Medicare Dental Coverage

Medicare was designed in 1965 without a dental benefit. Section 1862(a)(12) of the Social Security Act excludes routine dental care from coverage, a statutory exclusion that has survived every major Medicare reform since. Sixty years later, the exclusion holds, but the edges have been moving. CMS has progressively expanded its interpretation of the “inextricably linked” exception through three years of Physician Fee Schedule rulemaking. The ESRD expansion that took effect in 2025 created the most significant precedent since organ transplant coverage: dental care linked to dialysis is now covered, equaling the treatment of kidney transplant patients. Meanwhile, MA dental supplemental benefits are contracting under rate pressure, pulling back the coverage that tens of millions of beneficiaries enrolled in MA to receive. The structural coverage gap is as wide as it has ever been for the majority of Medicare beneficiaries.

The Statutory Exclusion and Its Exceptions

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The Medicare statute excludes dental services except in two narrow circumstances. First, where dental care is directly part of a covered medical service: extracting a tooth before jaw surgery, setting a fractured jaw, wiring teeth as part of covered medical treatment. Second, under a standard that CMS has developed through regulation: dental services that are “inextricably linked to, and substantially related and integral to, the clinical success of, an otherwise covered medical service.”

The 2023 Physician Fee Schedule final rule formalized this second standard into regulation, clarifying that the inextricably linked interpretation applies in both inpatient and outpatient settings and that CMS can expand the list of covered clinical scenarios through the annual PFS rulemaking process. That process was the vehicle for the 2023, 2024, and 2025 expansions. Beginning in 2023, Medicare covers dental exams and treatment of oral infection prior to organ transplant surgery, including hematopoietic stem cell and bone marrow transplants, and prior to cardiac valve replacement or valvuloplasty. Beginning in 2024, the list expanded to include treatment of head and neck cancer using radiation, chemotherapy, or surgery, and administration of high-dose bone-modifying agents used in cancer treatment. Beginning in 2025, dialysis services for ESRD were added: dental or oral examinations and medically necessary treatment to eliminate infection before or concurrent with Medicare-covered dialysis are now covered.

The ESRD dialysis expansion carries specific significance. Medicare previously covered dental exams prior to kidney transplant surgery. The 2025 rule extended equivalent coverage to dialysis, the alternative treatment pathway that a majority of ESRD patients are actually on. The policy corrected an inequity in the previous coverage framework: whether a beneficiary needed dental clearance before a transplant or before initiating dialysis, the clinical rationale for preventive dental care is identical, but only the transplant patients had coverage. Starting July 1, 2025, CMS also required use of the KX modifier on dental claims submitted for inextricably linked services, and ICD-10 coding on dental claim forms, to support proper documentation and claims adjudication.

The logical extension of the “inextricably linked” doctrine is not hard to sketch. If dental clearance matters before a kidney transplant, before cardiac valve surgery, before cancer treatment that damages oral tissues, and before dialysis, why does it not matter before elective cardiac catheterization in a patient with documented periodontal disease and cardiovascular risk? CMS has created the regulatory mechanism to ask and answer these questions through the annual rulemaking cycle. KFF has noted that the changes to date are projected to benefit a relatively small number of beneficiaries, with CMS estimating approximately 190,000 additional dental services covered under the transplant, cardiac, and valvuloplasty scenarios at an annual incremental cost of $200,000 to $2.55 million. That modest cost estimate reflects the narrow clinical circumstances covered, not a failure of evidence for broader coverage.

Conditions that advocates and clinicians have proposed for future coverage expansion, including diabetes and cardiovascular disease more generally, have not cleared the rulemaking threshold. The ADA commented in 2024 that it could not identify specific cardiovascular procedures whose clinical success could be inextricably linked to dental care in a way that would satisfy CMS’s evidence standard, reflecting the difficulty of meeting the regulatory threshold with available peer-reviewed evidence even where the biological relationship between periodontal disease and systemic conditions is well established.

MA Dental as Supplemental Benefit

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For the roughly 34 million Medicare beneficiaries enrolled in MA, dental coverage arrives primarily through supplemental benefits rather than the Part A and B inextricably-linked framework. In 2026, 98 percent of individual MA plans offer some dental benefit. The near-universal availability figure obscures a benefit design story that is moving in the wrong direction.

The 2025 plan year was the first year in recent MA history where supplemental benefit value declined. Milliman’s analysis found that the value of supplemental benefits fell by more than $6 per member per month in 2025, driven primarily by cuts to dental and reduced OTC allowances. Dental allowances are the largest single driver of that decline. Among the roughly 16.9 million MA members who had a dental allowance benefit in 2024, approximately 37 percent saw either a decrease in or removal of that allowance for 2025. The comprehensive dental benefit category, which had been among the fastest-growing supplemental offerings in recent years, saw its average annual limit fall by nearly 10 percent among plans that retained the benefit. Some plans moved comprehensive dental from a mandatory supplemental benefit to an optional supplemental benefit requiring a separate premium, reducing its effective availability.

What plans protected is preventive dental: exams, cleanings, and X-rays remain broadly available and continue to be offered by nearly all MA plans that offer any dental coverage. What contracted is the coverage that matters most to beneficiaries with unmet clinical needs: crowns, dentures, root canals, periodontal treatment, and comprehensive restorative care. For a beneficiary who chose their MA plan in 2023 or 2024 because it offered a comprehensive dental benefit, the 2025 benefit reduction represents a retroactive change to the implicit deal that drove their enrollment decision.

The mechanism driving the contraction is rate compression. MA plans face reduced revenue from the combination of the V28 risk adjustment model phasedown, lower benchmark rates, elevated medical cost trends, and Star Ratings pressure. When plans must reduce costs, supplemental benefits are the lever that does not affect mandatory benefit design, does not trigger network adequacy review, and is not subject to the Total Benefit Change caps that constrain changes to Medicare-covered benefits. Dental allowance reductions and OTC cuts are precisely the type of change that plans can execute without regulatory friction. The 2026 supplemental benefit data shows the same trajectory continuing: OTC allowances declined from 73 percent to 66 percent of plans, meal benefits from 65 to 57 percent, and transportation from 30 to 24 percent.

Beginning in 2026, CMS requires MA plans to notify enrollees of unused supplemental benefits between June 30 and July 31 of the plan year, a rule finalized in the CY 2025 MA and Part D final rule. This notification requirement will increase benefit awareness and utilization pressure, which may further accelerate benefit design adjustments in 2027 as plans confront higher-than-modeled utilization of dental benefits once members become more aware of what they have.

The Dental Access Crisis

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An estimated 47 percent of Medicare beneficiaries have not visited a dentist in the past 12 months. For beneficiaries without any dental coverage, whether in Original Medicare or an MA plan with minimal preventive-only coverage, that proportion is higher. A 2021 KFF analysis found that nearly half of Medicare beneficiaries did not use any dental services in a given year, and among those who did, approximately half paid an average of $874 out of pocket for the care they received.

The burden is not distributed evenly. Low-income beneficiaries, Black and Hispanic beneficiaries, and beneficiaries in rural counties have substantially higher rates of untreated dental disease. Dual eligibles present a particular paradox: some have Medicaid dental coverage through their state program, but Medicaid dental networks are often inadequate. States vary widely in Medicaid adult dental coverage, from comprehensive benefits in some states to emergency-only coverage in others, and even where coverage exists, the supply of dentists willing to accept Medicaid reimbursement rates limits practical access.

The clinical consequences of untreated oral disease in this population are not cosmetic. Periodontal disease worsens glycemic control in diabetes and is bidirectionally linked to metabolic dysregulation. Oral infections in frail elderly patients are a documented driver of aspiration pneumonia, a leading cause of preventable hospitalization and death in the Medicare population. The association between periodontal disease and cardiovascular events is well-established in the epidemiological literature, though the mechanism and the extent to which treating periodontal disease reduces cardiovascular risk remain areas of active research. For Medicare beneficiaries with diabetes, cardiovascular disease, or respiratory vulnerability, untreated oral disease is an unmanaged risk factor for the conditions that drive the highest Medicare costs.

For ACOs and MA plans operating under financial accountability, this represents a cost management opportunity. The case that dental investment reduces medical spending is supported by specific clinical pathways, particularly for high-risk populations. The challenge is that the dental costs fall outside Medicare reimbursement structures while the medical savings accrue to entities that bear financial risk for the overall care of the population. That misalignment, more than any lack of clinical evidence, is what has kept dental out of the core benefit design.

The Legislative Landscape

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Comprehensive Medicare dental coverage legislation has been introduced in multiple congressional sessions without advancing. The framework that has received the most attention would add a new Part B dental benefit covering a defined range of services, potentially with cost-sharing structures similar to existing Part B benefits. The barriers are predictable and entrenched.

The CBO score for comprehensive Medicare dental coverage is large. Estimates from prior sessions put the 10-year cost at $100 billion or more for broad coverage of routine dental services, depending on the scope and cost-sharing design. Any legislative vehicle requires an offset, and the available offsets are politically difficult. The Inflation Reduction Act of 2022, which was the legislative vehicle that came closest to including a dental benefit, ultimately excluded dental coverage in the final bill.

The current congressional environment, oriented toward fiscal restraint under the reconciliation package discussions in 2025 and 2026, is not favorable to a new mandatory benefit costing in the tens of billions. The incremental administrative pathway, expanding the inextricably linked doctrine through annual PFS rulemaking, continues to advance without the political friction of a legislative vehicle and without a CBO score. The 2025 ESRD dialysis expansion demonstrated that CMS can use the rulemaking process to achieve meaningful targeted coverage changes. The limitation is that the regulatory pathway is bounded by the statutory language: CMS cannot use rulemaking to create a routine dental benefit, only to identify additional clinical scenarios where dental care is integral to the success of other covered medical services.

The longer-term pathway that observers have identified is whether a future Congress creates a more flexible statutory framework for dental coverage, either by amending Section 1862(a)(12) or by directing CMS to develop a dental benefit with cost-sharing structures that limit total expenditure through annual caps or cost-sharing design. Short of that, the combination of incremental regulatory expansion and MA supplemental benefits remains the operational landscape, even as MA benefit contraction erodes the coverage that MA was supposed to provide.

Related Reading

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MCR-04_02 Benefit Design 2026-2027: What Plans Will (and Won’t) Offer MCR-10_02 Racial and Ethnic Health Equity in Medicare: HCC Coding Gaps, Benefit Disparities, and What the Data Shows