Most people receive dental coverage through their employer’s health coverage. However, according to the Centers for Disease Control and Prevention (CDC), fewer than 30% of seniors age 65 and older had dental insurance in 2017. Seeing the dentist regularly is essential to preventing major dental issues down the road.
It may be surprising to some that Medicare does not cover routine dental services. If a dental procedure is considered medically necessary, Medicare may cover it. There are a few situations where Medicare will help cover the costs of specific procedures, but dental treatment will typically need to be paid for out-of-pocket or covered by an alternative plan.
So, what would be categorized as a “medically necessary” dental procedure? The answer to this comes down to the way your doctor proves the need for the service or procedure. If the medical necessity is there and Medicare covers the service or procedure, it does not guarantee all follow up visits will be covered accordingly.
One example of Medicare providing coverage, is if an injury occurs that would require reconstruction of the jaw and tooth extractions were necessary. Medicare may cover the extraction, but not the future procedures, such as an implant for the extracted tooth.
Another example is if dental treatment is necessary for someone with oral cancer and extractions are needed to prepare for radiation or the removal of a tumor. Medicare may also cover dental exams requested prior to a complicated procedure such as a kidney or heart transplant.
In situations that are medically necessary, Medicare will likely cover part of the costs of the dental procedures. Be prepared that it might still be a battle to get certain dental services covered.
Typical routine dental services that would not be covered under Medicare would include basic cleanings, exams, and x-rays. Medicare also will not cover major services like fillings, extractions (unless medically necessary), bridges, or crowns. More expensive treatments such as root canals, implants, and dentures also fit under this category.
The costs for dental procedures can quickly add up. Though, they often outweigh the costs of further complications. Paying for these costs out-of-pocket in retirement can be overwhelming, especially when factoring in the costs of other health insurance premiums.
The setting in which the dental procedure is performed will determine what part of Medicare covers the service. Part A may cover the hospital stay if the dental procedure is performed in the hospital and you’re admitted as an inpatient, while Part B would cover the actual surgery. For either part to begin paying, the Part A and Part B deductibles would need to be met.
If the beneficiary has a Medigap plan is in place along with Original Medicare, the Medigap plan will help pick up some of the costs that Medicare does not pay. However, the Medigap plan will only pay after Medicare approves the claim.
There are alternative options for getting coverage for the dental services that are not medically necessary. One option that works well for Medicare beneficiaries is a Medicare Advantage plan. These plans often offer additional benefits for the routine services that are not covered under Original Medicare.
There may be a limit or reimbursement in place, but not every Medicare Advantage plan provides this kind of coverage. Plans that do not cover dental directly within the plan may offer a dental rider for an additional monthly premium. Medicare Advantage plans also have a network of dentists, so it is important to check and make sure the preferred dentist is in the network before going.
Plans also can change their benefits from year to year – one year, the plan could provide dental benefits then take it away the next.
The other option for lowering out-of-pocket costs is to purchase a standalone dental plan that is separate from Medicare. Typically, these plans have a maximum limit for dental services, and the coverage for preventive and major services can vary by plan. However, a benefit in purchasing this kind of plan is there may not be a restricted network of dentists. Additionally, standalone dental plans typically keep their benefits the same from year to year, unlike the Medicare Advantage plans.
Most dental treatments will not be covered under Original Medicare. Instead, those routine dental services can be covered under alternative insurance plans. Understanding dental coverage under Original Medicare and knowing the alternatives will help avoid those pesky and often expensive, out-of-pocket costs.
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