Expanding Medicare to Include Dental: A Path to Better Oral Health in Nursing Facilities – Justice in Aging

Introduction

This issue brief is the third in a series of papers that examine how to address barriers in access to care and oral health outcomes among certain groups of Medicare enrollees, including people of color, people with disabilities, and older adults with dementia and cognitive impairments. These briefs build on the issue brief, Creating an Oral Health Benefit in Medicare: A Statutory Analysis, where Justice in Aging provided an analysis of the statutory changes that would be needed to add an oral health benefit to Medicare Part B.

Medicare is the primary source of health coverage for most older adults and many younger individuals with disabilities. Yet, Original Medicare, also known as Traditional Medicare fee-for-service, explicitly excludes most dental services, leaving millions without comprehensive oral health coverage. In recent years, the Centers for Medicare & Medicaid Services (CMS) has issued regulatory changes that have clarified when Medicare will pay for certain medically necessary dental services, but Medicare coverage remains limited. While the majority of Medicare Advantage plans offer some dental coverage as supplemental benefits, the extent of coverage varies plan to plan. As a result, access to essential oral health treatment is out of reach for many Medicare enrollees – particularly nursing facility residents, who already face significant barriers to oral health care.

Nursing facility residents consistently experience poor oral health outcomes and limited access to dental services. This paper examines how adding a dental benefit to Medicare would reduce these disparities and address these challenges. The paper begins with a description of nursing facility residents enrolled in the Medicare program, followed by an overview of the disparities in access to oral health coverage, services, and outcomes residents face. Next, the paper examines how adding a dental benefit to Medicare would help improve access and outcomes and concludes with policy recommendations to address barriers beyond coverage that impede access to oral health care for residents.

Characteristics of Nursing Facility Residents

Approximately 1.2 million people live in nursing facilities across the United States. The majority—82%—are older adults aged 65 and over. Demographic data shows that the majority of nursing facility residents are white (73%), 16% are Black, and 6% are Hispanic or Latino. Long-term trends indicate a growing number of residents of color—especially in facilities that primarily rely on Medicaid.[6] Approximately 28% of nursing facility residents live in rural regions, and residents in those facilities are more likely to be age 65 and over.^[7]

Residents often have multiple chronic conditions and significant care needs.[8] Nearly half of all residents have been diagnosed with Alzheimer’s disease or another form of dementia. In addition, 46% have heart disease, more than one-third have diabetes, and 74% live with high blood pressure or hypertension.^[9] Research shows a strong, bidirectional link between oral health and overall health: oral disease can increase the risk of developing or worsening these chronic conditions, and these conditions can, in turn, negatively impact oral health.^[10] This connection highlights the urgent need for better oral health care in nursing facilities, as maintaining good oral health is vital for managing and preventing these serious health problems.

Disparities Impacting Oral Health Care for Nursing Facility Residents

Research has consistently documented the unique barriers nursing facility residents face in accessing oral health care.[15] These barriers can be understood through a multi-level framework: policy, organizational, and individual.

At the policy level, the most fundamental barrier is the lack of comprehensive oral health coverage in the primary insurance programs nursing facility residents rely on—Medicare and Medicaid. At the organizational level, facilities often lack the resources and training needed to support adequate oral health care. Many facilities also face logistical challenges, such as lack of a designated physical space to deliver clinical dental care, limited staff capacity to assist residents with oral hygiene or set up dental services, and a shortage of skilled geriatric oral health care professionals working in these settings. At the individual level, residents are more likely to experience physical frailty, functional limitations, or behavioral health issues that make both performing and accessing oral care more difficult.[16]

As a result of these barriers, nursing facility residents have reduced access to oral health care and experience poor oral health outcomes. While data directly comparing nursing facility residents with older adults residing in the community is limited, a pivotal California study conducted by the Center for Oral Health provides insight. Preliminary data from the Center’s current study found just over 30% of older adults residing in nursing facilities had untreated tooth decay compared to about 18% community-dwelling older adults. Similarly, about 27% of older adults residing in nursing facilities had lost all their teeth compared to about 11% of older adults in the community. The study also revealed that residents in rural nursing facilities were 13% more likely to have untreated tooth decay than their urban counterparts. ^[17]

Within nursing facilities, disparities also emerge by race, ethnicity, and health status. A recent study evaluating the oral health of Medicare enrollees in nursing facilities found that Black residents were 16% more likely to have no remaining natural teeth while American Indian or Alaskan Native residents were 34% more likely compared to white nursing facility residents.^[18] American Indian or Alaskan Native residents were 20% more likely to have cavities and broken teeth compared to white nursing facility residents. Again, residents in rural facilities experience worse oral health problems, with residents in rural facilities 70% more likely to experience multiple dental issues than residents in urban facilities.^[19]

Chronic conditions also compound risk of oral health disease. Residents with three or more chronic conditions face increased odds of experiencing numerous oral health issues—including broken or loosely fitting dentures, no natural teeth or tooth fragments, abnormal mouth tissue, pain, discomfort, or difficulty chewing—compared to residents without chronic conditions.^[20] Research on oral hygiene measures shows that nursing facility residents with dementia or Alzheimer’s disease presented with the lowest scores.^[21] Black older adult women face particular risk, with data showing they experience the highest prevalence of Alzheimer’s disease and related dementias.^[22]

With Black and Hispanic older adults facing higher rates of both oral health and chronic disease, and in light of research that shows that nursing facilities in neighborhoods with predominantly Black and Hispanic/Latino residents provide lower quality of care,^[23] the poor outcomes noted above are not surprising. To address these disparities and improve oral and health outcomes for all nursing facility residents, comprehensive reforms at every level—policy, organizational, and individual—are needed.

Adding a Medicare Oral Health Benefit to Address Disparities for Nursing Facility Residents

Adding an oral health benefit to Medicare Part B is an essential step to address long-standing disparities in oral health access among nursing facility residents. Currently, without Medicare coverage, nursing facility residents must rely on other sources of coverage or pay privately for dental care.

As noted previously, Medicaid is the primary payer of nursing facility care. Yet, oral health care coverage is not guaranteed. This is because adult dental coverage in Medicaid is optional under federal law for states to cover. As a result, Medicaid adult dental coverage varies considerably both across states and within states among different populations. As of 2022, eight states provide emergency coverage only, while 14 states provide limited coverage to adults.^[24] While half of states provide more extensive adult dental benefits, there is variability in terms of what services are covered.[25]

Medicaid reimbursement rates for dental services often do not account for the additional time needed for treatment or the added expenses of delivering services in a non-traditional setting rather than dental offices or other clinical spaces. Further, because these benefits are optional in Medicaid, states often turn to cutting dental benefits or eliminating benefits entirely during fiscal downturns—such as what states are facing today due to the significant cuts in federal Medicaid funding to states with the passage of the Budget Reconciliation Act of 2025 (H.R. 1).^[26]

Adding an oral health benefit in Part B would establish a standardized, nationwide benefit for all 67.6 million Medicare enrollees, regardless of whether they are enrolled in Original Medicare or Medicare Advantage (MA).^[27] Similar to other Part B covered services, oral health care and dental services would be based on medical necessity and not tied to disease-specific criteria or the requirement that services be inextricably linked to the success of another medical covered service, as is the case today. Importantly, as a result, nursing facility residents would have coverage of preventive and other medically necessary dental care irrespective of disease diagnosis, income, Medicaid status, or whether their state Medicaid program includes adult dental benefits.

A Part B dental benefit would also serve to expand the network of participating providers who could serve facility residents. Medicare reimbursement rates are generally higher than Medicaid’s, making it more feasible for dentists and other oral health professionals to serve nursing facility residents. By addressing cost barriers for providers, Medicare coverage would help ensure that residents can receive care in a timely manner. This would be particularly advantageous for facilities that serve high numbers of residents on Medicaid.^[28] Adding an oral health benefit to Medicare Part B would also minimize burden on facility staff, as it would simplify the process of accessing dental care. By establishing a standardized, nationwide benefit through Medicare, staff would spend less time managing access, billing, and coverage issues.

Ultimately, a Medicare benefit would increase access to oral health care and, as a result, reduce avoidable emergency department visits, hospitalizations, and complications related to poor oral health, improving the overall health outcomes for nursing facility residents.^[29]

Coverage is Essential, But More is Needed to Address Barriers to Oral Health Care in Nursing Facilities

Oral health coverage is the largest determinant of whether an individual can access oral health care. Therefore, expanding coverage is an essential step in ensuring access and reducing barriers to care for nursing facility residents, but it is not the only step. As noted previously other policy, organizational, and individual factors can impede access to oral health care. Below are additional recommendations that can help address these barriers:

Enhance Oversight and Accountability of Nursing Facilities

Under federal regulations, nursing facilities are required to evaluate oral health needs and provide access to care for residents. For example, nursing facilities are required to assess resident’s oral health needs upon admission and quarterly thereafter or when significant change occurs.^[30] Additionally, facilities are directly responsible for the oral health needs of their residents.^[31] This includes providing residents access to routine dental care, assistance with dental appointments, and arranging for transportation services to and from those appointments.^[32] For residents that require support to perform oral hygiene, facilities are required to provide services such as brushing of the teeth, cleaning dentures, and cleaning the mouth and tongue to maintain oral mucosa.^[33]

Despite these requirements, compliance is inconsistent. Oral health is often deprioritized due to staffing shortages, lack of training, limited resources, or competing demands. As a result, many residents’ basic oral health needs go unmet.^[34] Enhancing federal and state oversight and enforcement of these requirements would better ensure facilities meet their obligations. For example, at the federal level, surveyor guidance could be strengthened to ensure more consistent and effective monitoring of compliance during annual facility inspections. States could also require facilities train their staff on the provision of oral health and require an oral health professional to complete the oral health assessment portion of the Minimum Data Set, the screening tool that must be completed for every resident in Medicare and Medicaid facilities.^[35]

Bring Care to Nursing Facility Residents Where They Are

As was previously referenced, federal regulations require nursing facilities to make appointments and arrangements for transportation services to and from dental appointments when residents need assistance. Yet, available data shows limited capacity for nursing home staff to meet federal regulations.^[36] At the same time, nursing facilities often do not have dedicated space to provide dental care.

Strategies that help to bring oral health and dental services directly to nursing facility residents can serve to mitigate these barriers. Models such as tele-dentistry that use telecommunications technology to connect patients to dental providers remotely via a variety of different modalities including live video or by transferring health information via secure platforms has shown the potential to bridge the oral health equity gap for older adults and other special needs populations in long-term care.^[37]

Similarly, expansion of dental health teams trained to work in hard-to-reach communities and settings, including, for example, dental hygienists operating with expanded scopes of practice, Dental Therapists, Community Health Workers (CHWs), provides opportunities to effectively deliver quality oral health care to nursing facility residents. For example, research shows that dental hygienists operating with expanded scopes of practice have a positive impact in providing preventive care services and reducing the removal of teeth due to oral disease.^[38] In California, where Registered Dental Hygienists in Alternative Practice (RDHAPs) serve a majority of patients who are underserved including medically compromised and institutionalized populations, research shows improvement in access to preventive dental care services, case management, and referrals to dental providers.^[39]

Integrate Oral Health into Rural Health Care Delivery

Rural communities frequently experience poor oral health care access, utilization, and outcomes. Most rural areas are federally designated as Dental Health Professional Shortage Areas, with residents reporting higher rates of tooth loss, fewer dental visits, and longer travel to dental providers compared to urban and suburban populations.^[40] These barriers are even more acute in rural nursing facilities, where residents often present with untreated dental problems.^[41]

Medical dental integration (MDI) models can help to address workforce shortages and expand access in rural communities by incorporating oral health care as part of the health care delivery system. While MDI models can take various forms such as co-locating primary care and dental providers in the same site (e.g., community health clinics, Federally Qualified Health Center, etc.) or training primary care providers to deliver basic preventive dental services (e.g., screen for oral disease, conduct risk assessments and oral examinations, educate patients, apply fluoride, varnish, etc.), they promote a one-stop-shop approach, reducing the burden on individuals to seek oral health care separately from their medical care.^[42]

Research shows that MDI pilot programs have demonstrated improved oral health access and overall health outcomes.^[43] For rural nursing facility residents in isolated regions with limited access to public transportation services, a one-stop-shop MDI approach where residents receive preventive oral health care services via their primary care provider during their annual Wellness Visit or other Part B covered medical appointment has the potential for meaningful impact in preventing and reducing the progression of advanced oral disease.

Conclusion

Adding an oral health benefit in Medicare Part B would establish a standard benefit available to all enrollees, including the majority of nursing facility residents, regardless of income, Medicaid status, or whether their state provides coverage of Medicaid adult dental. Medicare coverage would also extend access to oral health care provided by their primary care provider, nurse practitioner, or other auxiliary personnel as part of their overall health care without having to leave the facility.

Multiple bills have been introduced in Congress this year that would add a dental benefit to Medicare.[44] If a Medicare oral health benefit package is ultimately passed, it would be a major step to address coverage and access to oral health care for nursing facility residents. Actions by advocates, health providers, dental schools, policymakers, and other stakeholders to address systemic challenges beyond coverage for facility residents would also have a significant impact on addressing disparities and poor outcomes and improving access to oral health care.

Endnotes

1. 42 U.S.C. § 1395y(a)(12). ↑

2. 42 C.F.R. § 411.15(i)(3). ↑

3. 87 FR 69404. ↑

4. 42 CFR 422.101(a); See also, Sec. 1852(a)(1) of the Social Security Act [42 U.S.C. § 1395w-22(a)(1)]. ↑

5. CMS established a process to accept and consider submissions from the public (the “public submission process”) to identify additional dental services that are inextricably linked to, and substantially related and integral to the clinical success of, other covered services in the CY 2023 Physician Fee Schedule final rule. See 87 FR 69663 through 69688. ↑

6. Shippee, Ttyana P., et al. “Addressing Racial and Ethnic Disparities in Nursing Homes,” AARP Public Policy Institute, p. 4 and 10, (February 2024) (Accessed August 19, 2024); see also Travers, Jasmine L. et al., “A Profile of Black and Latino Older Adults Receiving Care in Nursing Homes: 2011- 2017,” JAMDA 23(11): 1833-1837 (2022) (Accessed May 15, 2025). ↑

7. National Rural Health Association, “The Rural Nursing Home Landscape,” (February, 2024). ↑

8. Center for Disease Control, National Center for Health Statistics, “Table 4: Post-acute and Long-term Care User Demographic and Health related Characteristics: United States,” National Post-acute and Long-term Care Study (2020) (Accessed July 30, 2025) ↑

9. Id. ↑

10. U.S. Department of Health and Human Services, National Institutes of Health, “Oral Health in America: Advances and Challenges,” § 3B at 13-16, (2021), (Accessed July 16, 2025); see also McMains, Vanessa, “Healthy Mouth, Healthy Body: Decades of NIDCR-funded Research Reveal the Interconnectedness of the Mouth and Body,” National Institute of Dental and Craniofacial Research (May 8, 2024) (Accessed July 16, 2025). ↑

11. See CMS, “Medicare Benefit Policy Manual,” chapter 8, §30.2.1 (October, 5, 2023) (Accessed September 23, 2025). ↑

12. CMS, “Medicare Claims Processing Manual: chapter 7 SNF part B Billing (Including Inpatient Part B and Outpatient Fee Schedule),” §§10 – 10.1 (Reviewed August 6, 2021) (Accessed September 4, 2025). ↑

13. Chidambaram, Priya et al., “5 Key Facts About Nursing Facilities and Medicaid,” KFF (May 28, 2025) (Accessed September 8, 2025). ↑

14. Id. ↑

15. U.S. Department of Health and Human Services, National Institutes of Health, “Oral Health in America: A Report of the Surgeon General,” p. 262-69 (2000) (Accessed April 30, 2025); see also Dolan, Teresa et al., “Access to Dental Care Among Older Adults in the United States,” 69(9):961-74 Journal of Dental Education (Sept. 1, 2005) (Accessed April 30, 2025). ↑

16. Sarab El-Yousfi, “A Rapid Review of Barriers to Oral Healthcare for Vulnerable People,” Table 1. British Dental Journal (July 26, 2019) (Accessed August 16, 2024); see also Table 1 Barriers specific for different vulnerable groups. ↑

17. Center for Oral Health, “Oral Health Assessment of Older Adults in California Advisory Committee Meeting,” PowerPoint slides covering study data key findings (July 9, 2025) (Accessed July 9, 2025). Not available online. The Center for Oral Health will publish a report with study findings by the end of 2025. ↑

18. Chamut, Steffany, et al, “Oral Health Among Medicare Beneficiaries in Nursing Homes,” JAMA Network Open, 6(9) (September 12, 2023) (Accessed August 19, 2024). ↑

19. Id. ↑

20. Id. ↑

21. Zimmerman, Sheryl, et al. “Readily Identifiable Risk Factors of Nursing Home Residents’ Oral Hygiene: Dementia, Hospice, and Length of Stay,” J Am Geriatr Soc. 2017 Nov; 65(11): 2516–2521. (Accessed August 28, 2024). ↑

22. Findley, Caleigh A. et al. “Health disparities in aging: Improving dementia care for Black women,” Front Aging Neurosci. vol. 15 (Feb. 2023) (Accessed August 28, 2024). ↑

23. Shippee, supra note 6, at 2. ↑

24. National Academy for State Health Policy, “State Medicaid Coverage of Dental Services for General Adult and Pregnant Populations,” (October 22, 2022). See also, CareQuest Oral Health Institute, Medicaid Adult Dental Coverage Checker, (Accessed September 17, 2025). ↑

25. Id. ↑

26. For more information on the impact of the H.R. 1 on low-income older adults, see the Justice in Aging Medicaid Defense web page. ↑

27. See Board of Trustees, Federal Hospital Insurance and Federal Supplementary Medicare Insurance Trust Funds, “2025 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medicare Insurance Trust Funds,” p. 6 (June 18, 2025) (Accessed September 9, 2025). ↑

28. For a robust discussion on cost barriers and access to providers for low-income adults in Medicaid, see Hedges, Ian et al., “Improving Dental Care Access for Vulnerable Populations,” Health Policy Institute ADA (July 2024) (Accessed April 30, 2025). ↑

29. Research analyzing the elimination of adult dental benefits in state Medicaid programs provides a comparable lens to understand impacts to state resources and what low-income older adults face without dental coverage. For a robust discussion, see also Bhaumik, Deesha et al., “What Happens if the Adult Medicaid Dental Benefit Goes Away,” p. 7 Health Policy Institute ADA (March 2025) (Accessed April 30, 2025). ↑

30. 42 CFR 483.20(b)(1)(xi) ↑

31. See Surveyor’s Guideline to 42 CFR 483.25, Appendix PP to CMS State Operations Manual; and 42 CFR 483.55(a)(4) ↑

32. 42 CFR 483.55(a)(4) ↑

33. Surveyor’s Guideline to 42 CFR 483.25, supra note 31. ↑

34. See Foiles Sifuentes, Adriana M. and Kate L. Lapane, “Oral Health in Nursing Homes: What we Know and What we Need to Know ” (3-4), The Journal of Nursing Home Research (January 2020) (Accessed June 26, 2025). ↑

35. For more information on the Minimum Data Set, see CMS, “Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual,” § 2.1, v. 1.15 (October 2017) (Accessed September 9, 2025). ↑

36. Folies Sifuentes and Lapane, supra note 34. ↑

37. Kandala, Karthika, et al., “Comparison of Initial Dental Treatment Decisions Between In-Person and Asynchronous Teledentistry Examinations for People with Special Health Care Needs,” JADA 155(8): 687-698, (August 2024) (Accessed July 14, 2025). ↑

38. Langelier Margaret, et al., “Development of a New Dental Hygiene Professional Practice Index by State, 2016,” Oral Health Workforce Research Center, Center for Health Workforce Studies, School of Public Health, SUNY Albany (November 2016) (Accessed July 14, 2025); see also Langelier Margaret, et al., “Expanded Scopes of Practice for Dental Hygienists Associated with Improved Oral Health Outcomes for Adults,” Health Affairs 35:12 (December 2016) (Accessed July 14, 2025). ↑

39. Mertz, Elizabeth and Paul Glassman, “Alternative Practice Dental Hygiene in California: Past, Present, and Future,” Journal of the California Dental Association 39:1 (January 2011) (Accessed July 14, 2025). ↑

40. Martin, Paige et al.,“Still Searching: Meeting Oral Health Needs in Rural Settings,” p.6 CareQuest Institute for Oral Health (Nov. 2023) (Accessed July 7, 2025). ↑

41. Chamut et al., supra note 18, at 4. ↑

42. Tiwarei, Tamanna et al., “Medical-Dental Integration Models,” Delta Dental Institute (2022) (Accessed July 9, 2025). ↑

43. Heaton, Lisa J., et al., “Oral-Systemic Interactions and Medical-Dental Integration: A Life Course Approach,” CareQuest Institute for Oral Health p.9 (September 2023) (Accessed July 8, 2025); see also Tiwarei, supra note 42 at 5-6. ↑

44. H.R.2045 – Medicare Dental, Vision, and Hearing Benefit Act of 2025; S.939 – Medicare Dental, Hearing, and Vision Expansion Act of 2025. ↑