Medicare Coverage For Dental Services
Unfortunately, Medicare doesnt cover most routine dental care, procedures, or supplies however, certain dental procedures are covered when youre in a hospital or if the procedure is deemed medically necessary.
Its important to maintain proper dental care and hygiene throughout your life, but as you get older, oral surgery or other dental procedures may be necessary to fix issues or pain, or even diagnose more severe medical issues. However, according to the National Institute of Dental and Craniofacial Research, about one in four seniors ages 65+ have gone five years or more since their last dental visit.
If you are eligible for Medicare, you have options to help with the cost of dental procedures or oral surgery. There are a number of exclusions and exceptions to be aware of, so understanding what is and is not covered can help determine how much you will pay out-of-pocket.
When Original Medicare Will Not Cover Oral Surgery
Typically, Medicare covers dental services only if the dental procedure makes hospitalization necessary. Medicare will not cover the cost of dentures or other dental appliances even if the procedure results in the need to have your teeth replaced.
In that case, and in most cases of dental care, you are responsible for 100 percent of the cost of dental services.
What Medicare Does Not Cover
Medicare Advantage Dental Coverage
Some Medicare Advantage plans include dental insurance, and others dont. Dental benefits vary from plan to plan. Some plans cover only standard services, while others cover a wider range of dental procedures.
The easiest way to know what your plan covers is to do research beforehand. Every Medicare Advantage plan offers an outline of coverage available on Medicare.gov. Here, you can see what benefits your plan offers and where those benefits are accepted. You should never go into Medicare Advantage blind. Knowledge is key when enrolling in a Medicare Advantage plan.
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Possible Directions For Future Research
The committee identified several areas in which further research would be helpful, although it did not attempt to set priorities. In general, it was disappointed to find so little evidence documenting the effectiveness of accepted clinical practices in the oral health care of patients with leukemias, lymphomas, cardiac valvular disease planned for valve replacement or repair, and organ transplants. Lack of evidence is not itself evidence that the current standards of care are inappropriate, but it does point to the desirability of studies that could help assess the benefits and harms of that care.
Research on education and other strategies to encourage patient adherence to self-care regimens is important in dental care as in other areas. For example, even at the risk of tooth loss and bone damage, some patients who have undergone radiation therapy for cancers of the head and neck do not follow the recommended but very rigorous self-care routines, which may result not only in worse health outcomes but also in higher Medicare costs.
In addition, the link between oral health and coronary artery disease and stroke remains an important area for further research . With new research suggesting a relationship between oral health status and pneumonia , further investigation of this link and of the effectiveness of dental care and oral hygiene in preventing pneumonia also is warranted .
Legal Memorandum: Statutory Authority Exists For Medicare To Cover Medically Necessary Oral Health Care
The following is the Center for Medicare Advocacys legal analysis and does not represent the federal Medicare agencys position or interpretation of its dental coverage policy.
Medicare coverage for medically necessary oral health care is supported by the Medicare statute, its legislative history, Centers for Medicare and Medicaid Services policy, and precedent established by podiatry coverage. For this purpose, medically necessary oral health care refers to care that, according to accepted standards of practice, is reasonable, necessary, integral, and prudent to the management and/or treatment of a covered medical condition, and/or for prevention of a medical complication from oral/dental pathologies.
The Medicare Dental Exclusion is Limited and Should be Interpreted Narrowly
The Medicare statute excludes payment for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth Section 1862 of the Social Security Act . The provision bars payment when the primary purpose of the dental work is to address the teeth and supporting structures.
The Senate Report accompanying the legislation, however, expressly qualifies the scope of these exclusions:
The full section of the Senate Report repeatedly acknowledges there could be clinical situations in which an excluded item or service is medically necessary and clarifies firmly that coverage would be available in those instances.
1/3/2019 W. Kwok
Medicare May Cover Oral Surgery If It Is Medically Necessary
Oral surgery involves procedures performed on the bones, nerves or tissue of the jaw or mouth. When such a procedure is considered medically necessary and is performed by a Medicare-participating doctor or surgeon, it may be covered by Medicare.
Medically necessary is defined as a treatment or service that is required in order to treat a specific injury, illness, disease or condition.
- For example, if you suffer an injury that results in facial or jaw fractures and are admitted as a hospital inpatient, Medicare Part A may cover some of the costs of your hospitalization and surgery costs.
- If your oral surgery is performed in an outpatient setting, Medicare Part B may cover the surgery if it is medically necessary and is part of a Medicare-covered service.
It is important to keep in mind that Medicare will not cover oral surgery that is solely intended to treat your teeth, such as the installation of bridges, crowns or dentures.
If you require this type of surgery, you will likely pay the full cost of your treatment unless you have dental insurance or a Medicare Advantage plan that offers dental benefits.
Does Medicaid Cover Dental Care
Medicaid dental coverage depends on the state in which you live, as well as your age. Medicaid is required to provide children with access to dental coverage, but each state determines which dental benefits adults enrolled in Medicaid receive. Most states do provide coverage for emergency dental services for adults, but fewer than half currently offer comprehensive dental coverage to adult Medicaid enrollees.
This list summarizes each states current Medicaid dental offerings for adults.
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Effectiveness Of Dental Care In Improving Health Outcomes For Leukemia And Lymphoma Patients
No large, multicenter, randomized clinical trials have assessed the effectiveness of dental interventions to prevent or manage oral or systemic complications of chemotherapy for leukemia or lymphoma patients. A few controlled studies suggest that dental care for leukemia patients prior to chemotherapy may prevent or reduce subsequent episodes of septicemia and prevent or reduce the severity of common oral complications of chemotherapy that are associated with the prior burden of oral disease . Unfortunately, these studies involve few elderly patients.
A recent study with no control group that tested the effect of not treating chronic dental disease prior to chemotherapy concluded that treatment for chronic problems could be safely postponed with little effect on the subsequent risk of acute dental disease . It also concluded that a prechemotherapy oral examination was still needed to identify acute dental disease for treatment to prevent local exacerbations or systemic spread of infection
These few studies of prechemotherapy dental treatment have involved mostly or entirely leukemia patients, who tend to receive aggressive, combination chemotherapy that is associated with more severe immunosuppression. Additional studies would be needed to determine the effects of prechemotherapy dental treatment on lymphoma patients.
Treatment Of Cancers Of The Head And Neck
Treatment for most cancers of the head and neck involves radiation, surgery, or a combination, although some chemotherapy is also used . Treatment is a team effort, involving the head and neck medical oncologist, radiation oncologist, head and neck surgeon, dentist, and other personnel. Surgery to excise cancerous tumors can impair function and appearance. Dental services may be an integral part of treatments to reduce or correct such damage.
Surgery can be especially difficult and risky around the fine structures of the larynx. As a result, clinicians have pressed ahead with the development of chemotherapy for laryngeal cancers. Anticancer drugs in general work by inhibiting cell division in active tissues, which has the side effect of inhibiting healing and growth in the healthy tissue lining the mouth. The resulting irritation and inflammation of the oral mucosa is called mucositis, which can be treated by both physicians and dentists and is discussed further below.
Radiation therapy is used with surgery for most cancers of the oral cavity and pharynx. Radiation, like chemotherapy, can affect both tumor cells and healthy cells. The damage to healthy tissue depends on the size and number of radiation doses and on the location of the tumor and the therapy. Radiation therapy can be from either an external source or an implant in some cases, both are necessary .
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Original Medicare Dental Coverage
Original Medicare, Part A and B, does not cover routine dental care, including:
- Cleanings and oral exams
- Dental appliances, including dentures or dental plates
There are a few exceptions to this. Medicare Part A may cover certain dental services performed in a hospital if its a necessary part of a covered service. For example, if you need a preliminary oral examination before a surgery or organ transplant or if you need reconstructive jaw surgery, you may be covered for these dental procedures because the care is related to another service that Medicare does cover. You may also be covered for extractions if theyre needed to prepare your mouth for radiation for oral cancer. If you receive these services as an outpatient, youd be covered under Part B.
If you need inpatient emergency hospital care because of a complication from a dental procedure, Part A will cover your inpatient hospital treatment, even if the dental services arent covered.
Keep in mind that even if Original Medicare covers a specific dental service, you may not be covered for post-treatment dental services once the specific issue has been treated. So, for example, in the case of Medicare covering reconstructive jaw surgery, it may not continue paying for dental care after that operation.
How Important Is Medicare Oral Surgery Coverage For Seniors
If you are a current Medicare recipient, you may feel that your current coverage effectively meets your medical needs such as doctors appointments and hospital care, but what about coverage for additional healthcare needs? What about your teeth, for example?
The importance of having coverage for both routine dental needs, like teeth cleanings and fillings, and emergency dental surgery, like root canals and tooth extractions, cannot be understated.
The older we get, the more likely we are to encounter scenarios where this type of Medicare oral surgery coverage is necessary. Many seniors are at a higher risk for dental diseases, such as periodontitis, tooth decay, and oral cancer.
These conditions dont just affect your teeth, they can also limit your nutrition intake and in some cases, even increase your risk of stroke, heart attack, or diabetes. For this reason, its safe to say that effective dental coverage under Medicare is extremely important.
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Medicare Dental Coverage Under The Pace Program
PACE is a joint Medicare and Medicaid program that provides health-care services for people living in a community so that they can delay institutional or nursing home-care for as long as possible. PACE covers all services covered under Medicare and Medicaid and if you enroll in the program, youll get all of your Medicare coverage through your PACE organization as long as your health-care team determines theyre necessary for your care. In addition, PACE may include certain benefits beyond the Medicare program, such as dental services.
You may be eligible if youre 55 years or older and enrolled in Medicare, Medicaid, or both programs . You must also live in the service area of a PACE program be able to live safely in a community environment and need a nursing home-level of care . To learn more about PACE and see if youre eligible, visit Medicare.gov.
Does Medicare Cover Medications Before Or After Implant Surgery
Medications you may need before or after implant surgery, such as antibiotics and pain meds, are covered by the drug benefit associated with your MA plan or by Medicare drug coverage Part D, if you have a standalone drug plan instead of a MA plan. Part D or your MA plan with drug coverage will only pay for medications on the plans formulary. Typically, you have copay or coinsurance costs, which vary depending on which tier of drug your dentist prescribes for you.
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How Else Can You Get Coverage For Dental Services Medicare Doesnt Cover
For an added layer of protection, some Medicare Advantage plans may be paired with a . You’ll have to pay a monthly premium and satisfy deductibles and copays, but the cost may be offset by lower out-of-pocket fees. Most of these dental plans require that you see an in-network dentist. Some plans let you go to any dentist , but you may have to pay more for their services.
A may be worth considering if you dont have dental insurance. These discount plans arent dental insurance. They are a type of membership, similar to a warehouse club, but rather than getting bargains on food or clothing, you get discounted prices on dental services.
Medicare Advantage Plans May Cover Oral Surgery And May Cover Other Dental Care
By law, Medicare Advantage plans must provide the same minimum benefits as Medicare Part A and Part B, with the exception of hospice care, which you still receive from Medicare Part A. This means that qualified oral surgery is covered by a Medicare Advantage plan in the same way that it is by Medicare Part A and Part B.
Some Medicare Advantage plans may also provide coverage for routine dental services such as dental exams, fillings, tooth extractions, dentures and more.
Find Medicare Advantage plans that help cover oral surgery
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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.
Medicare has neither reviewed nor endorsed this information.
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Other Dental Coverage Options
Outside of getting Medicare dental benefits through a Medicare Advantage plan or a PACE program, you may find yourself having to pay the full cost for most routine dental care if youre enrolled in Original Medicare or in a Medicare Advantage plan that doesnt include dental coverage.
Dental insurance may be another option if you want help with dental costs. Keep in mind that stand-alone dental plans are not part of the Medicare program, and this coverage may come with certain costs, including premiums, deductibles, coinsurance, and copayments.
In addition, if you have limited income and qualify for Medicaid benefits, some state Medicaid programs include dental coverage. Check with your states Medicaid program to see if youre eligible for low-income assistance and if dental services are covered.
What Do The Australian Dental Association Codes Mean
The ADA codes are a universal set of numbers used to categorise various procedures for ease of reference. Importantly, the codes are descriptive of the procedure only, not who performs them.
Commonly Specialist and general dentists will use the same codes. However, the outcome will be very different due to training, tools and time taken to prepare and deliver the outcome.
There are particular categories of specialties registered. Commonly quoted roles such an implantologist and cosmetic specialist are not registered specialties and have no formal recognition.
As such, simply taking a quote from a specialist to another general dentist will not give a fair comparison.
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Learn More About Medicare Dental Coverage
If youre interested in Medicare dental coverage, I can find Medicare Advantage plan options that may offer routine dental benefits. To learn more about me, see my photo below and click the View profile link read more about my background. You can schedule a one-on-one phone call or request an email from me with more plan information find both of those links below as well. If you want to compare plan options now, click the Compare Plans button on this page.
This website and its contents are for informational purposes only. Nothing on this website should ever be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition, including decisions about the correct medication for your condition, as well as prior to undertaking any specific exercise or dietary routine.
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Table 42summary Of Dental Services Currently Covered And Not Covered Under Medicare For Selected Diseases Or Conditions
|Management of infection following transplantationOral examination prior to renal transplant surgery on an inpatient basis||Oral examination for transplants other than kidneyOutpatient oral examination performed by a dentist prior to kidney transplantDental treatment to reduce risk of infection or eliminate infection for any transplantation prior to or following transplant|
|Heart valve repair or replacement||None||Oral examination prior to repair or replacementDental treatment to reduce risk of infection or eliminate infection prior to or following repair or replacement of valve|
To guide its assessment of the evidence about dental care for these five conditions, the committee adapted the evidence pyramid introduced in as shown in . One distinguishing feature of compared to the generic pyramid is that it requires a link between a nondental condition or treatment and either dental services or dental complications. The first tier of the pyramid refers accordingly to the relationship between the medical conditions listed earlier and oral health conditions. The relationship could be manifest either as an increased risk to oral health caused by the medical condition or as an increased risk to systemic health related to poor oral health. The tiers above refer to the effectiveness of dental care in treating oral problems and improving outcomes for the medical condition.
Evidence pyramid for assessing medically necessary dental services. SOURCE: Adapted from IOM/NRC, 1999, p. 89.