In November 2022, the Centers for Medicare and Medicaid Services (CMS) announced that Medicare coverage would be expanded to include medically necessary dental services. The provisions in the final rule, which became effective on January 1, 2023, allow people with life-threatening conditions to receive dental care and operations related to conditions approved by CMS.
What Makes Dental Care Medically Necessary?
The final rule expanded the definition of “medically necessary.” Before, Medicaid defined “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.”
The final rule includes dental care in the definition of medically necessary care. It also expands 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 are limited to patients who:
- Have a jaw fracture and need their teeth stabilized or immobilized
- Need a tumor surgically removed and ridge reconstruction is required 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 (but 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 patients with diabetes. Nor does it cover normal dental examinations for patients with diabetes, despite the importance of regular dental checkups for this population. However, coverage may be expanded over the next several years.
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.