Researchers from the Coalition for Oral Health Policy in a recent article outlined strategies for expanding Medicare to include dental coverage, recommending a balanced, adaptable hybrid plan that leverages insights from current insurance models to improve access to dental care among older adults in the United States.

Efforts to add dental benefits to Medicare—currently limited to medically necessary dental procedures—gained traction after the Centers for Medicare and Medicaid Services (CMS) issued a 2022 ruling expanding coverage in certain cases. The CMS now conducts annual reviews to assess other scenarios where dental coverage may be warranted, potentially setting the stage for broader integration of oral health services within Medicare.

Medicare’s structure includes Parts A and B, which offer limited dental services tied to medical treatment, while Medicare Advantage (Part C) provides a bundled option that can include dental benefits. This has led to significant enrollment growth and expanded dental access for many older adults.

In an article, published in the Journal of the American Dental Association, the researchers recommend that any Medicare dental expansion meets five guiding principles: involvement from the American Dental Association; bipartisan legislative support; design alignment with existing oral health plans; insights from Medicaid’s dental framework, particularly in setting reimbursement rates that encourage dentist participation; and integration of successful cost-containment features from Medicare Advantage dental plans.

The article discussed three potential models:

• Plan B Variant: This option mirrors traditional medical insurance, covering 80% of dental costs with no cap, with enrollees paying the remaining 20%. While subsidies would support low-income enrollees, this model may face challenges such as high premiums and possible low dentist reimbursement rates.
• Preferred Provider Organization (PPO) Variant: Similar to private dental insurance, this model would involve co-pays and annual limits, with negotiated reimbursement rates. This approach aligns well with current practices, making it appealing to dentists and other stakeholders.
• Hybrid Model: This plan combines elements of the first two models, covering essential preventive and emergency procedures at 80% of usual and customary rates with a 20% co-pay, while elective services could be chosen at different coverage levels and premiums. This model seeks a middle ground between coverage and sustainability, with subsidies for low-income enrollees.

The researchers—who suggested that Medicare dental reimbursement rates be set above Medicaid levels but below the 80% typical in PPOs—acknowledged that the complexity of accommodating multiple coverage levels could strain administrative resources. Additionally, a dental plan without robust cost controls may struggle financially, requiring significant subsidies and creating risks of adverse selection—where healthier individuals opt out, skewing premium and reimbursement calculations. Medicare Advantage’s increasing popularity, which includes dental options, might overshadow the fee-for-service Medicare dental plans.

The researchers favored the hybrid approach, noting its broad appeal to political and clinical stakeholders. They argued that it meets their criteria for successful Medicare expansion of dental coverage.

Source: Dental Tribune