11.28.23

Durbin Highlights New Medicare Coverage for Dental Care, Urges CMS to Expand Coverage for State Medicaid Programs

Durbin calls on CMS Administrator to notify states of new Medicare coverage for oral health care services, to promote similar benefits for Medicaid patients Today’s letter follows Durbin’s previous request to MCOs in Illinois for answers on barriers to providing dental care to Medicaid enrollees

WASHINGTON – U.S. Senate Majority Whip Dick Durbin (D-IL) today sent a letter to Centers for Medicare and Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure urging her to notify states of recent Medicare changes in coverage and billing practices for oral health care services that were outlined in the 2024 Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System final rule.  As states often model their Medicaid coverage and billing practices after Medicare’s, Durbin called on Administrator Brooks-LaSure to inform states of these changes, which could improve treatment and care for Medicaid enrollees as well.

Each year, CMS publishes the OPPS and ASC Payment System rule to determine reimbursement rates for the 3,500 hospital-owned outpatient departments and 6,000 ASCs across the United States.  As part of the its 2023 OPPS and ASC Payment System final rule, CMS included a new billing code for a dental surgical procedure in outpatient hospitals, increasing reimbursement rates for these services from $200 to about $2,000.  CMS also included more than 25 new dental billing codes for dental surgical procedures in ASCs as part of the 2024 OPPS and ASC final rule, allowing more oral health services to be offered in more health care settings.

Durbin began today’s letter by highlighting the importance of delivering dental care to Illinoisans because untreated cavities and periodontitis can lead to more serious health conditions.

“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,” Durbin wrote.  “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.”

Durbin applauded the updated OPPS and ASC Payment Systems final rule, acknowledging that more oral health care services will be covered for Medicare enrollees because of the changes.

“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,” the letter continued.

Durbin concluded his letter by urging Administrator Brooks-LaSure to notify states of the finalized 2024 OPPS and ASC Payment Systems rule and to encourage states to model their Medicaid coverage and billing practices after the updated Medicare practices.

“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,” Durbin wrote.

Today’s letter follows Durbin’s three oversight letters to DentaQuest, Envolve, and Avesis – three companies that administer dental benefits for Medicaid managed care companies (MCOs) in Illinois – to seek answers on barriers to providing dental care to Medicaid enrollees.  The letters raised concerns and investigate certain insurance practices that can limit and discourage provider participation in Medicaid, which exacerbate existing reimbursement rate challenges, resulting in an estimate of only 24 percent of Illinois dentists accepting Medicaid.  As a result, Medicaid enrollees, including children and people with disabilities, have difficulty accessing adequate dental care—often facing extensive wait lists for necessary treatment.

A copy of the letter is available here and below:

November 28, 2023

Dear Administrator Brooks-LaSure:

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. 

Sincerely,

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