Medicare’s expanded coverage for certain dental services is creating new opportunities for oral health professionals to care for patients undergoing serious medical treatment. But many providers still have questions about who qualifies, what services are covered, and how to navigate the benefit.
Lisa Simon, MD, DMD
Katherine France, DMD, MBE
Those questions were front and center during CareQuest Institute’s webinar “From Policy to Practice: Caring for Patients Covered Under Medicare’s Dental Benefit.” During the webinar, two experts — Lisa Simon, MD, DMD, with Harvard School of Dental Medicine and Harvard Medical School; and Katherine France, DMD, MBE, with Mass General Brigham and Harvard School of Dental Medicine — shared practical guidance on navigating the benefit and applying it in real-world clinical settings. More than 450 learners attended the session, which explored recent policy developments, provider participation, and case-based examples involving medically complex procedures, including cancer treatment.
During the Q&A portion of the webinar, participants asked a range of practical questions about Medicare Advantage plans, provider participation, covered services, care coordination, and preparing patients for medical treatment. Our experts provided these thoughtful answers:
1. What would cause Medicare Advantage payers to have a stronger appetite to cover dental services? Do you see it being an expansion of the scope of services or an increase in the annual benefit amount?
Unfortunately, the trends we are seeing are moving away from providing a meaningful dental benefit or toward a regression in service quality. Offering and advertising a dental benefit is very appealing for Medicare Advantage plans. Benefits such as free gym memberships or dental coverage may also attract healthier Medicare beneficiaries, since people who are very ill may be less able to use those benefits.Within the Medicare Advantage space, star ratings assess whether plans are likely to give patients the care they need. However, these ratings do not apply to dental benefits, in part because traditional Medicare does not offer a dental benefit, so almost anything is considered better than nothing. One potential advocacy opportunity for the dental profession is to explore how quality expectations could be strengthened for supplemental benefits such as dental care.
2. Can silver diamine fluoride (SDF) applications be billed and covered for patients with head and neck cancers or other conditions, such as organ transplants and bisphosphonate use?
Medicare has not published a definitive list of dental billing codes that are covered or excluded under this benefit. While SDF CDT codes (D1354 and D1355) are not among the 20 most commonly reimbursed Medicare dental procedures, SDF can be considered a treatment for infection. In clinical practice, dental professionals should consider incorporating SDF before medical treatment because it can arrest active caries and reduce the risk that those lesions will develop into more serious infections.
3. Does Medicare offer credentials to providers who participate? Does Medicare pay for services provided by a dental hygienist or dental therapist
Providers must first enroll in Medicare and be accepted before beginning the billing process. This requires a National Provider Identifier, or NPI. Depending on the state and its scope-of-practice rules, eligible providers may include dental therapists or public health dental hygienists.Generally, Medicare reimburses providers it recognizes as direct providers. Care provided by a dental hygienist may still be eligible, but the claim would need to be submitted under the NPI of the dentist who has a supervisory relationship with the hygienist.
4. When determining whether a patient is ready to proceed with medical treatment, do untreated cavities also need to be addressed, or are you primarily looking for signs of infection, such as periapical radiolucency?
The approach depends on the patient’s medical status and the treatment they are preparing to undergo. The term “clearance” can be misleading because new oral health issues can develop at any time.For patients preparing for cardiac surgery, the primary focus is on acute or active infections and conditions likely to progress to a spreading infection within approximately three months. These patients are often not in ideal health before surgery but are likely to feel better and be able to receive additional dental treatment a few months afterward.
The approach is different for patients preparing for radiation therapy because they will face a lifelong increased risk of osteoradionecrosis. For these patients, clinicians should address teeth that may eventually require extraction, including teeth with extensive caries that are unlikely to be saved and teeth that are already beyond saving. The goal is to limit the need for procedures that affect the bone later in the patient’s life.
5. What is the current state of electronic health record integration (HER) of oral health and primary care? Could better EHR integration help increase utilization?
Better EHR integration could play a significant role in improving utilization and coordination of care. Currently, integration between dental and medical records is limited because many dental EHR systems are designed primarily for dental workflows and billing and often do not communicate well with larger medical record systems. Some platforms, such as Epic Wisdom, are helping bridge that gap by making it easier for dental providers to access patients’ medical histories.
Improved integration offers several benefits. It helps dental professionals more easily determine whether patients are medically safe to undergo treatment, supports communication between dental and medical teams, and allows providers to document services such as evaluations, extractions, or SDF applications in a way that is visible to the rest of the care team. Integration can also simplify Medicare participation and billing, particularly within larger health systems that already have credentialing and billing infrastructure in place.
Editor’s Note: View the full presentation — and download the accompanying slides — in CareQuest Institute’s webinar library.