Updated Medicare toolkit available on ADA website

ADA offers guidance for dentists who treat beneficiaries under new Medicare rules

The American Dental Association has updated its website to include a new toolkit of resources surrounding Medicare and medically necessary services. This release of educational materials follows new Medicare regulations that institute payment for limited dental services deemed medically-necessary prior to medical procedures, which took effect Jan. 1, 2023. No new dental benefit has been established with this change. 

The toolkit includes an overview of what Medicare covers, how it is organized and information providers should know. Medicare does not cover most routine dental services, but the Centers for Medicare and Medicaid Services recently began reimbursing for dental services that are linked to the clinical success of a medically-necessary procedure. 

CMS notified the Association that dentists who treat patients under the limited medically necessary payment rules should choose one of the enrollment options to remain in compliance with CMS regulations.  

For more information about enrolling as a participating provider, non-participating provider or opting out, visit each individual fact sheet. 

The procedures Medicare may cover include:

•    Dental or oral exams as part of a comprehensive workup prior to covered services and medically necessary services to eliminate oral infections prior to organ transplant, cardiac valve replacement, valvuloplasty procedures and chemotherapy. 
•    Dental or oral exams as part of a comprehensive workup prior to certain medically necessary services, and to eliminate an oral or dental infection before or during those services;, and medically necessary diagnostic and treatment services to address dental or oral complications after, Medicare-covered treatment of head and neck cancer using radiation, chemotherapy, surgery, or any combination of these.
•    Dental ridge reconstruction done as a result of and at the same time as surgery to remove a tumor.
•    Services to stabilize or immobilize teeth related to reducing a jaw fracture.
•    Dental splints, only when used as part of covered treatment of a covered medical condition such as dislocated jaw joints. 

“We understand that Medicare beneficiaries with complex conditions will be seeking care for covered services from dentists. The Centers for Medicare and Medicaid Services has notified us that providers wishing to treat the patients scheduled for these medical procedures need to be enrolled or opted out,” said Dr. Linda J. Edgar, D.D.S., ADA President. 

Dr. Edgar emphasized that the ADA is not asking all members to take action, only to be aware of their need to enroll, opt-out of Medicare, or refer to another dentist if a patient presents in their office with one of the above medical procedures. Further, these rules do not impact beneficiaries covered under Medicare Advantage usually referred to as supplemental dental benefit or part C plans. 
“At the 2023 House of Delegates, the House adopted policy emphasizing that payment for dental services through Medicare to improve medical outcomes should be such that at least eight out of 10 dentists receive their full fee. The ADA Board of Trustees took action to explore opportunities to acquire data to communicate this policy and fee guidance to CMS,” Dr. Edgar said.

Medicare, which is a health insurance program administered by CMS under the U.S. Department of Health and Human Services, covers people age 65 and older, people under age 65 with certain disabilities and people of all ages with end-stage renal disease, a condition that requires dialysis or a kidney transplant. 

Medicare is organized into four major “parts” most relevant to dentists, which include:

•    Part A covers inpatient hospital stays, skilled nursing facility stays, some home health visits and hospice care. 
•    Part B covers physician visits, outpatient services, preventive services and some home health visits. 
•    Part C refers to the Medicare Advantage program through which beneficiaries can enroll in a private health plan and receive all Medicare-covered benefits in part A, B and possibly part D. 
•    Part D covers outpatient prescription drugs through private plans that contract with Medicare, including both stand-alone prescription drug plans and Medicare Advantage drug plans. 

By statute dentists are considered “physicians” and regulations applicable to medical providers often apply to dentists treating Medicare covered beneficiaries for covered services. Read the Basics of Medicare for an overview of the Medicare fundamentals and to learn more about what has changed.  

For more information, visit the ADA’s Overview of Medicare and Dentistry toolkit. 

For information about submitting a dental claim form, visit CMS’ Medicare Dental Coverage webpage. 

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