Does Medicare Cover Medically Necessary Dental Work
If youre looking for affordable oral surgeons that accept Medicare, know that Medicare does cover several types of dental care.
If youre trying to figure out if your dental needs will be covered, consider the difference between medically necessary and what falls exclusively in the realm of dental insurance.
Procedures that Medicare will cover as long as its medically necessary include:
- Tooth extraction before an organ transplant
- Reconstructive surgery after traumatic injury or tumor removal
- Tooth extraction before radiation treatment
There are more dental procedures that arent covered by Medicare than procedures that are.
Medicare doesnt cover:
- Extraction of an infected tooth
- Tooth replacement and dentures
If you think you qualify for Medicare coverage of a dental procedure, youll need a doctor to explicitly say the procedure is medically necessary.
Quick Note On Medicare Coverage
Although the bulk of this article will focus on Medicaid, it will be relevant to many to understand how Medicare health insurance approaches dental procedures as well. Simply put, Medicare doesnt provide dental benefits, only coverage for medical care.
The one exception to this is Medicare Part C plans, also known as Medicare Advantage. These plans wont always provide dental benefits, but they will in some cases. More complex and costly services such as root canals tend to cost more and may not be covered, so make sure that you check all of the details with your insurance company.
Why Did I Get Denied For Medicaid
Theres a multitude of reasons why someone may get denied for Medicaid coverage. Aside from not meeting the financial or demographic requirements, some common reasons for a denied Medicaid application include:
- Incomplete application or documents
- Failure to respond to a request within a timely manner
- Late filing
- Disability not proven or otherwise not medically qualified
Dont forget that mistakes can be made on behalf of Medicaid, and you have a right to appeal Medicaids decision concerning your coverage. Contact your state Medicaid program for instructions about how to appeal a decision if you are denied benefits.
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Can You Have Medicaid And Medicare At The Same Time
Yes, some beneficiaries are eligible for both Medicaid and Medicare. Depending on where you live and your eligibility, you may be able to enroll in a special type of Medicare Advantage plan called a Dual-eligible Medicare Special Needs Plan .
A D-SNP can offer benefits that Original Medicare dont cover, such as dental, hearing, vision and more. All D-SNP plans are required to cover prescription drugs.
To learn more about these special types of plans and to find out if any are available where you live, you can compare plans online or call to speak with a licensed insurance agent.
Best For Potential New Offerings: Wellcare
WellCare is our top choice for a newcomer to the field of Medicare Advantage plans. Founded in 1985, theyre an up-and-coming provider.
Access to a personal emergency response system
Easy to navigate website
Only available in 27 states
Not as established as some other providers
Founded in 1985, WellCare is a relative newcomer. We picked them as one to watch for potential new offerings in their Medicare Advantage Plans for two reasons: In 2018, WellCare acquired Aetnas Part D prescription drug plan and in 2020, they were acquired by Centene, one of the largest providers of Medicaid. This deal-making activity could result in new Medicare Advantage Plan offerings that address specific pricing or feature needs.
Benefits offered with some WellCare Medicare Advantage Plans include over-the-counter coverage and access to a personal emergency response system. The OTC benefit is a fixed dollar amount for non-prescription medications and wellness-oriented items that can be shipped directly to you. The personal emergency response system, for people who live alone or are left alone for long periods, is connected to your phone and allows you to get emergency help with the push of a button.
WellCare Medicare Advantage Plans are available in 27 states. They have a full range of plans with premiums ranging from $0 to over $100 each month, depending on your needs and location.
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What To Dentures Cost
Dentures can vary in cost and quality. According to Bankrate.com, some of the potential costs for dentures include:
- Low-cost dentures range from $300â$500 for an upper or lower set to $600â$1,000 for a complete set.
- Mid-priced dentures typically use higher quality materials and may look more natural. Costs range from $500â$1,000 per upper or lower to $1,000 â$3,000 for a complete set.
- Premium dentures use the highest quality materials and techniques to create a long-lasting denture. Costs range from $2,000â$4,000 per upper or lower denture to $4,000â$8,000 for a complete set.
What Are The Potential Costs For Dentures With Medicare
Medicare Advantage plans offer various types of coverage for dental services. Most plans will not cover the full denture costs.
Some plan coverage and cost examples, using the Find a Medicare Plan tool, are shown in the chart below.
There are other options a person may access to get dental coverage or reduced dental costs:
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Does Pregnancy Medicaid Cover Dental
Medicaid may cover dental work during your pregnancy depending on your income level and the state you live in. Even if you aren’t eligible for Medicaid normally, you may find that you are eligible for Medicaid during pregnancy.
If this is the case, you should complete the ACA health insurance application, and remember two very important things:
- Where it asks if you are pregnant, mark yes
- If it asks if you have a special life event, mark yes
Additionally, if you ask for help in completing the form, or correcting mistakes you may have made on the form, make sure to tell the person helping you that you have a life event because you are pregnant.
Medicare Part B Dental Benefits
On the other hand, if the physician conducts the examination needed prior to kidney transplant or heart valve replacement, the CMS states that Part B benefits will apply.
However, when it comes to Medicare Part B, there are two specific sets of services that it will not cover.
The first involves services used to care, treat, remove, or replace teeth to structures supporting the teeth. For example, this can include pulling teeth prior to getting dentures.
The second set of services Medicare Part B wont cover also include those related to the teeth and their supporting structures, unless those services are needed to effectively treat a non-dental condition.
In this type of situation, the dental service must be performed at the same time as the covered service in order for Medicare to pay its portion. It must also be performed by the same healthcare professional who performed the covered service, whether that person is a physician or dentist.
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Many Medicare Advantage plans do offer dental coverage, according to Medicare.gov, though the exact benefits provided varies based on the plan chosen.
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How Much Does Oral Surgery Cost With Medicare
The cost of your oral surgery or dental procedure depends on what is performed, your coverage, and where you get the procedure done.
In general, youll be responsible for 20% of the price of any procedure. The deductible for Medicare Part B changes yearly, but its currently at about $203.
Finally, youll be stuck paying the price for all your medications if you dont have Medicare Part D.
How Much Do Dentures Cost Under Medicare
Dentures can cost anywhere from a few hundred to a few thousand dollars, depending on the type of dentures you get.1
The amount that you pay for dentures may depend on the level of coverage provided by your Medicare Advantage plan.
First, you may have a monthly premium in order to belong to the plan. In 2021, the average premium for a Medicare Advantage plan with prescription drug coverage is $33.57 per month .2 In fact, $0 premium Medicare Advantage plans may be available where you live.
Your Medicare Advantage plan may also have a deductible, which is the amount of money you must pay for covered services and items before your benefits kick in.
Lastly, you may have some coinsurance or copayment amount for your dentures, which is your portion of the cost-sharing after you meet your deductible.
When you consider potential cost of dentures, you may find that enrolling in a Medicare Advantage plan that includes dental benefits could help you save you money in the long run.
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How Do I Find Low
To find dental clinics for low-income families or individuals:
- Contact your local health department
- Contact a local dental school
- Participate in a clinical study
- Contact a Health Insurance Navigator
And to find dentists and dental clinics that accept Medicaid:
- Consult the provider booklet that came with your insurance to find Medicaid dental offices
Medicaid Dental For Adults
Dental help for low-income adults is a bit more complicated. Each state gets to choose what Medicaid dental for adults they will provide. There are no minimum requirements for adult dental coverage and less than half of the states in the US provide coverage for emergency dental care.
That being saiddo not despair!
If you are an adult on Medicaid and your state doesn’t cover the services you need, there may be other options available to you. We’ll talk about these options further down in the article.
If accessibility is a concern, be sure to check out our article on dental care for adults with disabilities.
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Finding A Dentist That Accepts Medicaid
Now that youve determined if your Medicaid plan includes dentures, its time to find a dental provider in your area that accepts Medicaid benefits. Like many types of government plans , Medicaid isnt always accepted by private practice dentists. Only certain providers will be able to file benefits on your behalf, and if theyre listed as a Medicaid provider it may be challenging to try to find an opening for an appointment.
How Medicare Advantage Dental Coverage Compares To Affordable Care Act Marketplace Coverage
As context for assessing the scope of dental benefits offered to Medicare Advantage enrollees, we reviewed dental coverage available to those who purchase dental coverage through the ACA Marketplaces. Adults purchasing plans through the ACA Marketplace may have dental coverage as part of their medical plan, or may choose to purchase separate stand-alone dental coverage. Among stand-alone dental plans available to adults on HealthCare.gov in 2021 , 100% cover routine preventive dental services , 97% cover basic dental care , and 81% cover major dental care . Unlike the analysis of Medicare Advantage plans, the data on the ACA Marketplace is not enrollment-weighted.
Like Medicare Advantage plans, most plans have little to no cost sharing for preventive services. For adult routine dental coverage, most plans charge no coinsurance , followed by no coinsurance after meeting the dental deductible . The median dental deductible for an individual is $50. For adult basic dental care, the most common cost sharing amount is 50% coinsurance after meeting the dental deductible .
Most plans on the ACA Marketplace have an annual limit the plan will pay toward covered services, typically ranging from $1,000 to $2,000. For stand-alone dental coverage, premiums vary slightly depending on the age of the enrollee. For an adult age 40, the average premium in 2021 is $290 per year, and ranges from $97 per year to $780 per year.
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Oral Surgeons That Accept Medicare
Medicare provides coverage to eligible Americans for medically necessary procedures. This includes surgery, medicine, routine check-ups, and anything else you need to keep you healthy.
However, dental coverage is not covered by original Medicare. You can opt for more coverage with Medicare advantage, which sometimes adds dental to your plan. The more coverage you add to your Medicare plan, however, the more youll pay.
Medicare does provide coverage for certain dental procedures, though. As long as your doctor signs that the procedure is medically necessary, Medicare will cover you.
Oral surgeons work almost exclusively with dental insurance, so it can be difficult to find a dentist that takes Medicare and Medicaid. In fact, it can be a struggle to find a dental doctor that accepts even the best insurance companies at all.
Before you schedule a procedure, you should call your preferred doctor and ask if they accept Medicare. While you have them on the phone, ask about how much your care will cost. Rates for oral surgeons that accept Medicare can vary greatly.
Medicare Advantage Dental Policies
One exception to the dental exclusions under Original Medicares parts A and B is Medicare Advantage. Commonly referred to as Part C, these types of policies are offered by private insurance companies and are intended to cover all of the same basic expenses participants receive under the Original Medicare plan.
Many Medicare Advantage plans do offer dental coverage, according to Medicare.gov, though the exact benefits provided varies based on the plan chosen.
Additionally, these plans can be:
- PFFS Plans
The type of plan chosen depends on what benefits youd like to receive, the cost of the plan, and any coinsurance or copayments that would apply.
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Denture Coverage Through Medicaid
Medicaid beneficiaries who are also eligible for Medicare may be able to enroll in a certain type of private Medicare plan called a Medicare Advantage Special Needs Plan. These plans are designed for people with certain health, living or financial circumstances, and one of the available plans is a Dual-eligible Special Needs Plan .
These plans are designed for people on both Medicare and Medicaid and feature a set of benefits that cater to those specific needs. Plan members do not pay a monthly premium and most plans include dental benefits that may include coverage for dentures.
If you are eligible for Medicare, speak to a licensed insurance agent to find out if Dual-eligible Special Needs Plans are available in your area and how they might cover dentures and other dental benefits.
Medicaid Coverage Varies Considerably Depending On Which State You Live In
Although most beneficiaries know that Medicare doesnt provide dental benefits, the situation with Medicaid is substantially more complex. The main reason for this is that Medicaid covers different dental services in different states. Medicaid does provide some level of dental care in many states, and will even cover root canals and other complex forms of dental care in some.
However, Medicaid still doesnt provide a lot of dental care in most states. While we cant go over the detailed dental treatment coverage structure for every single state, well go over some key distinctions you should understand as well as some general classification of state coverage limits.
Does Maryland Medicaid Cover Dental
Medicaid is a program developed to defray some or all health care costs for people with limited income and financial resources. Funding for the program is shared between the federal government and states. The federal government sets the requirements, and the states administer the programs. Beyond the federal requirements, states have a certain amount of flexibility in establishing eligibility and benefits.
Medicare Benefits Solutions
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All states must adhere to federal mandates that require basic dental coverage for children, but the states are given discretion with regard to dental coverage for adults. Until 2019, Maryland Medicaid excluded dental benefits for adults. Now there is a program in place to cover certain dual-eligibles.
Types Of Medicaid Plans Including Dental
The type of Medicaid that you have could impact whether it pays for dental work for adults. Each state offers a variety of plans designed for different groups of low-income individuals.
In addition to the straight or regular program, you could enroll in unique plans for pregnant women, dual-eligible Medicare recipients, and individuals deemed medically needy.
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Services Excluded Under Part B
The following two categories of services are excluded from coverage:
A primary service 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 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 .
Find Dental Plans For Medicare Near You
To find a dental plan near you, you should visit the websites of the companies offering Medicare Advantage plans to view the details of each plan. Many company websites also allow you to see if your dentist accepts the plan. If youre not sure where to start, consider talking to a broker or consultant. Good resources include theState Health Insurance Assistance Programs at 877-839-2675 or call Medicare at 800-MEDICARE to get answers to questions not answered in your research.
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Are Dentures Covered By Medicaid
Are you new to Medicaid or trying to get affordable dental care after losing your dental benefits at retirement? You may be wondering if routine services and treatments like exams and dentures are covered under your Medicare or Medicaid benefits.
Medicare and Medicaid are both very different from one another, both in what they cover and in regard to who is included in their plans.