Are Dental Benefits Coming to Original Medicare?

Medicare has been providing America’s seniors with comprehensive health insurance coverage for more than half a century. However, neither Original Medicare nor Medigap insurance cover dental care, though some Medigap insurers let members combine their coverage with supplemental plans that cover or offer discounts on dental and vision services. This means that dental care remains […]

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Medicare has been providing America’s seniors with comprehensive health insurance coverage for more than half a century. However, neither Original Medicare nor Medigap insurance cover dental care, though some Medigap insurers let members combine their coverage with supplemental plans that cover or offer discounts on dental and vision services.

This means that dental care remains an out-of-pocket expense, even if you have a good health plan with Original Medicare + Medigap + Part D prescription drug coverage. And, as the cost of dental care continues to increase, this is becoming a real challenge. Between 1990 and 2016, average per-capita dental spending rose by 81%.

Medicare Advantage plans, a private health insurance alternative to Original Medicare, can provide standard dental, eye, and hearing services as additional benefits. Medicare Advantage plans are sold by private companies, and they’re similar to commercial insurance in that they have a deductible and an out-of-pocket limit.

One reason why seniors have flocked toward these private plans is the greater convenience they offer compared to the traditional Medicare. Enrollment has increased from approximately 12 million in 2011 to over 26 million in 2021, and Medicare Advantage currently accounts for 42% of enrollment, compared to 25% a decade ago.

Considering that 94% of the people who enroll for Medicare Advantage choose plans that include dental coverage, it’s safe to say that this is a very popular benefit.

Those who stay on the traditional Medicare program can purchase supplemental insurance to cover some of their out-of-pocket costs or benefits that aren’t included. Around one in every four enrollees in traditional Medicare purchases a so-called Medigap plan, creating another profitable secondary market for insurers.

Improving standard Medicare benefits, such as adding new vision and dental coverage or reducing patient cost-sharing, puts health insurers’ interests at risk.

It would also cost money, and one way to fund these added benefits would be to reduce provider payments or impose new taxes on private insurance plans.

Both options are sure to meet resistance.

The US Dental Crisis

As part of a $3.5 trillion infrastructure package, Congressional Democrats are trying to Expand Original Medicare to include dental, eye, and hearing benefits.

Since dental coverage is not recognized as “medically necessary,” Original Medicare not only does not offer it, but is actually prohibited by law from offering it. It does not cover routine dental care, nor does it cover issues stemming from conditions that are included – at least in most cases.

For example, Medicare won’t cover the costs for services needed to repair chemotherapy-related damage, but it will cover the cost of dental repair if a dentist needs to extract a tooth in order to treat a tumor.

According to the Kaiser Family Foundation, 37 million people, or about two-thirds of Medicare beneficiaries, currently lack dental coverage. Half of all Medicare beneficiaries admit to not having been to a dentist over the past year, and a staggering 15% no longer have any teeth.

These are alarming statistics not only in terms of oral health but general health as well. Untreated dental diseases can increase the risk of developing other medical conditions such as diabetes and cardiovascular disease.

Moreover, people over the age of 65 are seven times more likely to develop oral disease, and having access to routine dental exams provides a means to detect it early. Despite the fact that all other age groups witnessed improvements in this area, the percentage of American seniors who said cost was a barrier to getting dental care has increased.

Based on these figures, it’s reasonable to conclude that we’re dealing with a dental crisis in the United States. Although the Affordable Care Act recognized dental coverage as an essential health benefit for children, when it comes to adults, there’s no requirement for insurance carriers to provide it.

While most health insurance plans cover major medical expenses, it’s tough to find dental coverage that does not place the burden on the enrollees to pay a considerable portion of the bill if they require extensive dental work.

This holds true for a variety of plans like Medicare Advantage dental coverage, stand-alone dental plans, and employee and retiree group dental plans. Most dental plans have benefit maximums between $1,000 and $2,000, while a single root canal can cost $1,500 or more, and implants cost up to $7,500 per tooth.

That being said, some coverage is still better than none. Even if they have low benefit maximums, people with dental insurance are more likely to go for routine check-ups and get preventative care, resulting in fewer untreated problems that get worse with time.

What Are Legislators Planning to Do About It?

American adults still struggle to get affordable, quality dental insurance. Bills to include dental care in Medicare’s list of covered services are regularly introduced in Congress, but without much success.

Senator Ben Cardin (D-MD) recently introduced the Medicare Dental Benefit Act of 2021 – a bill requiring Medicare Part B to cover services “that are necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions.” Exams, cleaning, x-rays, fillings, extractions, root canals, crowns, dentures, and emergency dental treatment would all fall under this category.

Senator Cardin has already introduced this bill several years in a row, and it still hasn’t made any progress.

However, later this year, Congress will be considering a $3.5 trillion social spending bill that looks to expand traditional Medicare benefits. This would be the most significant expansion since 2003 when Congress added prescription drug coverage through the Medicare Prescription Drug, Improvement, and Modernization Act.

Senators Chuck Schumer (D-NY) and Bernie Sanders (I-VT) are working together to expand Medicare’s dental, vision, and hearing health coverage.

The initiative, according to Schumer, is intended to address “a gaping hole” in the health insurance program that covers millions of Americans aged 65 and over. He stated that these benefits would be attached to President Biden’s American Jobs Plan and American Families Plan, two multi trillion-dollar proposals announced earlier this year.

We also need to note that, according to the National Institute of Health, hearing loss affects a third of Americans between the ages of 65 and 74, and nearly half of those aged 75 and up, while hearing aids cost between $1,000 and $5,000 on average.

President Biden recently issued an executive order advocating for hearing aids to be sold in drug stores over the counter, which might help make them more affordable.

Making hearing aids a part of standard Medicare coverage can help millions of older adults with hearing loss improve the quality of their lives.  

If adding these benefits to Original Medicare gets approved, it would make the plan more competitive with the private Medical Advantage alternative – one of the reasons why progressive Democrats support this initiative led by Senator Bernie Sanders.

Some legislators argue that Medicare Advantage plans offer considerable marketing and financial advantages over Original Medicare, and if these benefits were added to Original Medicare, then this gap would be narrowed but might also result in higher Medicare Advantage premiums.

Who Is Going to Cover the Cost?

The Democrats will have to figure out how they’re going to cover the cost of adding these benefits to Original Medicare. Will premiums be raised, and if so, by how much?

Taxpayers already cover around 75% of the costs associated with Medicare Part B. The rest is paid by Medicare beneficiaries.

There’s a good chance that Sanders will want at least the same percentage of the cost to come from taxpayers, but this initiative comes at a time when the future of Medicare and Social Security is uncertain.

Plus, as we mentioned before, the insurance industry is concerned about the potential these changes would have on Medicare Advantage payments.

Some experts believe that adding these benefits to Original Care won’t have a strong influence on Medicare Advantage enrollment rates. Although it’s clear that dental coverage is a popular benefit, there are other aspects that give Medical Advantage a competitive edge, and if people switch to Original Medicare, they will still need a Medicare supplemental plan for cost-sharing and a standalone prescription drug plan, resulting in higher premiums compared to Medical Advantage.

Medical Advantage also offers other benefits like the out-of-pocket cap and gym memberships that might keep enrollees interested.

Some shifting in enrollment is possible once these changes level the playing field a bit, but this depends mostly on why people enroll in Medicare Advantage in the first place.

“I have been reporting for several years that the Centers for Medicare & Medicaid Services gives private health plans an unfair advantage. Dental, vision, and hearing benefits top the reasons why,” says David Bynon, senior research analyst at MedicareWire.

Bynon explains how the government uses biased language in the official handbook, “Medigap & You,” designed to sway beneficiaries into joining Medicare Advantage plans.

One of the issues he cites is how the Medigap & You Handbook suggests that Medicare Advantage is a better option (page 8) because the plans feature an out-of-pocket limit. 

What is missing is a reference to how Medicare Products fill the gaps in Original Medicare, with the top plans all eliminating the need for an out-of-pocket limit, Bynon suggests.

In its current form, Medicare does not provide comprehensive coverage for all of its beneficiaries. Yet, reforms to the program might be met with opposition from the private insurance industry that now turns a profit from selling plans that fill the gaps left by traditional Medicare.

Similarly, we’ll have to wait and see if Democrats will succeed in passing provisions that target Medicare drug pricing, which are fiercely opposed by drug companies.

Insurance providers will surely be keeping a close eye on how this legislation is drafted since the exact policy language is being finalized now.

The major insurance group America’s Health Insurance Plans (AHIP) warned Congress that any changes to traditional Medicare would require a change in the benchmark used to determine MA payments. This benchmark takes into account traditional Medicare spending in a given area.

If Congress adds the benefits to Medicare without changing this benchmark, AHIP is concerned that Medicare Advantage plans will have between 48% and 73% fewer rebate dollars available to cover supplemental benefits that alleviate health disparities.

A Medicare Advantage plan puts a bid on the costs of providing services to enrollees, with the benchmark set at what the beneficiary would have paid if he or she had been on traditional Medicare. If a bid falls short of the benchmark, the plan receives a rebate to make up for the difference.

AHIP also expressed concerns that Congress would use Medical Advantage to pay for new benefits.

Not many benefits have been added to Medicare since it was enacted over five decades ago. Some preventative care such as pneumonia vaccines and mammograms was added in the 80s and 90s, and in 2003, when Republicans controlled both Congress and the White House, they spearheaded the addition of prescription drug coverage but decided to keep such coverage separate from the traditional benefit package.

Other attempts to expand benefits have not been as successful. In 1988, a bipartisan effort in Congress resulted in the Medicare Catastrophic Coverage Act, which would have added prescription drug coverage to basic Medicare while also filling a huge gap: the fact that there is no cap on how much patients can be charged for their share of covered care.

That initiative, however, was quickly repealed after seniors objected to being required to foot the bulk of the cost for the increased benefits through a new income “surtax.” Beneficiaries of Medicare are still at risk of incurring uncapped costs.

Democrats in Congress have proposed a wide range of Medicare expansion possibilities, ranging from new vision and dental benefits to reducing the qualifying age to 60 and making Medicare benefits available to everyone. According to media reports, the leading contenders for the impending reconciliation bill are new dental, vision, and hearing benefits.

Although President Biden wants to spend more money on Medicaid’s home-based services benefits, it does not appear that improving the program’s traditional benefits or adding long-term care coverage is on the table right now.

Every policy choice entails a trade-off. In theory, Democrats have three options: new benefits, expanded eligibility, and improved traditional coverage. The debate over the next few months will determine how Medicare will change in the future — and which gaps will stay.

However they decide to handle Medicare, the Democratic majorities are certainly walking a tightrope.

For example, if Congress tries to expand the program to people under the age of 65, hospitals and doctors are sure to oppose it because Medicare pays providers less than the commercial plans in which many of these people would otherwise be enrolled.

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