An estimated 6 million Medicare beneficiaries could be served by the new medically necessary benefit

The Consortium for Medically Necessary Oral Health Coverage is a partnership of 250 national, state, and local organizations dedicated to expanding Medicare beneficiaries’ access to medically necessary oral and dental treatment. The Consortium is working with government decision makers to close a longstanding gap in Medicare coverage – namely, the exclusion of oral and dental care vital to the success of covered medical treatment – and has achieved landmark regulatory policy clarifying Medicare payment policy for dental services that are inextricably linked to and substantially related and integral to the clinical success of Medicare-covered services.

Medicare beneficiaries whose physicians determine that oral or dental treatment is needed to enable a covered medical service to be successfully delivered.

Under Section 1862(a)(12) of the Social Security Act, routine dental services are statutorily excluded from Medicare coverage. Importantly, this exclusion does not and has never applied to dental services that are inextricably linked to and substantially related and integral to the clinical success of Medicare-covered services. This important distinction was confirmed by the Department of Health and Human Services (HHS) Office of General Counsel (OGC) in 2020. CMS formalized this policy under 42 C.F.R. § 411.15(i) and established an annual nominations process so stakeholders could nominate medical conditions warranting this coverage. In the years since, the Agency has extended medically necessary oral and dental coverage to exams, diagnostic, and treatment services to eliminate oral or dental infections prior to or contemporaneously with a range of Medicare-covered medical services, including organ and stem cell transplantation, cardiac valve replacement, valvuloplasty procedures, head and neck cancer treatment, cancer chemotherapy, chimeric antigen receptor (CAR) T-cell therapy, high-dose bone-modifying agents, and dialysis for End Stage Renal Disease (ESRD).

For years, the oral health community was frustrated by the lack of Medicare coverage for oral and dental care but was unable to make headway. Under the leadership of the late Dr. Mike Alfano, the Consortium was established to achieve unprecedented change in CMS coverage policy in the Physician Fee Schedule (PFS) to authorize access to dental services for targeted medical conditions using proven advocacy strategies.

Medicare dental coverage has been promulgated and is now available for specific medical conditions whose outcomes are inextricably liked to access to dental services. Work is underway across the medical, dental, and patient communities to increase awareness of this change in the Physician Fee Schedule, increase implementation and collect the resulting clinical, fiscal, and human outcome data.