Medical-Dental Integration in Medicare: Where are We Now?

ABSTRACT

Medicare provides comprehensive medical coverage for nearly all U.S. adults over age 65 and those with disabilities, with far-reaching improvements in health care access and equity for those it serves. Despite recent political action, the dental coverage gap persists. Considering data through 2023, this review examines the status of oral health provisions through traditional Medicare and Medicare Advantage and the logistics of expanded dental benefits in Medicare. The mechanism of dental coverage as well as the generosity of this benefit have important implications for oral health equity among older adults.

KEYWORDS:

• Medicare
• health policy
• dental insurance
• health equity
• oral health

Since its passage in 1965, the Medicare program has provided near-universal medical coverage for older adults and individuals with disabilities. In 2021, almost 64 million Americans were enrolled in Medicare,¹ and this group is only expected to grow as the population ages.

Reaching Medicare eligibility at age 65 results in a greater than 30% decrease in out-of-pocket health care costs and lower patient-reported rates of being unable to afford care.^2,3

Despite demonstrable benefits to health and health equity, the Medicare program has important coverage gaps: Dental, hearing, and vision benefits are not covered by traditional Medicare plans. As a result, these forms of care represent a substantial expense for beneficiaries. In 2016, only half of Medicare beneficiaries visited a dentist. Those who did spent more than $1,000 out of pocket on dental care, and reaching the age of Medicare eligibility from 2010 through 2019 was associated with a 4.8% point increase in complete edentulism.^4,5

In 2021, Medicare appeared poised to legislate a dental benefit through the Build Back Better Act, with robust support from stakeholders including older adults, patient advocacy groups, and a rising number of health care organizations. While this comprehensive change ultimately fizzled, increasing public awareness of this important omission in Medicare coverage and ever-increasing efforts by advocacy groups and politicians to continue to pursue a Medicare dental benefit have made the prospect more realistic than ever before.

This article will explore recent changes to traditional Medicare that impact dental coverage, review dental benefits through Medicare Advantage, and discuss structural considerations of a comprehensive Medicare dental benefit.

For reference, the current structure of the Medicare program, divided into Parts A, B, C, and D, is displayed in Table 1.

Table 1. Function of Medicare Parts A, B, C, and D.

Medicare Part	Coverage and limitations
Part A	Inpatient medical care and some rehabilitation services; usually premium-free
Part B	All outpatient clinical visits; requires additional premium
Part C (Medicare Advantage)	Private plans that include all services covered under Parts A, B, and D and may include additional benefits, such as dental care; requires additional premium
Part D	Prescription drug coverage; requires additional premium

Traditional Medicare and the 2023 Medicare Physician Fee Schedule Final Rule

Historically, dental coverage has been nearly absent from the traditional Medicare program (Parts A and B). Until 2023, dental procedures could only be covered under Medicare Part A if patients are admitted to the hospital and receive dental care considered necessary for medical reasons. From June 2018 to December 2019, only 186 patients received covered dental services under these circumstances.⁶ Also covered under Medicare Part A was admission to the hospital due to severe dental disease, which affects an estimated 13,000 older adults each year, even though dental care to definitively treat these problems is not covered.⁷

2023 marked a promising advance in Medicare’s dental coverage. The Center for Medicare and Medicaid Services (CMS) released the 2023 Physician Fee Schedule (PFS) Final Rule that included reimbursing dental care that is “integral to treating a beneficiary’s medical condition”⁸ in both inpatient and outpatient settings. That includes oral examinations prior to organ transplantation, some cardiac surgeries, and treatment for head and neck cancer. It also encompasses ancillary services essential to these dental services, including radiographs and operating room use.

Although this change will impact relatively few beneficiaries, it will require Medicare to develop reimbursement procedures for dental care – and will situate them definitively in Medicare Parts A and B.”⁹ Importantly, payment for oral health services within Medicare Parts A and B can only occur with medical-dental integration, when dentists and physicians are coordinating care.

Finally, this rule establishes a promising precedent for considering future coverage of oral health services when they are “inextricably linked and substantially related and integral to the clinical success of other covered medical services,” including immunosuppressant therapies and management of diabetes. Even though advocates for oral health equity argue that the 2023 final rule took an overly narrow interpretation of medically necessary dental care, this represents progress toward greater accessibility to essential oral health care through Medicare.⁹

Medicare Advantage

Medicare Advantage plans (MA; also known as Medicare Part C) are private plans that replace the traditional coverage provided by Medicare Parts A, B, and D. Many MA plans offer additional benefits beyond those provided by traditional Medicare, including dental care. MA enrollment has been increasing in popularity, with 46.5% of Medicare beneficiaries opting into an MA plan and rates of MA enrollment expected to exceed 50% of beneficiaries this year.¹⁰

Recent estimates suggest that up to 94% of MA plans provide some dental coverage, representing a substantial mechanism through which older adults may obtain dental insurance.¹¹ Inclusion of dental benefits may incentivize patients to sign up for these plans. However, these benefits have no minimum requirements and no standardization regarding the scope of covered procedures, so coverage varies widely.

It is also important to note that MA beneficiaries spend near-equal out-of-pocket amounts on dental care as older adults with traditional Medicare, and rates of annual dental visits are similarly low for both groups.⁴ Clearly, even though substantially more MA beneficiaries may have dental coverage compared to those in traditional Medicare, all Medicare beneficiaries struggle to achieve dental access. This indicates that the current system of varied dental benefits through MA is not adequate to translate to dental utilization and coverage of services.

MA plans are required to include all services otherwise covered by Medicare Parts A, B, and D in addition to any ancillary services offered. By including dental benefits within Medicare Part B, as the 2023 physician fee schedule does, and similar to how it includes a robust range of outpatient services, CMS has begun the process of establishing requirements for a minimum level of dental benefits provided through both traditional Medicare and MA. Beginning to cover some dental care under Part B could be especially impactful, because it will affect the benefits of both traditional Medicare beneficiaries and the ever-increasing proportion of MA enrollees.

Designing a Comprehensive Medicare Dental Benefit

The 2023 PFS paves the way for the implementation of a more robust set of dental benefits. Yet as discussions of Medicare dental benefits evolve, legislators will need to develop a comprehensive model of how the benefit will be delivered, including eligibility criteria, payment and fee schedules, and consideration of insurance models, which we discuss below. Common terms used in discussions of Medicare dental benefits are defined in Table 2.

Table 2. Common terminology and definitions in discussions about Medicare dental benefits.

Accountable Care Organization	An insurance model in which health systems are provided with risk-adjusted payments to keep individual patients healthy, rather than being paid for each episode of care. Often utilizes validated quality metrics to ensure high-quality care is being provided to patients.
Dual eligibility	Individuals who qualify for both Medicare (due to age or disability) and Medicaid (due to income eligibility).
Fee-for-service	An insurance model in which providers or health systems are paid separately for each service they provide. Incentivizes over-treatment and undervalues preventive services, which are generally lower-cost.
Means Testing	Restricting services or benefits to individuals who meet specific income or wealth benchmarks.
Part D “donut hole”	A gap in Medicare Part D prescription drug coverage, which required Medicare beneficiaries to pay 100% of drug costs when their medication costs exceeded a certain threshold but did not yet reach an even higher limit. This “donut hole” was closed as part of the Affordable Care Act.

Eligibility Criteria

Previous discussions examined the idea of incorporating means testing (i.e., setting an income limit for eligibility) in the inclusion of a dental benefit. At first glance, including only low-income adults may not be counter-intuitive; low-income older adults are most likely to be missing teeth and have unmet oral health needs.¹² Yet they are already more likely to have a dental benefit through Medicaid (the dual-eligible population). In addition, this policy would exclude almost 40% of beneficiaries from the Medicare dental benefit, 25% of whom did not visit a dentist in the past year. It is clear that even at higher income levels, older adults still struggle to afford and access dental care and would stand to greatly benefit from coverage through Medicare.¹³

It is also important to note that the Medicare program overall is available to all who qualify, regardless of wealth or income. The large, heterogeneous population of Medicare beneficiaries has allowed Medicare to continue to innovate, expand, and exert an important influence in health care policy since 1965 – much of which has almost certainly contributed to the improvements in health care access, life expectancy, and health equity in older adult populations.¹⁴ While higher-income older adults do pay higher premiums for their care through Medicare, the services all Medicare beneficiaries are eligible to receive are the same, which would render dentistry an extreme outlier if a means-tested benefit were to come to pass.

Payment and Fee Schedules

Under Medicare law, enrolled dentists are included as physicians. Currently, Medicare payments to dentists are determined by the physician fee schedule. However, it is important to know that a variety of fee-setting schedules are included for a wide range of outpatient services, which “can accommodate a distinct and separate process for dentistry that sets adequate reimbursement levels and includes dentists’ input.”¹⁵ All outpatient services are funded through a resource-based relative value scale.

To develop a fee schedule with reimbursement levels acceptable to most dentists – which will be critical to enroll a critical mass of oral health providers in Medicare – it is necessary to incorporate dentists in this process.¹³ At the core of the current physician fee schedule is a system of relative value units (RVUs) assigned to each service. These encompass factors including the provider’s work values, practice expenses, geographic location, and the overall health system. Publications such as the American Dental Association (ADA) Survey of Dental Fees provide a reference point for determining a dental fee schedule.¹⁶

Fee-For-Service (FFS) Vs. Accountable Care Organizations (ACOs)

Medical and dental insurance have been structured differently since their inception in the early 20th century.¹⁷ Unlike most medical insurance, dental insurance traditionally covers a decreasing share of more expensive procedures (e.g., root canals or implants) while covering a larger share of low-cost procedures such as prophylaxis. This fee-for-service structure, in which individual procedures are reimbursed, persists even in most publicly funded dental insurance systems.

The fee-for-service model results in a misalignment of incentives between patients and providers. Dental clinicians receive the most reimbursement when patients have the most severe oral disease, and preventing dental disease, while better for patients, results in lower pay for clinicians. This conflict has led medical insurers to move away from fee-for-service and toward innovative models such as bundled payments and accountable care organizations (ACOs).

In ACOs, health systems are provided with risk-adjusted payments for whole-person care, rather than payments for individual episodes of care. The ACO system incentivizes innovations in care delivery to prioritize prevention and streamline care – yet the vast majority of ACOs do not include dental care. Under Medicare Parts A and B, 11 million Medicare beneficiaries are cared for in an ACO model.¹⁸ Within an ACO, dental care could be covered in one of two ways. In the first, dental payments would continue to be fee-for-service as a “carve out” from the amount used to care for patients. Many systems that embed dental care within ACOs currently use this model.¹⁹

In the second, more compelling way, dentistry itself could be a part of the shared savings model. In a truly value-based system, dentists would receive flexible funding that they could use for innovations that improve both patient care and provider satisfaction. Some possibilities include 1) increasing recall frequency for higher-risk patients, 2) communicating with patients via phone or patient portal, and 3) coordinating with medical specialists.²⁰

Additional Considerations

Besides these components, other policy considerations must address implications of a comprehensive Medicare dental benefit on patients, providers, and the health care system. Relevant decisions include the determined scope of covered benefits, calculation of premiums and cost sharing, and logistics of provider participation (e.g., administrative requirements and electronic health record interoperability). Systems-level deliberations include the development of dental quality metrics as well as both anticipated and unintended spillover effects on other insurance payers and programs.

A Collective Call to Action

From a health care perspective, Oral Health in America: Advances and Challenges, the 2021 report released by the National Institute of Dental and Craniofacial Research (NIDCR) as a 20-year follow-up to the landmark Surgeon General’s report, repeatedly comments on the lack of dental care within Medicare as a major barrier for health care access among older adults.²¹ Dental advocacy groups including the American Dental Education Association, National Dental Association, and the CareQuest Foundation for Oral Health also support a universal Medicare dental benefit.^22–24

While the ADA did not unequivocally support President Joe Biden’s proposed Medicare legislation, it is important to acknowledge that the ADA’s proposed Medicare dental benefit represents a seismic shift. While the model advocated for by the ADA would restrict care for many older adults and reduce opportunities to align with the health care system, it nonetheless represented a path forward for dentistry’s integration into Medicare from an organization that had opposed such a role for more than 60 years.

For the first time, the American Medical Association (AMA) is currently debating a resolution that would call for a dental benefit within Medicare Part B.²⁵ The experience of the medical profession may also serve as encouragement for those in the oral health community who are more hesitant at the prospect of a Medicare dental benefit. In 1961, the AMA referred to the yet-unpassed Medicare proposal as “the most deadly challenge ever faced by the medical profession.”²⁶ Yet in a survey of physicians’ attitudes shortly before and after the passage of Medicare, support for Medicare increased from 38% prior to passage to 81% in 1968.²⁷ It may be that time, along with policy innovation, results in increasing acceptance of Medicare as a payer in the oral health landscape.

In addition to support from health care organizations and consumer advocacy groups, and perhaps most importantly, patients themselves heavily supported a Medicare dental benefit. In one survey, 94% of Medicare enrollees surveyed supported a Medicare dental benefit.²²

While many political uncertainties remain in passing such landmark legislation, the eventual implementation of a comprehensive Medicare dental benefit seems more likely than at any other point in Medicare’s history. The design of such a benefit will have a meaningful and lasting impact on whether older adults are truly able to achieve oral health equity and whether dentists and other oral health professionals become a part of the health care system.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

Lisa Simon

Lisa Simon MD, DMD is a physician, dentist, and health services researcher. She has been involved in the implementation of medical-dental integration projects in both the primary care, dental, and inpatient setting and has published more than 60 peer-reviewed articles on oral health policy and the separation of medicine and dentistry. She is a faculty member in the Division of General Internal Medicine and Primary Care at Brigham and Women’s Hospital, Harvard Medical School, and the Harvard School of Dental Medicine.

Elizabeth Alpert

Elizabeth Alpert, DDS, MPH is a Lecturer on Oral Health Policy and Epidemiology, Part time, at the Harvard School of Dental Medicine. Dr. Alpert completed a General Practice Residency at the University of Washington, with her first year focused on Hospital Dentistry and second year on Special Care Dentistry. She also completed a year-long fellowship in Leadership Education in Neurodevelopmental and Related Disabilities and graduated with a Master of Public Health degree in Health Policy from the Harvard T.H. Chan School of Public Health. Her research focuses on oral health equity and medical-dental integration.