Who is Eligible for Medicare?
Most older adults age 65 and older, as well as certain younger people with disabilities, are eligible for Medicare. Today, there are over 68 million individuals enrolled in Medicare, including over 7 million people with disabilities under age 65.
What Are the Different Parts of Medicare and What Do They Cover?
Medicare coverage and benefits are nationwide. Unlike Medicaid, Original Medicare (Parts A and B) does not vary from state to state.
There are four parts to Medicare:
- Part A includes coverage of inpatient hospitalizations, limited days in skilled nursing facilities, home health care, and hospice care.
- Part B includes coverage of medically necessary and preventive health services usually provided in an outpatient setting. Examples include physician services, diagnostic tests like mammograms and colonoscopies, specialist and primary care visits, therapy, durable medical equipment (DME), and ambulance services.
- Part C, also known as Medicare Advantage, is an optional way for Medicare enrollees to receive their Medicare benefits from plans administered by private insurance companies. Medicare Part C covers everything that Original Medicare (Parts A and B) covers and may cover extra benefits, such as limited dental care. Most Medicare Advantage plans also include Medicare Part D prescription drug coverage.
- Part D covers outpatient prescription drugs provided through private prescription drug plans. Prescription drug coverage via Part D can be received as a standalone prescription drug plan or via a Medicare Advantage plan that includes prescription drug coverage.
Why Doesn’t Medicare Include Oral Health Coverage?
The Medicare statute excludes coverage of routine preventive and restorative oral health care. Although Medicare regulation recognizes an exception for medically necessary dental care that is inextricably linked to other Medicare-covered services, access to care under that exception is currently limited. As a result, 24 million Medicare enrollees have no comprehensive oral health coverage and only half of Medicare beneficiaries saw a dental provider in the last year.
Why Add Oral Health Coverage to Medicare Part B Rather Than Creating a New Benefit?
Recognizing that oral health is integral to overall health, adding oral health coverage into Part B integrates oral health with the delivery of other health benefits, including preventive services. Adding oral health to Part B would also minimize administrative complexity by using Part B’s coverage criteria, payment structure, rate setting, appeals, and low-income beneficiary protections that are already in place.
Don’t Medicare Advantage Plans Cover Oral Health? Why Wouldn’t Everyone Just Sign Up for One of Those?
Most Medicare Advantage (MA) plans do offer oral health coverage, but coverage varies greatly from plan to plan, can limit the scope of benefits, and can require enrollees to pay premiums and cost sharing. Additionally, MA plans are not the right choice for everyone due to network restrictions. MA enrollees generally can only see providers contracted with the plan. Adding a dental benefit to Part B could expand dental provider participation in Original Medicare which does not impose provider network restrictions.
Furthermore, there are significant limitations and barriers to accessing dental care for MA enrollees. An analysis of CMS Medicare Advantage denials data for dental services, demonstrate that just 2% of the denials resulted in a favorable decision requiring the plan to cover the dental services. The majority of denials resulted in an unfavorable decision with cost implications for enrollees. [1]
The top unfavorable decision reasons included:
- 38% Exhausted the MA plan dental benefits
- 47% Not a covered service under the MA plan dental benefits
- 7% Not a covered service because the dental service was received out of network
If oral health is added to Medicare Part B, all MA plans would be required to offer comprehensive oral health benefits to their members. The almost half of all Medicare enrollees in Original Medicare would also get the benefit.
The Medicare Trust Fund Is Almost Insolvent, so Can It Afford to Add Another Benefit?
The Medicare trust fund finances Part A. Part B is funded separately, so expanding Part B benefits does not directly impact the Part A trust fund. Moreover, the Part A trust fund is not on the verge of bankruptcy. It is projected to be able to pay 100% of Part A costs through 2033 and there are multiple options to further extend its solvency.
But Part B Is Fee-For-Service—Shouldn’t We Be Creating a Benefit That Pays Based on Health Outcomes?
Including the benefit in Part B does not preclude value-based payment approaches or lock the benefit into any one payment model. Much innovation and experimentation in payment for health care is taking place both in Medicare—including Medicare Part B—and in the private health care market, and we expect payment models in Part B to evolve. With an oral health benefit included in Part B, the unique issues in oral health payment in Medicare would be woven into those broader models.
How Are Payments for Providers Set In Medicare Part B?
Part B has established procedures for annually determining provider fee schedules, adjusted by region and subject to annual stakeholder comment. Though most providers in Part B are paid based on these fee schedules, some providers and provider groups are participating in alternate payment arrangements. Providers, such as Accountable Care Organizations (ACOs), can receive bonuses or pay penalties based on their performance in reaching certain quality and savings benchmarks. Medicare Advantage plans pay providers in various ways, including capitation, depending on the plan and provider type.
What About Medicaid Coverage?
Medicaid provides health coverage for about 12 million Medicare enrollees with low incomes and assets. However, state Medicaid programs are not required to provide adult dental coverage. Accordingly, there is wide variation of adult coverage from state to state, with some states offering extensive benefits while others only cover dental in emergency departments. And because it is an optional benefit, states often choose to eliminate the benefit when they face budget constraints. Adding a dental benefit to Medicare would mean that all Medicare enrollees would have access to the same oral health benefit.
How Does This Help My State?
If oral health is added to Medicare, all individuals eligible for Medicare would have access to comprehensive oral health coverage no matter which state they live in. This would also help to reduce disparities in access and oral health outcomes based on race, income, residence, and disability. By relieving the significant burden of providing oral health care to low-income older adults and younger adults with disabilities, a Medicare Part B benefit would allow state Medicaid agencies to provide more comprehensive oral health or other benefits to other underserved populations.
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Endnotes
Justice in Aging analyzed a total of 500 CMS Medicare Advantage appeals decisions filtered for dental services covering a five month period from January to May 2025. ↑
