where the pressures to add dental benefits are coming from and how support for it has grown over the years with consumers, advocates and legislators alike. Also important to this work was understanding that providers have different opinions about whether this benefit would provide opportunities to their respective practices and patients.
Regardless of individual perspectives on the pros and cons to dental practices, the consensus among CDA Task Force members and CDA leadership was that it is essential for organized dentistry to be directly engaged in discussions to ensure dentists’ expertise is considered and can influence the benefit’s development and implementation. Also, CDA members voiced that the actions of organized dentistry should be consistent with its mission and role as the expert on oral health, and that organized dentistry be responsive to the growing and often vulnerable portion of aging Americans.
CDA convenes Medicare workgroup
Earlier this year, when news of Congressional interest in adding the dental benefit became clear, CDA convened a Medicare Workgroup, chaired by CDA Immediate Past President Dr. Richard Nagy, to further examine and monitor the issue and to be prepared to react when the issue became active in Congress.
The workgroup has met multiple times to discuss the legislative dynamics and the key elements of a dental benefit, taking into account that a benefit will very likely come together and be added to Part B. The workgroup has contributed invaluable expertise for the purpose of CDA providing information to lawmakers about what dentists and patients think is important.
The workgroup has contributed and discussed key points of input, including:
- Identifying the oral health needs of older adults and benefits that meet their needs.
- Identifying the need for a rate-setting process/methodology that is separate from the physician fee schedule and includes dentists’ perspective and needs.
- How to identify adequate reimbursement levels (defined as those that most dentists would accept as fair and reasonable) to ensure dentists who want to participate are able to.
- A logical approach to increasing the number (or level) of services if the benefit is phased in over time.
- Reasonable provider administrative requirements and removing barriers to dentists’ participation as much as possible, e.g., simple claims, easy enrollment, realistic electronic record requirements and incentives, etc.
CDA leadership believes members must have access to full and complete information about the Medicare program and current congressional activity regarding a Medicare Part B dental benefit.
While current unknowns can cause concern, there is also the potential for great opportunities for dentists and patients if America’s senior population were to gain dental benefits with their Medicare coverage.
Being responsive to the growing and often vulnerable portion of aging Americans is one goal. In addition, if dentistry and others successfully help to construct a quality benefit with adequate reimbursement and simple claims and participation rules, the result could potentially be a positive development for dental practices. Early work conducted by ADA’s Health Policy Institute indicated that a Medicare dental benefit could be favorable for dental practices and that it has wide support among dentists.
CDA will continue to update members as more information becomes available and will develop information sessions and support for members if the legislation is successful.
Reference Information: How Medicare works now and dental benefits in Medicare
Unlike Medicaid, which is largely determined by state legislators and state funding streams, Medicare is primarily funded by federal dollars and is available to all seniors.
Medicare benefits help pay for health care costs for people ages 65 and older as well as people of all ages with disabilities or end-stage renal disease. As of 2020, over 61 million people in the United States were enrolled in Medicare, 6.4 million of them in California.
Medicare is composed of multiple parts and has changed and grown since it was created in 1965.
- Part A helps cover inpatient hospital care and stays in skilled nursing facilities, some hospice and home health care. Most people receive Part A for free.
- Part B helps cover the costs for outpatient care, including some preventive services and tests, physician’s services, durable medical equipment, clinical laboratory services, and more. Medicare beneficiaries pay a Part B premium to the Social Security Administration, and though Part B services are the same for all beneficiaries regardless of income, low-income beneficiaries that qualify for Medicaid receive subsidies for Part B at no extra cost ($0 premium). For most services, Medicare pays 80% of the cost (using an established fee schedule) and patients have a 20% co-pay.
- Part C allows Medicare recipients to select to receive their Part A and Part B covered services via a managed health care plan (known as Medicare Advantage) rather than accessing them through the traditional fee-for-service network of participating providers.
- Medicare Advantage plans must provide at a minimum the same benefits provided under Medicare, but they can provide additional coverage as noted above for additional fees. The plans may charge beneficiaries an additional premium fee to manage all their care and establish a different co-pay arrangement with patients. They may also offer extra coverage above what is required under Parts A and B. Many do that now and may include prescription drug coverage plus dental, vision, hearing and wellness programs.
- The annual dental benefit in Medicare Advantage plans is often capped, and each of the plans determines what benefits it will cover and sets its own rates.
- Part D, instituted in 2006, provides prescription drug coverage. Part D is offered by plans that manage the drug formulary and enrollees’ cost sharing like premiums and deductibles.
Dental benefit in Medicare
Current Medicare law specifically “excludes” the provision of dental care except in a limited and defined set of circumstances where treatment of conditions within the oral cavity is necessary for another Medicare covered treatment service to proceed.
CDA thanks the members serving on the Medicare Workgroup for providing expertise and monitoring this work:
Dr. Richard Nagy, CDA Immediate Past President (Chair)
Dr. Wade Banner, Practicing dentist in Los Angeles County
Dr. John Blake, CDA Vice President
Dr. Elisa Chavez, Professor, University of the Pacific, Arthur A. Dugoni School of Dentistry
Dr. Viren Patel, CDA Trustee
Dr. Stephanie Sandretti, CDA Government Affairs Council Chair
Dr. Ariane Terlet, CDA President-Elect
Dr. Julia Townsend, CDA Trustee