Medicaid and Medicare Enrollees Need Dental, Vision, and Hearing Benefits
December 8, 2020
More than 88 million adults in the United States are enrolled in Medicare or Medicaid. Most do not have comprehensive health coverage for vision, dental, or hearing benefits, often leaving them without the care they need to protect their health and quality of life. Congress increasingly appears to be considering adding coverage for these services in Medicare — as it should. But in doing so, it should also guarantee access to the same benefits for low-income adults with Medicaid coverage.
Lack of access to dental, vision, and hearing care can pose serious risks for overall health. The absence of routine care can delay diagnosis of some serious health conditions, leading to complications and more costly treatments later. For example, researchers have found that lack of dental coverage in Medicaid leads to additional emergency department visits — dental-related emergency department visits increased by 32 percent among adult Medicaid enrollees in California after the state eliminated dental coverage in 2009. Even when not associated with other health concerns, dental, hearing, and vision problems can decrease individuals’ quality of life and impede participation in their communities.
"Ensuring that Medicaid as well as Medicare enrollees can access these benefits could reduce disparities in access to care and prevent more serious health problems."
People with lower incomes are less likely to be able to access needed dental, vision, and hearing services than those with higher incomes. Adults in poverty are more than three times as likely to have untreated dental caries (tooth decay) than adults with higher incomes and are more likely to report unmet dental needs due to cost. People of color are also less likely than white people to get needed care — 9 percent of Black people and 12 percent of American Indians and Alaska Natives reported having no natural teeth, compared with less than 7 percent of white people.
Ensuring that Medicaid as well as Medicare enrollees can access these benefits could reduce disparities in access to care and prevent more serious health problems and the need for invasive, costly care later in life.
Medicare and Medicaid Coverage of Dental, Vision, and Hearing Benefits Is Very Limited
Most Medicare beneficiaries lack coverage for dental, vision, and hearing services, even for conditions that are associated with or could lead to other significant health conditions. In many states, adult enrollees in Medicaid have only limited coverage or none at all.
Traditional Medicare provides only limited dental, vision, and hearing coverage. Most Medicare Advantage (MA) plans cover some of these services, although data on the extent of this coverage are limited. A recent analysis suggests that MA enrollees with coverage still pay a high proportion of the cost of these services out of pocket (65 percent of vision, 76 percent of dental, and 79 percent of hearing costs).
Dental and Oral Health Care. The Social Security Act explicitly excludes coverage under traditional Medicare for most dental services, defined as “services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth.” Another section of the law provides coverage for services “furnished as an incident to a physician’s professional services.” Medicare also covers “medically necessary” dental care, although the Centers for Medicare & Medicaid Services (CMS) currently interprets this category very narrowly.
About three-quarters of MA enrollees — amounting to a quarter of all Medicare beneficiaries — have access to some dental coverage as a supplemental benefit under their MA plan. Of those with dental benefits, one-third have coverage only for preventive services, such as examinations, cleanings, and X-rays. Two-thirds have more extensive coverage. These dental benefits frequently come with additional premiums, cost sharing, and limits on the amount of coverage.
In addition, some 11 percent of Medicare beneficiaries have dental coverage from Medicaid, or MA and Medicaid, and 8 percent have coverage from private plans, including employer-sponsored retiree health plans and individually purchased plans. In many cases, however, this coverage is subject to dollar caps or other limitations. Overall, the majority of people on Medicare have no dental coverage.
Hearing Care and Audiology Services. Traditional Medicare excludes coverage for “hearing aids or examinations therefore.” However, it covers a “hearing and balance exam” if needed to diagnose another health condition, such as dizziness. Nearly three-quarters of Medicare Advantage enrollees are in plans that provide some benefit for hearing aids. However, typical MA plans that provide some coverage for hearing aids pay between $800 and $1,000 every three years, which only covers half the cost of the cheapest available option.
Vision Care and Eyeglasses. Traditional Medicare does not cover eyeglasses except after cataract surgery, examinations for prescribing or fitting eyeglasses, or refractive examinations. It does cover eye care related to illness or injury of the eye, including cataract surgery, glaucoma screening, eye examinations for persons with diabetes, and certain tests and treatments for age-related macular degeneration. Almost four-fifths of MA enrollees have access to eye exams or glasses.
States are not required to offer dental, vision, or hearing services to adult Medicaid enrollees. Even in states that offer some coverage, enrollees’ access to care is inconsistent: the scope of the benefits varies widely between states, and states often cut these benefits when facing budget shortfalls.
Dental and Oral Health Care. Most states provide coverage for some dental services. A 2018 survey of states found that at least 38 states and Washington, D.C. offer some dental coverage, but many states offer only emergency care. (See Figure 1.) And many states that offer some non-emergency dental coverage also restrict access to the benefit by requiring co-payments, limiting the dollar amount of expenditures an enrollee can receive to around $1,000 in services per year, or excluding coverage of preventive care or other specific types of services. Some states offer pregnant women or adults with disabilities a more robust dental benefit than other adults. And some states limit dental and other optional benefits to enrollees who pay premiums or engage in other behaviors.
Hearing Care and Audiology Services. Medicaid coverage for hearing services is also inconsistent across states. At least 28 states offered some hearing services in 2015, but many have significant limits; for example, Maine covered one set of hearing aids but only once every five years.
Vision Care and Eyeglasses. Similarly, Medicaid coverage of vision services varies widely between states. In 2018, at least 33 states offered some vision coverage, but many of those states significantly limited coverage. For example, Idaho covers glasses only after cataract surgery or to treat a condition that would result in permanent eye damage, and Indiana covers glasses but only one set every five years.
States’ decisions to cover optional benefits also frequently change based on the state’s fiscal outlook. Between 2009 and 2013, when many states faced budget shortfalls, 27 states made cuts to dental benefits, and 17 states cut vision benefits.
Lack of Access to Dental, Vision, and Hearing Benefits Affects Enrollees’ Health
Untreated oral health problems or hearing or vision loss can pose serious risks for overall health. Absence of routine dental care can delay diagnosis of some serious health conditions — such as HIV and certain infections and cancers — and thereby lead to complications and more costly treatments later. Untreated cavities and gum disease can result in infections, tooth loss, and chronic pain. Lack of teeth, in turn, makes eating difficult, reduces quality of life in other ways, and often causes poor nutrition and related health problems. Gum disease is associated with increased risk of heart disease and stroke, higher mortality for those with kidney disease, higher risk of cancer, and more difficult diabetes management.
Individuals with a range of chronic conditions are more susceptible to oral disease, which can contribute to complications from these chronic conditions and exacerbate their symptoms, including diabetes and respiratory conditions. Untreated periodontal disease in pregnant people may also affect pregnancy outcomes.
Untreated hearing or vision loss in older adults can lead to a variety of physical and mental health problems. Hearing loss increases the risk of dementia, falls, and depression and may increase social isolation and reduce cognitive function. Nevertheless, few people with hearing loss use a hearing aid, often because of the cost. Poor vision is associated with an increased risk of falls, depression, cognitive impairment, hospitalization, and limited mobility.
There is also direct evidence that lack of dental coverage in Medicaid leads to additional emergency department visits. States’ dental benefit cuts are associated with an increase in emergency department visits due to untreated dental issues, studies have shown. For example, when California eliminated its comprehensive dental benefit in 2009, emergency department visits for dental problems among Medicaid enrollees substantially increased. By monitoring adults aged 21 and over with Medicaid coverage between 2006 and 2011, one study found that the rate of emergency department visits for dental conditions rose by 32 percent (from a monthly average rate of 42 visits to 56 visits per 100,000 adults). The policy change had a racially disparate effect — while it affected all racial and ethnic groups, the effects were most clear among Black and Hispanic adults.
Similarly, Oregon cut dental coverage in 2003, along with several other benefit changes for a subset of adult Medicaid enrollees. Researchers surveyed members over time who had lost their dental benefits and compared the use of care between members who had lost dental benefits and those who had not. This research found that adults who lost dental benefits were significantly more likely to use the emergency department for dental problems compared with those who still had dental coverage. Those who lost benefits were nearly three times as likely to report having unmet dental needs as those who retained their benefits, and only one-third as likely to get routine dental care.
Low-Income Adults and People of Color More Likely to Have Unmet Needs for Dental Care
Low-income adults are particularly likely to suffer the effects of poor access to dental care. (See Figure 2.) Adults in poverty are more than three times as likely to have untreated dental caries (tooth decay) than adults with incomes above 400 percent of the federal poverty level. Between 2005 and 2008, 42 percent of non-elderly adults with incomes below the poverty line ($17,600 per year for a family of three in 2008) had untreated dental caries, compared to just 11 percent for those with incomes above 400 percent of poverty (about $70,400 for a family of three). Poor oral health among young adults can also lead to more significant dental problems as they age. Among adults aged 65 and older, 37 percent of those in poverty had complete tooth loss, compared to just 16 percent of those with incomes at or above 200 percent of the poverty line.
There are also significant racial disparities among people reporting trouble with vision or hearing and those who have lost all of their natural teeth. Nine percent of Black people and 12 percent of American Indians and Alaska Natives reported having no natural teeth, compared with less than 7 percent of white people. (See Figure 3.)
Congress Should Ensure That All Medicare and Medicaid Enrollees Have Access to Dental, Vision, and Hearing Benefits
If Congress considers legislation to expand coverage for dental, vision, and hearing benefits in Medicare — as it should — it should also require states to offer these critical services to low-income non-elderly adults with Medicaid coverage. Failing to do so would leave out a group even more likely to have unmet needs for dental care due to cost than Medicare enrollees.
Congress Should Expand Medicare’s Dental, Vision, and Hearing Benefits
Analysts have identified a range of options for expanding dental, hearing, and vision coverage under Medicare. The most straightforward and comprehensive approach for beneficiaries would be to add these benefits to Part B of Medicare. Another would create a new voluntary benefit under a separate part of Medicare, similar to the prescription drug benefit under Part D. Each of these approaches would require decisions about covered benefits, cost sharing, premiums, payment rates, provider participation, and assistance for low-income beneficiaries. Other more limited options include broadening the coverage of medically necessary dental care, testing alternative models of coverage under the CMS demonstration authority, and offering discount cards or other cash assistance to help cover the cost of services.
H.R. 3, which the House passed in December 2019, would add comprehensive dental, hearing, and vision coverage to Part B of Medicare. Its dental and oral health benefit would cover preventive services, including examinations, cleanings, and X-rays; basic treatments, such as tooth restorations, extractions, and periodontal treatment; major treatments, such as bridges, crowns, and root canals; and one set of dentures every five years. The Secretary of Health and Human Services would determine which basic and major treatments would be covered. Medicare would pay 80 percent of the cost of oral health services other than major treatments starting in 2025. It would pay 10 percent of the cost of major treatments in 2025, gradually rising to 50 percent in 2030 and thereafter.
The hearing benefit in H.R. 3 would cover aural rehabilitation services and one set of hearing aids every five years for people with profound or severe hearing loss starting in 2023. It would also designate audiologists as practitioners under Medicare. The vision benefit would cover routine eye examinations and contact lens fitting services, but no more than once every two years, starting in 2023. It would cover eyeglasses and contact lenses starting in 2024, up to $85 for frames and $85 for eyeglass lenses once every two years, and up to $85 for a two-year supply of contact lenses.
The Congressional Budget Office estimates that the additional benefits would increase Medicare spending by $358 billion over the 2020-2029 period. Of this total, $238 billion would be for dental and oral health, $89 billion for hearing care, and $30 billion for vision care. By 2029 the total annual cost would be $84 billion, or about $1,180 per Part B beneficiary, of which the dental benefit would represent three-quarters. Under H.R. 3, prescription drug savings would offset these additional costs, as well as improvements in Medicare benefits for low-income seniors and people with disabilities.
The cost of the new dental, hearing, and vision benefits in H.R. 3 would not be included in the calculation of Part B premiums but would be financed fully from general revenues. Policymakers could reasonably consider including these benefits in the calculation of premiums as a way of holding down federal costs to make room for other coverage improvements. Phasing in the premium increase over several years could soften its impact.
Licensing All Qualified Providers Would Expand Access to Needed Dental Care
In conjunction with improving dental benefits, Congress may also want to consider policies that further enable skilled providers other than dentists to offer dental services. While states are generally responsible for licensing and defining the scope of practice of health care providers, federal policymakers could offer incentives for states to modernize their policies and consider federal options to allow dental therapists to provide care to Medicare and Medicaid enrollees. Doing so could improve access to dental care while also lowering the cost of making care widely available.
States are generally responsible for licensing and defining the scope of practice of health care providers, including dental providers. Since 2004, 11 states have authorized midlevel dental providers, or dental therapists, who are similar to physician assistants and are generally authorized to provide services such as exams, dental fillings, and extractions, though their scope of practice varies by state.a Dental therapists can operate in dentists’ offices, freeing dentists to provide more complex care, or they can provide needed care in community settings, such as schools or nursing homes.b
More than 58 million people in the United States live in areas with shortages of dental care providers. Widespread use of dental therapists could significantly expand access to care, and dental therapy can provide a career pathway for people from underserved areas to provided needed services to their communities.
aAllison Corr, “What Are Dental Therapists?” Pew Charitable Trusts, October 9, 2019, https://www.pewtrusts.org/en/research-and-analysis/articles/2019/10/09/what-are-dental-therapists.
Medicaid Enrollees Need Access to Dental, Vision, and Hearing Services
Fixing gaps in coverage only in Medicare without making the corresponding changes in Medicaid would exclude many people with significant unmet needs. Providing access to a full range of preventive services and treatment for non-elderly adults with Medicaid coverage could prevent more serious conditions later in life as well as the need for more invasive, costly procedures.
As shown in Figure 4, while a significant share (about 11 percent) of traditional Medicare enrollees aged 65 and over report having unmet dental needs due to cost, the share is almost two-thirds higher (over 18 percent) among Medicaid enrollees under age 65, who are low income by definition. While Medicaid enrollees under the age of 21 are eligible for dental care as part of the Early and Periodic Screening, Diagnostic, and Treatment benefit, once young adults turn 21, many no longer have access to treatment options. Adult Medicare beneficiaries under age 65 with disabilities — many of whom also receive Medicaid — face disproportionate challenges in obtaining needed dental care. Low-income seniors enrolled in both Medicare and Medicaid also have higher rates of unmet dental needs due to cost than other Medicare enrollees.
People with Medicaid coverage are also substantially more likely to report hearing, vision, and dental problems than people with private insurance. Those who are dually eligible for Medicare and Medicaid — primarily low-income seniors — are substantially more likely than other Medicare enrollees to face vision and dental problems.
Congress would need to make various design decisions in adding dental, vision, and hearing benefits to Medicaid. They include: how the federal government and states would share the cost; what benefit standards the federal government would set; and whether Congress would permit nominal cost sharing.
No official estimate of the cost of adding comprehensive dental, hearing, and vision benefits to Medicaid, in addition to Medicare, is available, but it might be half or less than that of adding this coverage to Medicare alone, depending in part on these design choices. For one, fewer enrollees would get the benefits than under Medicare: the number of adult Medicaid beneficiaries who are not receiving Medicare (the population who would be eligible for a new mandatory dental benefit in Medicaid) is only about half the number of Medicare Part B beneficiaries. Also, utilization of dental, hearing, and vision services is somewhat lower among working-age adults than among seniors and persons with disabilities. And as noted above, access to preventive care is associated with a reduction in utilization of the emergency department for dental services, which would likely offset a share of the cost of the new benefit. In addition, some states already cover some of these services, and states would likely share some of the cost of the new Medicaid benefits, depending on the federal matching rates and maintenance-of-effort requirements. Unlike Medicare, however, Medicaid has little or no cost sharing (because its enrollees are low-income), which would add to the federal cost.
 CBPP analysis of Congressional Budget Office’s March 2020 Medicare and Medicaid baseline estimates and 2018 Centers for Medicare & Medicaid Services (CMS) Program Statistics data.
 Amber Willink et al., “Dental, Vision, and Hearing Services: Access, Spending, and Coverage for Medicare Beneficiaries,” Health Affairs, February 2020, p. 302, https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2019.00451.
 Social Security Act, section 1862(a)(12).
 Social Security Act, section 1861(s)(2)(A).
 W. Kwok, Coverage for Medically Necessary Oral Care Is Unduly Restricted by Medicare’s Dental Policy, Center for Medicare Advocacy, March 2, 2017, https://medicareadvocacy.org/medically-necessary-oral-health-care-is-coverable-under-current-medicare-law/.
 Meredith Freed, Anthony Damico, and Tricia Neuman, A Dozen Facts About Medicare Advantage in 2020, Kaiser Family Foundation, April 22, 2020, https://www.kff.org/medicare/issue-brief/a-dozen-facts-about-medicare-advantage-in-2020/.
 Meredith Freed, Tricia Neuman, and Gretchen Jacobson, Drilling Down on Dental Coverage and Costs for Medicare Beneficiaries, Kaiser Family Foundation, March 13, 2019, https://www.kff.org/medicare/issue-brief/drilling-down-on-dental-coverage-and-costs-for-medicare-beneficiaries/. Data for 2016.
 Social Security Act, section 1862(a)(7).
 Freed, Damico, and Neuman, op. cit.
 Amber Willink, Cathy Schoen, and Karen Davis, How Medicare Could Provide Dental, Hearing, and Vision Care for Beneficiaries, Commonwealth Fund, January 18, 2018, https://www.commonwealthfund.org/publications/issue-briefs/2018/jan/how-medicare-could-provide-dental-vision-and-hearing-care.
 Social Security Act, section 1682(a)(7).
 CMS, MLN Fact Sheet: Medicare Vision Services, April 2018, https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/visionservices_factsheet_icn907165.pdf.
 Freed, Damico, and Neuman, op. cit.
 The Early and Periodic Screening, Diagnostic, and Treatment benefit requires states to provide comprehensive dental, vision, and hearing services to children and young adults enrolled in Medicaid under age 21.
 Kaiser Family Foundation, “States Focus on Quality and Outcomes Amid Waiver Changes: Results from a 50-State Survey,” October 2018, http://files.kff.org/attachment/Report-States-Focus-on-Quality-and-Outcomes-Amid-Waiver-Changes-Results-from-a-50-State-Medicaid-Budget-Survey-for-State-Fiscal-Years-2018-and-2019.
 Federal Medicaid regulations define dental services as “diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist in the practice of his profession, including the treatment of – (1) the teeth and associated structures of the oral cavity; and (2) disease, injury, or impairment that may affect the oral or general health of the recipient.” (42 CFR 440.100.)
 Kaiser Family Foundation, “Medicaid Benefits: Dental Services,” 2018, https://www.kff.org/medicaid/state-indicator/dental-services/.
 Medicaid and CHIP Payment and Access Commission (MACPAC), “Medicaid Coverage of Dental Benefits for Adults,” June 2015, https://www.macpac.gov/wp-content/uploads/2015/06/Medicaid-Coverage-of-Dental-Benefits-for-Adults.pdf.
 Judith Solomon, “Kentucky Waiver Will Harm Medicaid Beneficiaries,” Center on Budget and Policy Priorities, January 16, 2018, https://www.cbpp.org/research/health/kentucky-waiver-will-harm-medicaid-beneficiaries; see also CMS, “CMS Approves Nebraska Medicaid Demonstration to Provide Pathway to Enhanced Benefits for Eligible Adults,” October 20, 2020, https://www.cms.gov/newsroom/press-releases/cms-approves-nebraska-medicaid-demonstration-provide-pathway-enhanced-benefits-eligible-adults.
 Kaiser Family Foundation, “Medicaid Benefits: Hearing Aids and Other Hearing Devices,” 2018, https://www.kff.org/medicaid/state-indicator/hearing-aids.
 Kaiser Family Foundation, “Medicaid Benefits: Eyeglasses and Other Visual Aids,” 2018, https://www.kff.org/medicaid/state-indicator/eyeglasses/.
 Kaiser Family Foundation, 50-State Medicaid Budget Survey Archives, 2008-2009, 2010-2011, 2012-2013, https://www.kff.org/medicaid/report/medicaid-budget-survey-archives/.
 Freed, Neuman, and Jacobson, op. cit.
 Bruce Dye et al., “Selected Oral Health Indicators in the United States, 2005-2008,” Centers for Disease Control and Prevention (CDC), National Center for Health Statistics, May 2012, https://www.cdc.gov/nchs/data/databriefs/db96.pdf.
 World Health Organization, “World Report on Vision,” 2019, https://www.who.int/publications/i/item/world-report-on-vision.
 Center for Medicare Advocacy, “Medicare Coverage of Hearing Care and Audiology Services,” n.d., https://medicareadvocacy.org/medicare-info/medicare-coverage-of-hearing-care-and-audiology-services/.
 Willink et al, op. cit.
 Astha Singhal et al., “Eliminating Medicaid Adult Dental Coverage in California Led to Increased Dental Emergency Visits and Associated Costs,” Health Affairs, May 2015, https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2014.1358.
 Neal T. Wallace et al., “The Individual and Program Impacts of Eliminating Medicaid Dental Benefits in the Oregon Health Plan,” American Journal of Public Health, November 2011, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3222412/.
 MACPAC 2015, op. cit.
 Kaiser Commission on Medicaid and the Uninsured, “Oral health and Low-Income Nonelderly Adults: A Review of Coverage and Access,” June 2012, https://www.kff.org/wp-content/uploads/2013/03/7798-02.pdf.
 Dye et al., op. cit.
 Meredith Freed et al., Policy Options for Improving Dental Coverage for People on Medicare, Kaiser Family Foundation, September 18, 2019, https://www.kff.org/medicare/issue-brief/policy-options-for-improving-dental-coverage-for-people-on-medicare/.
 Willink, Schoen, and Davis, op. cit.
 H.R. 3, 116th Congress, The Elijah E. Cummings Lower Drug Costs Now Act, Title VI, https://www.congress.gov/bill/116th-congress/house-bill/3.
 For suggested improvements in the Medicare oral health benefit, see Shawn Greminger and Cheryl Fish-Parcham, Medicare Oral Health Benefit Passed by the House of Representatives Sets Bold Precedent but Should Be Strengthened to Best Serve Low- and Moderate-Income Enrollees, Families USA, February 2020, https://familiesusa.org/wp-content/uploads/2020/02/OH_Importance-of-Oral-Coverage_IssueBrief.pdf.
 Congressional Budget Office, Letter to the Honorable Frank Pallone Jr., “Budgetary Effects of H.R. 3, the Elijah E. Cummings Lower Drug Costs Now Act,” December 10, 2019, https://www.cbo.gov/system/files/2019-12/hr3_complete.pdf. Note that, because fiscal year 2029 begins on a weekend, there are only 11 payments to Medicare Advantage plans that year. Also, the dental benefit in H.R. 3 is not fully phased in until 2030.
 United States Department of Health and Human Services, “Oral Health in America: A Report of the Surgeon General,” 2000, https://www.nidcr.nih.gov/sites/default/files/2017-10/hck1ocv.%40www.surgeon.fullrpt.pdf.
 Amber Christ and Jennifer Goldberg, Adding a Dental Benefit to Medicare: Addressing Oral Health Inequity Based on Disability, Justice in Aging, October 2020.