BALTIMORE, US: A recent health policy article has explored strategies to incorporate dental coverage into Medicare, addressing the evolving recognition of oral healthcare as a critical component of overall health. The researchers, who are involved in the Coalition for Oral Health Policy advocacy group, suggest a balanced and adaptable approach to expanding dental coverage, recognising the complexities and differing needs of stakeholders. Their proposed hybrid plan offers a potential solution that incorporates lessons learned from existing insurance models to achieve improved oral healthcare access for older adults in the US.
The present situation
Pursuit of adding a dental benefit to Medicare, the US federal health insurance programme for people aged 65 and older or with certain disabilities, was initially spurred by the 2022 administrative ruling by the Centers for Medicare and Medicaid Services (CMS) that allows an expanded set of medically necessary dental services under certain conditions. Subsequently, CMS established an annual review process to consider additional circumstances that may justify dental coverage, opening a pathway for broader integration of oral healthcare into Medicare.
Medicare currently offers limited dental coverage, primarily when considered medically necessary. The programme is divided into different parts: Part A, which covers inpatient hospital services, and Part B, which includes outpatient services. Both parts provide minimal dental benefits, such as when oral health services are deemed necessary for the treatment of an underlying medical issue. Part C, or Medicare Advantage, offers a bundled alternative with optional dental benefits, and this has led to substantial growth in enrolment and increased access to dental care for older adults.
The article authors propose that any plan seeking to expanding dental coverage to Medicare recipients should meet five tenets. First, the American Dental Association should actively participate in and support the process. Second, legislative outreach should be bipartisan. Third, plan design should align closely with existing oral health coverage plans. Fourth, dental Medicaid design and implementation should inform the approach, for example setting reimbursement rates high enough to encourage dentist participation. Fifth, the design and implementation of Medicare Advantage dental plans should inform a dental plan for Medicare, for example incorporating cost containment measures.
The options
The article discusses three potential models for expanding dental coverage within Medicare:
- Plan B variant: This approach mimics traditional medical insurance, providing dental coverage for an additional premium. It proposes covering 80% of costs of services with no annual limits or maximum fee, requiring beneficiaries to pay the remaining 20%. The fee schedule would be set by CMS. Subsidies would be offered for low-income enrollees, and premiums would be actuarially determined. Although this plan aims to mirror medical insurance models, it faces challenges related to high premiums, potential low reimbursement rates for dentists and significant government funding requirements.
- Preferred provider organisation (PPO) variant: In this model, beneficiaries would receive dental coverage for a premium, similar to private market dental insurance. Coverage would include cost containment measures like co-pays and annual limits, and services would be reimbursed at varying (negotiated) rates as a percentage of usual, customary and reasonable (UCR) rates depending on the procedure. Subsidies would also be offered for low-income enrollees, and premiums would be actuarially determined. This plan is considered more manageable because it aligns with existing dental insurance practices and is likely to gain broader support from dentists.
- Hybrid approach: The hybrid model integrates features of both the Plan B and PPO variants. It would provide mandatory coverage for a select set of procedures, such as preventive care, infection treatment and pain relief, at 80% coverage of discounted UCR rates with a 20% co-pay. Additional services would be offered under elective plans offering options for different coverage levels (low, medium, high) at varying premiums and with co-pays and annual limits. This approach aims to strike a balance between comprehensive coverage and financial sustainability. Subsidies could be offered for low-income enrollees, and premiums would be actuarially determined.
Challenges to implementation
Several significant challenges have been identified in expanding dental coverage under Medicare, including low reimbursement rates, which have historically led to provider shortages in programmes like Medicaid. The researchers suggested setting reimbursement levels higher than Medicaid rates but lower than the typical 80% of UCR rates found in PPO plans. This balance is crucial to encourage dentist participation while controlling costs. Adequate compensation and legislative assurances regarding reimbursement floors are necessary to maintain provider involvement.
Additionally, the adoption of new dental plans would require adjustments by dentists and insurance companies to accommodate different coverage levels and service types. This complexity could pose an administrative burden, making implementation difficult. The hybrid model would require little change in this regard.
Without traditional cost control measures, a dental plan could become financially unsustainable, requiring substantial subsidies. Adverse selection, where healthier beneficiaries opt out, can distort premium, reimbursement and subsidy calculations.
As enrolment in Medicare Advantage plans continues to grow, their role in providing dental coverage may overshadow fee-for-service Medicare efforts. Promoting Medicare Advantage uptake, could serve as an alternative strategy to enhancing oral healthcare access.
The favourite
Summarising their hybrid plan, the authors noted that “there is something for everyone to like and little for anyone to dislike” and that it would easily merit the backing of major political and clinical stakeholders. The researchers also noted that the hybrid model fulfils their five tenets for acceptance of Medicare expansion of dental coverage.
The article, titled “Medicare adult dental coverage: A novel approach”, was published online on 9 September 2024 in the Journal of the American Dental Association, ahead of inclusion in an issue.
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