Nearly half of Medicare enrollees--24 million older adults and people with disabilities--do not have comprehensive and routine oral health coverage. Because Original Medicare explicitly excludes most dental services, only half of Medicare enrollees have seen a dentist in the past year.
In recent years, the Centers for Medicare & Medicaid Services (CMS) clarified when Medicare will pay for certain medically necessary dental services that are inextricably linked to covered medical services. While clarifying this coverage was an important step in ensuring some Medicare enrollees have access to the oral health care they need, Medicare coverage of dental services remains limited. And though the majority of Medicare Advantage (MA) plans offer some dental coverage as supplemental benefits, the extent of coverage varies widely from plan to plan, and the benefits can be difficult to access.
Why Access to Oral Health Care Matters
For older adults and people with disabilities, going without dental coverage is particularly detrimental. Recent clinical studies show the bidirectional link between oral health and chronic diseases such as dementia, cardiovascular disease and diabetes. Oral disease can increase the risk of developing or worsening these chronic conditions, and these conditions can, in turn, negatively impact oral health.
The lack of access to oral health care disproportionately impacts communities of color, the lowest income individuals, and people with chronic conditions. National data demonstrates higher rates of tooth loss, and dental caries for individuals from communities of color and individuals with low incomes. Research on oral health outcomes for nursing facility residents shows that residents with three or more chronic conditions face increased odds of experiencing numerous oral health issues compared to residents without chronic conditions.
Without access to oral health care coverage, Medicare enrollees with dental pain will turn to costlier options to obtain care. Research has demonstrated increased costs to states and overburdened local health care systems when individuals without access to dental coverage resort to emergency department (ED) visits to receive treatment for dental conditions that are largely preventable. Increased costs are especially pronounced for individuals managing chronic conditions such as diabetes and coronary artery disease.
Medicare is not immune to cost increases due to ED visits for preventable dental conditions. By CMS’ own estimation, Medicare spends $520 million annually on dental related emergency department visits that could have been avoided if these were caught early with preventive care.
Why Medicare Advantage Isn't the Answer
For many Medicare enrollees, MA plan supplemental dental benefits are an important factor in their decision to enroll in private plan coverage. However, MA plan supplemental dental benefits, especially those deemed as comprehensive benefits, are not as accessible to plan enrollees as advertised. MA plans can impose provider network restrictions, prior authorization, and can require enrollees to pay premiums and cost sharing. A recent analysis of CMS Medicare Advantage appeals data demonstrates that the majority of appeals for dental services resulted in an unfavorable decision with cost implications for enrollees.
Why Maintaining and Expanding Oral Health Coverage in Original Medicare is Needed Now More than Ever
Given how difficult it is for enrollees to access MA supplemental dental benefits, maintaining and expanding coverage of oral health care in Original Medicare is critical. First, we must work to maintain current Medicare coverage of medically necessary dental services and improve access to ensure that the estimated 1.31 million Medicare enrollees who are eligible annually can get the oral health care they need now.
Next, building on this existing coverage, adding a dental benefit to Part B would provide Medicare enrollees with a comprehensive and standardized oral health benefit. Recognizing that oral health is integral to overall health, adding oral health coverage in 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 enrollee protections that are already in place. Justice in Aging's statutory analysis shows how such a benefit could be structured and where statutory language could be changed to accommodate such a benefit.
Finally, it is imperative that Medicare maintain and expand oral health coverage to offset oral health cuts at the state level. The Budget Reconciliation Act of 2025 (H.R. 1) makes significant cuts to state Medicaid funding, putting Medicaid adult dental benefits at risk. Colorado, Idaho, and Massachusetts have already proposed cuts that impact adult dental benefits.
Incorporating an oral health benefit in Part B is needed now more than ever to ensure all people with Medicare, regardless of their income or the state where they live, can access the oral health care they need to improve their quality of life and health outcomes.
