How Does Medicare Advantage Dental Coverage Work
Medicare Advantage plans are the primary method for dental coverage under Medicare.
Whatâs usually covered:
- Tooth extractions
Medicare Advantage are bundled plans that combine add-on benefits such as dental or vision with Original Medicare and additional cost-sharing for medical needs. About 94% of Medicare Advantage plans offer the option for dental coverage. However, sometimes there is an additional fee to include dental coverage in your plan.
For example, the standard Medicare Advantage plan from Kaiser Permanente does’t include dental care, but if you upgrade to the Medicare Advantage Plus plan, you’ll get dental, vision and hearing coverage.
The level of dental coverage with Medicare Advantage plans varies. Some have an annual payout limit, such as only contributing $1,500 to your dental care each year. Other plans could have coverage specifications on the number of cleanings per year or denture coverage.
Defining Medically Necessary Dental Services
The 1997 Balanced Budget Act, which provided for this study, included no definition of medically necessary dental services. One definition of such services is found in a bill submitted earlier in 1997 . It called for coverage of dental services that are medically necessary as a direct result of, or will have a direct impact on, an underlying medical condition if the coverage of such services is cost-effective . It also included explicit provisions for Medicare to cover dental care related to several specific illnesses. The bill’s languageminus the wording about cost-effectivenessis similar to that used three years earlier in a bill that included medically necessary oral health care in a proposed set of basic benefits to be covered as part of broad health care reform . This earlier proposal also included oral care intended to control pain and infection and to restore function. The committee understands these definitions of medically necessary servicesparticularly the one proposed in 1997to be narrowly constructed to continue the general exclusion of Medicare coverage for dental care but to broaden the scope of the exceptions to include dental care needed to prevent or effectively manage systemic conditions including the oral complications of specific illnesses or their medical treatment.
Best Dental Insurance For Seniors On Medicare Of 2022
- Best Customer Service: Kaiser Permanente
- Best Online Tools: Humana
- Best for Potential New Offerings: WellCare
- Best for Special Needs: Cigna
- Coverage Limit : $1,000 to $2,500
- Providers In Network: 1,300,000
United Healthcare is our top overall pick for dental insurance for seniors on Medicare. It offers Medicare Advantage plans with an expansive network and flexible premiums.
Limited plan options depending on your location
Not all Advantage plans include dental coverage
United Healthcare, founded in 1977, was chosen as the best overall based on its popularity and its affiliation with the American Association of Retired People . In 2021, 26 million people were enrolled in Medicare Advantage plans nationwide. Of those 26 million people, United Healthcare insured the largest share of them, 27%.
Although United Healthcare was ranked below average for overall customer satisfaction in a 2021 J.D. Power study , more than 74% of Medicare beneficiaries have access to at least one United Healthcare plan in 2022.
Their full range of plans has premiums ranging from $0 to over $100 each month, depending on your needs and location. If you choose United Healthcare, you’ll also receive access to additional AARP programs and services such as discounts on shopping and travel, savings on home and auto insurance, and free financial advice.
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Which Types Of Medicare Plans Provide Dental Coverage
Some offer extra dental and vision benefits that Original Medicare doesnt cover. Medicare Advantage plans may offer basic coverage for dental services, which can include:
- Preventive dental exams
could help you pay for things such as copayments or deductibles for medical care. However, these plans do not offer coverage for dental services.
Assessment Approach: Intervention Population And Outcomes
The selection of conditions and services for assessment was guided in part by historical context. A few months before the passage of the 1997 Balanced Budget Act, legislation had been introduced, first, to cover a specific set of medically necessary dental services that were described as cost-effective and, more generally, to provide for future coverage of other services subsequently determined to result in reductions in expendituresthat exceed expenditures resulting from such coverage . This latter requirement is quite stringent generally, services are considered to be cost-effective whether or not they produce cost savings that fully offset direct service costs. The more restrictive language reflects the rules that Congress has adopted requiring increases in spending in one area to be offset by cuts elsewhere or by increased taxes.
The five conditions listed in the 1997 bill had been presented in prior analyses of health conditions that sought to identify those for which the cost of covering inpatient dental services would likely be offset by savings related to complications avoided, especially additional hospitalization . The five conditions were
valvular heart disease.
The population of interest includes Medicare beneficiaries age 65 and over as well as younger people qualified for Medicare on grounds of disability or diagnosis of end-stage renal disease . Evidence related to all age groups was reviewed.
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.
Medicare Supplemental Dental Coverage
When enrolled in a Medicare Supplement plan, you will need to purchase a stand-alone dental plan or utilize dental discount plans to receive coverage for dental services. Because Medigap plans are extensions of Original Medicare benefits, your policy will only cover medical costs Original Medicare leaves behind. This does not include dental coverage.
There are many great options available for those on Medicare Supplement plans who want dental coverage as well. Popular carriers for dental plans include Cigna, Manhattan Life, Aetna, and National General.
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Original Medicare Vision Coverage
Original Medicare also covers limited vision care. It does not cover routine eye exams for contact lenses or glasses.
However, Medicare Part B will cover some preventive or diagnostic eye exams, including glaucoma tests, yearly eye exams to test for diabetic retinopathy and eye tests for macular degeneration.
Medicare will typically cover cataract surgery to implant an intraocular lens if its performed with traditional surgical techniques or with lasers.
Following the procedure, Medicare Part B will typically provide some coverage for corrective lenses. The coverage for corrective lenses under these circumstances is limited to one pair of eyeglasses with standard frames or one set of contact lenses.
Medicare also covers eye prostheses for patients with an absence or shrinkage of an eye due to a birth defect, trauma or surgical removal. Coverage includes polishing and replacements every five years.
If you need vision coverage for routine services, you may want enroll in a Medicare Advantage plan that includes that benefit.
Oral Health Problems Associated With Radiation Treatment Of Cancers Of The Head And Neck
Because radiation therapy disrupts cell division in healthy tissue as well as in tumor, it also affects the function and structure of the oral mucosa and underlying organs and tissues such as salivary glands and bone. If directed at the lymph nodes in the jaw area, radiation may impinge in varying degrees on the salivary glands, which are very sensitive to radiation effects. Radiation can irreversibly damage these glands, resulting in insufficient production of saliva, known technically as xerostomia . Saliva is important to keep the oral tissues moist and to buffer the acidity of the oral environment, which is critical both to reducing bacterial growth and infection and to laying down new mineral deposits that keep the teeth strong and dense. After radiation, the teeth tend to become demineralized and to develop cavities easily, a tendency so marked that it has the special name radiation caries.
The likelihood of ORN is increased by trauma to the bone, including the trauma to the jawbone caused by a tooth extraction . The effect of such trauma on the risk of ORN is especially marked when the extraction or other trauma occurs near the time of the radiation . This occurs presumably because the radiation damage to blood vessels makes healing a recent extraction wound more difficult.
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Find A Medicare Advantage Plan That Covers Dental And Vision Care
Medicare Advantage plans can come in a variety of types, such as HMOs or PPOs.
The type of plan you have may affect which dental or vision providers you can visit in your plan network. Before enrolling in a plan, its wise to check the plans network participants to see if your favorite dentist or optometrist accepts the plan.
Compare Medicare Advantage plans in your area
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1 Fugelsten Biniek, J. et al. . Medicare Advantage 2021 Spotlight: First Look. Kaiser Family Foundation. Retrieved from www.kff.org/issue-brief/medicare-advantage-2021-spotlight-first-look.
About the author
Christian Worstell is a senior Medicare and health insurance writer with MedicareAdvantage.com. He is also a licensed health insurance agent. Christian is well-known in the insurance industry for the thousands of educational articles hes written, helping Americans better understand their health insurance and Medicare coverage.
Christians work as a Medicare expert has appeared in several top-tier and trade news outlets including Forbes, MarketWatch, WebMD and Yahoo! Finance.
Christians passion for his role stems from his desire to make a difference in the senior community. He strongly believes that the more beneficiaries know about their Medicare coverage, the better their overall health and wellness is as a result.
How Else Can I Get Senior Dental Coverage
You can purchase a stand-alone dental plan not associated with Medicare to help pay for dental out-of-pocket costs. Most of these stand-alone plans have monthly premiums and annual maximum benefits. You can find dental plans through eHealth .
You also might be interested in a dental discount plan. A dental discount plan charges a fee and in return gives you discounted rates to see a certain group of dentists.
According to the Mayo Clinic, problems in your mouth can affect the rest of your body. You can contribute to your overall health by taking care of your dental needs.
Medicare information is everywhere. What is hard is knowing which information to trust. Because eHealthâs Medicare related content is compliant with CMS regulations, you can rest assured youâre getting accurate information so you can make the right decisions for your coverage.Read more to learn about our Compliance Program.
How Current Proposals Would Add A Dental Benefit To Medicare
In the 116th Congress, the House of Representatives passed the Elijah E. Cummings Lower Drug Costs Now Act , which among many provisions, provided for dental coverage under Part B of the Medicare program, starting in 2025 if enacted into law. Medicare would cover 80% of the cost of preventive services and basic treatments, and would phase up coverage for more major treatments, covering 10% of the cost in 2025, increasing 10 percentage points per year to 50% in 2029 and thereafter. The Congressional Budget Office estimated this benefit would cost almost $238 billion over 10 years . The recently reintroduced version of H.R. 3 does not include coverage for a dental benefit.
Representative Doggett introduced the Medicare Dental, Vision, and Hearing Benefit Act in July 2021 that would provide dental coverage under Medicare Part B. In contrast to H.R.3, the proposal, according to a press release, would require no coinsurance for preventive services, and impose a 20% coinsurance for more extensive benefits, which is similar to how the Part B benefit is structured for physician and other outpatient services, and is lower than the 50% coinsurance typically charged by Medicare Advantage plans.
Dental Care For Patients With Leukemia Or Lymphoma
As described in , the standard evaluation for patients diagnosed with leukemia or lymphoma includes a careful oral examination and full-mouth radiographs to identify both existing infection and potential sources of infection. In addition to cleaning of the teeth, indicated periodontal or extraction procedures, and instruction in oral hygiene, mouth rinses may be prescribed to prevent or control microorganisms associated with oral infection and reduce the probability and severity of mucositis and stomatitis and systemic infection. Other patient management goals for leukemia and lymphoma patients are to relieve symptoms and encourage adequate nutrition and hydration. Topical anesthetics, saline rinses, and other strategies, which may be prescribed by both physicians and dentists, may provide some relief of symptoms.
Because bacteria in the mouth may enter the bloodstream through oral ulcers and areas of mouth tissue breakdown, the goals of dental care for patients who have developed treatment-related stomatitis or mucositis include reducing the level of organisms in the mouth and preventing any breach of its epithelial lining that provides an avenue for infection. Histopathological or microbiological analysis to identify the infectious organisms involved may be useful in guiding antimicrobial therapy .
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Does Medicare Cover Anything Dental
Although there is no primary coverage of dental care in Medicare, there is some limited insurance through Medicare Part A, which is hospital insurance. Medicare Part A will cover some dental procedures that happen in a hospital stay. For instance, if youre in a car wreck that damages your jaw and you go to the hospital, Medicare would cover any reconstruction of your jaw.
Medicare may also cover the following types of things:
- A dental exam in a hospital before a kidney transplant or heart valve replacement
- Dental services related to radiation treatment for some jaw-related diseases
- Dental splints and wiring needed after jaw surgery
- Jaw reconstruction if you have surgery to remove a tumor from your face
But if you need a complex dental surgery that has to be done in a hospital, Medicare would cover your hospital stay, but not the dental surgery.
Keep in mind that even if Medicare covers a procedure like the ones listed above, it wont cover any related dental care that might follow from something that happened in the hospital.
Medicare Advantage May Have Dental
Medicare Advantage plans are different than Original Medicare. They can add important additional benefits, like dental care, to your Medicare coverage.
Sometimes these benefits are automatically on your plan. In other cases, you may have to request them from your insurer.
Medicare Advantage Dental Rules: When you see the dentist on Medicare Advantage, you may have to pay some costs on your own. There will probably be additional rules, like a maximum number of visits or poor coverage for costly procedures. You may have a relatively low maximum annual benefit enough to get regular cleanings and a set of dentures, but not enough for unlimited dental work.
Expect limited help from your plan even if other medical procedures are well-covered. Medicare Advantage plans must have equal or better coverage as Original Medicare for benefits that are in Part A and Part B. However, Medicare Advantage plans create their own limits on dental coverage.
Medicare Advantage Dentist Networks: Medicare Advantage plans rely on provider networks, like PPOs and HMOs, instead of letting you see any doctor. Dental coverage is no exception. Heres a typical example of an optional dental plan on Medicare Advantage:
- 100% coverage onin-network routine exams
- 50% coverage on out-of-network routine exams
- Partial coverage for basic procedures and major services
- $1500 maximum annual benefit
What Does Medicare Cover For Dental Care
Some Medicare Advantage plans may offer additional benefits for dental care, including services related to dental implants. Medicare Advantage plans are offered by private Medicare-approved insurance companies, so they are able to include supplemental benefits not available under Original Medicare. For example, many Medicare Advantage plans include coverage for routine dental care such as annual exams and cleanings.
Some Medicare Advantage plans even offer supplement dental insurance with coverage for more complex dental procedures such as extractions, fillings, and other types of tooth replacement or restoration, which may include dental implants. You may have to get your dental care from a network provider, and your plan may only pay a set amount for these additional services, regardless of the actual charge. There may be a separate monthly premium for supplemental dental insurance with your Medicare Advantage plan.
Medicare And A Lack Of Dental Coverage
Unfortunately, having Medicare doesnt always help with this issue. According to Medicare.gov, this federal health insurance program typically does not cover dental care, procedures, or supplies.
Medicare doesnt provide benefits toward regular cleanings or services designed to treat and/or correct problematic oral issues, such as fillings or tooth extractions.
Medicare also does not generally offer benefits for dental devices, including dentures and dental plates.
So, what does Medicare cover when it comes to dental health care?
Medicare will also contribute toward oral examinations needed before kidney transplants or heart valve replacements in certain situations.
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