ADA urges for operational improvements with payments for limited dental services in Medicare
Letter sent in response to 2026 Medicare Physician Fee Schedule proposed rule
The ADA is asking the Centers for Medicare & Medicaid Services to maintain the current scope of dental services under Medicare but is pushing for significant improvements in how those services are reimbursed and coordinated.
This was part of a formal response to the agency’s proposed Medicare Physician Fee Schedule.
In a Sept. 12 letter, the ADA noted CMS’ decision not to expand the list of qualifying medical conditions that make dental services eligible for Medicare coverage. Payment for dental services are currently limited to certain medical procedures in which dental care is considered “inextricably linked” to a covered procedure’s clinical success, such as cancer therapy or heart valve surgery.
“The ADA appreciates the continuation of payment for dental services inextricably linked to other covered services and agrees with CMS’s choice to not include additional qualifying conditions,” wrote ADA President Brett Kessler, D.D.S., and Interim Executive Director Elizabeth Shapiro, D.D.S., J.D.
“The ADA believes that CMS and stakeholders should continue work to operationalize the current limited benefit by ensuring proper enrollment of providers [who wish to treat Medicare beneficiaries], timely claims adjudication, and measurement of health outcomes due to this limited benefit before further expanding the list of qualifying conditions,” the letter said.
Additionally, CMS made changes to the merit-based incentive payment system, which incorporates financial incentives or penalties based on certain quality improvement activities undertaken by Medicare-enrolled providers. CMS is now allowing primary care physicians to screen patients with an oral health risk assessment or refer patients to a dentist as a quality improvement activity, which can help physicians qualify for financial incentives.
Drs. Kessler and Shapiro applauded the proposed inclusion of an oral health risk assessment as a merit-based incentive payment system improvement activity, but warned that the improvement activity would not ultimately improve outcomes without stronger referral requirements, better data sharing, and a visit to a dentist due to the persistent divide between the medical and dental care system.
They urged CMS to require both a screening and a referral as part of the activity to ensure patients receive follow-up care as many physicians may lack the complete clinical training to conduct a comprehensive oral health risk assessment
“Providers may default to only conducting screening activities and leaving patients as the intermediary and lost within the fragmented healthcare system,” according to the letter.
To best facilitate a referral, Drs. Kessler and Shapiro recommended CMS mandate electronic referral systems for electronic health records based on fast health care interoperability resources standards. They said these digital tools would allow real-time sharing of patient data between medical and dental providers, which helps prevent delays, reduce costs and improve outcomes.
“Delays in care coordination between medical and dental providers not only harm patients but also generate significant costs for the healthcare system,” they wrote.
To learn more about the payment of dental services within Medicare, including qualifying medical procedures, visit ADA.org/Medicare.
