Medicare explicitly excludes coverage of dental, vision, and hearing services as a core benefit, leaving beneficiaries responsible for paying for these services on their own or for finding alternative supplemental coverage. There is evidence of a higher risk for avoidable hospitalizations and emergency department visits among the Medicare population with unmet needs for dental, vision, and hearing services both as a direct result of needing dental, vision, and hearing services as well as an indirect consequence.1- 3 According to 1 report,1 compared with those with commercial insurance, Medicare beneficiaries have an increased likelihood (odds ratio, 1.90) of seeking emergency department care for treatment of nontraumatic dental problems. The inclusion of dental, vision, and hearing benefits within the Medicare program has long been supported in the scientific community and has the potential to be beneficial for older adults, health care professionals, and the Medicare program.2- 6
Evidence of the need is compelling. The vast majority of the 56 million older and disabled individuals covered by Medicare are responsible for the costs of their dental, vision, and hearing care. Although some Medicare Advantage plans or supplemental private insurance plans provide coverage for some of these services, only 12% of 52 million Medicare beneficiaries reported having some type of dental coverage in 2012.7 State Medicaid program coverage for dental, vision, and hearing services for low-income Medicare beneficiaries varies widely, and among the states that do cover these services, the extent of coverage is often very limited.
Most Medicare beneficiaries, especially those constrained by low incomes, forgo necessary dental, vision, and hearing services. According to 2012 data from the Medicare Current Beneficiary Survey cost and use file that included 11 299 individuals (reflecting an estimated 52 million Medicare beneficiaries), 75% reported having a lot of trouble hearing, and of those who reported hearing difficulties, 84% did not have a hearing aid.8 Among the estimated 11 million Medicare beneficiaries who reported trouble eating because of dental problems, 70% reportedly had not seen a dentist during the prior year.8 Among the estimated 20.5 million Medicare beneficiaries who reported vision problems, 57% reportedly had not had an eye examination during the prior year.8
Receipt of these services is strongly associated with income. Among low-income beneficiaries with income levels at less than 100% of the federal poverty level, the majority (74%) reportedly had not received any dental care during the year compared with 28% of those with incomes at or above 400% of the poverty level who had not received any dental care.7 Even low-income beneficiaries with a clear need for dental services forgo care. For instance, among those who reported having trouble eating and who had incomes less than 100% of the federal poverty level, access to dental services was substantially lower than for those with incomes at or above 400% of the federal poverty level (77% vs 42%, respectively, did not receive dental care within the past year).
Cost is the most commonly cited reason for not accessing these services, with 50% of older individuals in the United States reporting that they did not have a dental appointment during the previous year due to cost.9 Hearing aids for both ears cost $4700 on average.2- 5 In 2016, Medicare beneficiaries spent 4% of their incomes on dental, vision, and hearing services. Among those who received care, the average annual spending was $927 for dental services, $715 for vision services, and $1338 for hearing services.8 Due to the limited coverage of these services, most of the costs were paid out-of-pocket.
Greater attention is being paid to both the effects of forgoing care, as well as the high costs of receiving these services among older adults.3,5 Two bills have been introduced in Congress to consider providing coverage for dental, vision, and hearing services under Medicare. On May 17, 2017, the Energy and Commerce Committee held hearings to examine initiatives to advance public health that included a discussion of the bill entitled “Action for Dental Health Act of 2017.” However, to date, most initiatives remain vague in the design specifications and cost implications of providing these services under Medicare.
Although it is difficult to speculate about the specific design or costs of providing dental, vision, and hearing services under Medicare, a possible illustrative policy option could be modeled as a voluntary supplemental benefit similar to the Medicare Part D Prescription Drug benefit. For instance, a potential supplemental dental, vision, and hearing benefit with a $150 deductible, and 20% cost sharing on necessary services up to a maximum of $1500 would cost approximately $1.95 billion per year including 5% for administrative costs. This estimate is based on numerous assumptions including (1) an estimated average total spending on dental, vision, and hearing services of $479 for those who enroll in the program (this reflects the current dental, vision, and hearing spending of those with incomes at or above 200% of the federal poverty level); (2) the population likely to purchase the benefit would be limited to those with incomes greater than 150% of the federal poverty level who relied on Medicare only for health insurance or had a Medigap plan; (3) individuals in Medicare Advantage or Medicare-Medicaid “dual eligibles” likely would not purchase the plan; and (4) evidence from the uptake of other public programs suggests that 70% (6.4 million Medicare beneficiaries) would purchase the plan.10 Assuming these levels of participation and with a maximum benefit of $1500, these expanded services could be paid for by a monthly premium of $25 per enrolled beneficiary.
The design of the program could include 1 preventive dental examination and cleaning per year, an annual eye examination, and access to more affordable hearing aids. A possible way to reduce the costs of hearing aids could be through requesting competitive bids for providing hearing devices. The benefit would cover the cost for the lowest bid for a high-quality device and beneficiaries would be eligible to obtain a new device every 3 years. Based on US and international evidence that the price of hearing aids could be much lower, Medicare may likely be able to cover devices at one-third of the current average cost.4 These sorts of design features would be important to ensure access to services for beneficiaries and to keep costs of the benefit down.3- 5 Without changes to the cost of these services, particularly hearing aids, a more generous benefit package that would cover their cost would be far more expensive.
The potential program could include a low-income premium subsidy and lower cost-sharing requirements to address the high levels of access inequality for these services among low-income Medicare beneficiaries, similar to the sliding scale, low-income subsidies provided under the Part D Prescription Drug Benefit. It is possible that approximately 9 million beneficiaries may purchase the dental, vision, and hearing benefit if the low-income subsidies were included, and this component would cost the federal government $1.05 billion per year. It is important to note that these estimates are based on numerous assumptions, and the cost of the program could be greater depending on how many individuals participate. In addition, at a maximum benefit of $1500, the program would not cover the current cost of hearing aids or substantial vision or dental services. A more generous package would certainly cost far more.
Nonetheless, there is public and legislative support for the recognition of dental, vision, and hearing services as an integral part of overall health and health services. The evidence points to consideration of ways to include such services in available coverage options under the Medicare program. Low-income older adults are at a greater risk of forgoing necessary services not covered by Medicare that have consequences for the rising costs of the covered services such as avoidable hospitalizations and emergency department visits.1- 3 Continuing to exclude dental, vision, and hearing services from the covered services under Medicare fails to acknowledge that all these health services and the systems that provide them are interconnected. Due to these Medicare gaps in coverage, health care professionals are limited in their ability to appropriately and comprehensively address the health issues of beneficiaries as they age.
Corresponding Author: Amber Willink, PhD, Roger C. Lipitz Center for Integrated Health Care, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Hampton House 698, Baltimore, MD 21205 (firstname.lastname@example.org).
Published Online: June 29, 2017. doi:10.1001/jama.2017.8647
Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Funding/Support: The research for this article was supported by grant 20160346 from the Commonwealth Fund.
Role of the Funder/Sponsor: The Commonwealth Fund had no role in the preparation, review, or approval of the manuscript or decision to submit the manuscript for publication.
Willink A, Schoen C, Davis K. Consideration of Dental, Vision, and Hearing Services to Be Covered Under Medicare. JAMA. Published online June 29, 2017. doi:10.1001/jama.2017.8647