Durbin Highlights New Medicare Coverage For Dental Care, Urges CMS To Expand Coverage For State Medicaid Programs

Letter

"I am writing to thank you for the actions undertaken by the Centers for Medicare and Medicaid Services (CMS) to improve Americans' access to oral health care services through the 2024 Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System final rule.

Oral health is essential to overall health and well-being. However, more than 25 percent of adults--and more than 50 percent of children--have cavities. Nearly half of adults and children have periodontitis as well. Left untreated, these conditions can lead to pain and tooth loss, affecting individuals' ability to eat, talk, and smile. In some instances, untreated cavities and periodontitis also can contribute to the development of chronic health conditions.

Patients who have significant oral health issues often need surgical interventions that require general anesthesia. But, in communities across Illinois and the country, many patients face unconscionable wait times--up to 12 months, or longer--to access this essential treatment in a hospital or another qualified health care setting. That is unacceptable, and too often leads to worsened health outcomes and increased health care costs.

As part of the 2023 OPPS and ASC Payment Systems final rule, CMS recognized this issue and established a new billing code for oral health care services in outpatient hospital facilities. In the 2024 rule, CMS built upon this progress by including more than 25 new billing codes for oral health care services in ASCs. These changes will increase reimbursements and enable more providers to furnish these essential dental services, making it easier for beneficiaries who need surgical intervention to receive much-needed care and treatment.

As you know, many states model their Medicaid coverage and billing practices based upon Medicare's benefit and reimbursement decisions. CMS' recent changes to expand access under Medicare hold the potential to benefit those who receive coverage under Medicaid as well. Given the potential to benefit additional patients, I urge CMS to send a Dear Medicaid Director letter to notify states of these recent Medicare changes, and to encourage states to consider these changes as part of their own Medicaid coverage and billing practices. Thank you for considering this request."

Source