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CDA supports proposed federal rule to expand Medicare coverage of dental services tied to medically necessary conditions

CDA submits detailed recommendations to CMS on proposed coverage and fees to make the coverage meaningful for dentists and their patients

September 15, 2022 3384

Quick Summary:

CDA’s Medicare Workgroup has been meeting since July to guide CDA’s response to CMS’s request for feedback on the Medicare expansion proposal and submitted comments last week with specific recommendations on coverage of services and how to make any expansion of dental services feasible and functional for dentists and patients. The rule will likely be finalized in November and implemented in 2023.

CDA is committed to addressing the oral health needs of seniors and submitted comment to CMS on a proposal to expand medically necessary dental services. 

The Center for Medicare & Medicaid Services in July issued a Notice of Proposed Rule Making to cover medically necessary dental services as part of the existing medical services benefit in Medicare. This proposed rule is a public statement of the agency’s interest in making an important policy change, and the comment period allows stakeholders to weigh in on proposal, including details of the implementation.

CDA’s Medicare Workgroup has been meeting since July to guide CDA’s response to CMS’s request for feedback on the proposal and submitted comments last week with specific recommendations on coverage of services and how to make any expansion of dental services feasible and functional for dentists and patients. The rule will likely be finalized in November and implemented in 2023.

Proposed rule ‘opens many possibilities for providers and patients’

According to the federal Medicare definition, “Medically necessary dental services” means dental care that is necessary for, and integral to, a covered medical service or procedure. Hundreds of organizations, including CDA, have pursued an expansion of these services for many years. Through this proposed rule, the Biden administration has taken a significant step in expanding coverage for dental services by moving forward with this proposed expansion of medically necessary care. 

The Biden administration’s proposed rule opens many possibilities for providers and patients alike. by allowing additional dental services to be covered when they are linked to a specific medical service or procedure. For a dental service to meet this test, it must be inextricably linked to, and substantially related and integral to the clinical success of, a covered medical service.

In this way, the CMS’s proposed policy is not the same comprehensive dental benefit supported by the Biden administration and congressional Democrats during previous negotiations on a stimulus package. The benefit debated by Congress last year, as reported by CDA, would have covered a specified set of dental services for all Medicare beneficiaries.

“CDA is pleased that CMS’s proposal is going in this direction because we strongly believe that the expanded coverage will significantly improve patient care and outcomes for Medicare patients,” said CDA past president Richard Nagy, DDS, chair of CDA Medicare Workgroup. “The proposed expanded coverage is especially important for underserved populations that face higher rates of the chronic health conditions and medical challenges discussed in the proposed rule.”

CDA’s coverage recommendations to CMS

The CDA Medicare Workgroup has primarily focused on reviewing evidence of the clinical procedures that meet the legal definition laid out by CMS and has been working with legal counsel to understand what is legally viable to ensure that CDA’s comments on the CMS proposal are as relevant and useful as possible. The detailed comments were drafted by CDA and its legal team to provide specific recommendations that are based on legal and policy standards for CMS rule-making.

The workgroup’s recommendations for coverage include: 

  • Support for CMS’s proposal to cover dental exams as part of the workup prior to renal organ transplant, reconstruction of a dental ridge connected to removal of a tumor, wiring of teeth connected to a jaw fracture, extraction of teeth to prepare jaw for radiation and dental splits. 
  • Suggestions for CMS to cover dental exams and treatment of infection prior to and following organ transplant, cardiac valve replacement or surgery, treatment for head and neck cancers and joint replacement, as well as for patients with diabetes or who are undergoing bisphosphonate or immunosuppressive therapies.
  • Suggestions that CMS pursue demonstration (pilot) projects to explore coverage of dental services to reduce non-ventilator hospital-acquired pneumonia and for patients with Alzheimer’s disease, dementia and cardiovascular disease. 

CDA’s recommendations on coding and fees

Because the proposed rule indicates the intention of CMS to include expanded coverage of dental services for medically necessary procedures, CDA’s subsequent comments have focused on how to make any expansion of dental services feasible and functional for dentists and their patients by recommending: 

  • Paying dentists an appropriate rate based upon fair market billing rather than benchmarking at Medicaid or other public program rates.  
  • Allowing for appropriate regional variation in markets to be considered. 
  • Using CDT codes for billing, recognizing that CDT codes are the dental professions’ standard and will reduce barriers for dentists.
  • Proposing a specific approach to the fee structure that keeps dentists out of the physician fee schedule and the budget-neutral requirements that have held down Medicare physician fees over the last 20 years. 

“CDA’s proposed mechanism for setting appropriate and sufficiently high rates will be essential for engaging dentists and making the expanded benefits real for Medicare beneficiaries,” Dr. Nagy said.

Changes likely to take effect January 2023

CMS is expected to issue a final rule in early November with implementation of the changes starting in January. However, CDA expects that the Biden administration will continue to seek opportunities in future years regarding Medicare dental benefits, even if limited to medically necessary situations.

CDA will continue to engage with CMS and the many varied national stakeholders to ensure members are actively represented in any discussions around dental services in Medicare and make sure any changes to Medicare dental services are appropriate for dentists and their patients. 

Increasing the facility fee for dental anesthesia

The CDA Medicare workgroup and staff are engaged on two additional rule proposals and comment opportunities.

CMS has proposed a substantial increase in the facility fee for dental anesthesia after advocacy from the American Academy of Pediatric Dentistry, the American Association of Oral and Maxillofacial Surgeons and ADA. This increase is intended to address the significant challenges posed for access to care when dental care is needed in a hospital outpatient or ambulatory surgery center.

CDA submitted comments Sept. 13 in support of the facility fee increase. 

Lastly, CMS has asked for information about Medicare Advantage managed care plans, and CDA submitted a third comment letter on Aug. 31 highlighting ways to improve standardization and transparency in Medicare Advantage plans that offer an optional dental benefit. 

CDA will keep members informed about approval of any Medicare changes and their implementation dates and any implications for dentists and patients.