Medicare doesn't cover dental? How does this compare to Canada?

Medicare Dental Coverage Overview

Currently, Medicare will pay for dental services that are an integral part either of a covered procedure (e.g., reconstruction of the jaw following accidental injury), or for extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw. Medicare will also make payment for oral examinations, but not treatment, preceding kidney transplantation or heart valve replacement, under certain circumstances. Such examination would be covered under Part A if performed by a dentist on the hospital's staff or under Part B if performed by a physician.

Statutory Dental Exclusion

Section 1862 (a)(12) of the Social Security Act states, "where such expenses are for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth, except that payment may be made under part A in the case of inpatient hospital services in connection with the provision of such dental services if the individual, because of his underlying medical condition and clinical status or because of the severity of the dental procedure, requires hospitalization in connection with the provision of such services."

Background

The dental exclusion was included as part of the initial Medicare program. In establishing the dental exclusion, Congress did not limit the exclusion to routine dental services, as it did for routine physical checkups or routine foot care, but instead it included a blanket exclusion of dental services.

The Congress has not amended the dental exclusion since 1980 when it made an exception for inpatient hospital services when the dental procedure itself made hospitalization necessary.

Coverage Principle

Coverage is not determined by the value or the necessity of the dental care but by the type of service provided and the anatomical structure on which the procedure is performed.

Services Excluded under Part B

The following two categories of services are excluded from coverage:

A primary service (regardless of cause or complexity) provided for the care, treatment, removal, or replacement of teeth or structures directly supporting teeth, e.g., preparation of the mouth for dentures, removal of diseased teeth in an infected jaw.

A secondary service that is related to the teeth or structures directly supporting the teeth unless it is incident to and an integral part of a covered primary service that is necessary to treat a non-dental condition (e.g., tumor removal) and it is performed at the same time as the covered primary service and by the same physician/dentist. In those cases in which these requirements are met and the secondary services are covered, Medicare does not make payment for the cost of dental appliances, such as dentures, even though the covered service resulted in the need for the teeth to be replaced, the cost of preparing the mouth for dentures, or the cost of directly repairing teeth or structures directly supporting teeth (e.g., alveolar process).

Exceptions to Services Excluded

The extraction of teeth to prepare the jaw for radiation treatment of neoplastic disease.

An oral or dental examination performed on an inpatient basis as part of comprehensive workup prior to renal transplant surgery or performed in a RHC/FQHC prior to a heart valve replacement.

Definition

Structures directly supporting the teeth means the periodontium, which includes the gingivae, periodontal membrane, cementum of the teeth, and the alveolar bone (i.e. alveolar process and tooth sockets).

subtitle B—Funding

SEC. 211. Overview: funding the USNHI Program.

(a) In general.—The USNHI Program is to be funded as provided in subsection (c)(1).

(b) USNHI Trust Fund.—There shall be established a USNHI Trust Fund in which funds provided under this section are deposited and from which expenditures under this Act are made.

(c) Funding.—

(1) In general.—There are appropriated to the USNHI Trust Fund amounts sufficient to carry out this Act from the following sources:

(A) Existing sources of Federal government revenues for health care.

(B) Increasing personal income taxes on the top 5 percent income earners.

(C) Instituting a modest and progressive excise tax on payroll and self-employment income.

(D) Instituting a small tax on stock and bond transactions.

(2) System savings as a source of financing.—Funding otherwise required for the Program is reduced as a result of—

(A) vastly reducing paperwork; and

(B) requiring a rational bulk procurement of medications under section 205(a).

(3) Additional annual appropriations to USNHI program.—Additional sums are authorized to be appropriated annually as needed to maintain maximum quality, efficiency, and access under the Program.