In November 2022, the Centers for Medicare and Medicaid Services (CMS) announced that Medicare coverage will be expanded to include medically necessary dental services. This change in Medicare rules will allow people with life-threatening conditions to receive dental care and operations related to conditions approved by CMS.
The provisions in the final rule become effective on January 1, 2023.
What makes dental care ‘medically necessary’?
The final rule expanded the definition of “medically necessary.” Medicaid currently defines “medically necessary” as “health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.”
When it goes into effect, the final rule will include dental care in the definition of medically necessary care.
The final rule also expanded the definition of “physician” to include dentists and oral surgeons.
What dental care is included in the final rule?
The types of dental care and procedures covered will be limited to patients who:
- Have a jaw fracture and need their teeth stabilized or immobilized.
- Need a tumor surgically removed, and ridge reconstruction must be performed to remove the tumor.
- Have a neoplastic disease, and teeth extraction is necessary to prepare the jaw for radiation.
- Have certain heart diseases and need to receive examinations and treatment before receiving cardiac valve replacement, organ transplant procedures, or valvuloplasty.
- Need dental splints (only if they get this treatment in connection with a medically necessary treatment).
In addition to the above services, Medicare coverage will be applied to other necessary medical care, including:
- The use of an operating room to perform dental services
Expanded dental coverage does not apply to patients with diabetes
Neither the final rule nor the interim rule expanded dental coverage for diabetes patients. The final rule does not cover normal dental examinations for diabetic patients, despite the importance of regular dental checkups for this population. However, coverage could expand over the next several years.
The effect of having dental coverage on Medicare recipients
The expansion of Medicare dental coverage will have a positive impact on some seniors, while others will not receive any benefit. Because of the language included in the final rule, some seniors will receive savings for dental care if dental work is required to treat qualifying medical conditions. Seniors who do not qualify for the expanded dental care coverage in the final rule are still required to pay a fee for services not covered by Medicare.
Patients with diabetes can expect to continue to pay for dental examinations and surgeries out-of-pocket if Medicare does not cover the procedure.
The future of expanded coverage for Medicare recipients
Seniors enrolled in Medicare can expect more changes to coverage in the future. CMS announced its intention to complete an annual review of covered services, as well as possibly expand the definition of “medically necessary” and include more services for dental care.
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