Medicare helps out numerous people by providing them with health insurance, but does Medicare cover dental benefits as well? If yes, then to what extent?
Did you know that having good oral hygiene can help you prevent heart disease and diabetes? The many drawbacks of poor dental health are undeniable. Many studies have shown that your chances of heart attack or stroke increase if your gums are infected with bacteria. Additionally, gum diseases can make it harder to control your blood glucose. Poor oral health is associated with pulmonary infections and can also increase your risk of developing dementia by a third.
Around nineteen percent of older adults have untreated tooth decay, and another nineteen percent have complete tooth loss. A study conducted in Korea confirmed that the prevalence of edentulous loss of teeth and the incidence of dental caries was higher in persons with a disability than in the non-disabled. On a distinct note, simple dental procedures are way costly for the average person to afford. For instance, a simple root canal can cost from $300 to $2000 and with dentures and dental crowning costing up to $3000.
There is an overall scarcity of affordable dental services despite the high demand for the services.
Studies have found that there is a low rate in the usage of dental treatment services owing to the high costs and lack of insurance coverage for dental services. Under these circumstances, it comes as no surprise people aren’t willing to pay hundreds and thousands for simple routine procedures regardless of the health risk that poor dental hygiene may pose.
Considering everything, affordable dental procedures are not available for people, so people look towards health insurance such as medicare for a solution.
Now the question is, does Medicare provide dental benefits?
Table of Contents
- 1 What is Medicare?
- 2 What are the different plans under Medicare?
- 3 What are the eligibility criteria for Medicare?
- 4 What are dental benefits?
- 5 Does Medicare cover Dental Benefits?
- 6 Does Medicare Cover Dental Implants?
- 7 Alternative and Low-Cost Dental Options
- 8 Conclusion
What is Medicare?
Medicare is a U.S. Federal program that provides health insurance to people that are at the age of 65 or above, or people with certain disabilities regardless of their age.
Congress created this program as a part of the Social Security Program in 1965. The purpose of medicare was to equip people of age 65 and older with coverage provided that they did not have any health insurance, to begin with. It has now grown to cover people that have end-stage renal disease and amyotrophic lateral sclerosis (ALS), or Lou Gehrig’s disease.
Whilst the program helps one with the cost of health care, it does fail to cover all the medical expenses, or more particularly the cost that comes under most long-term care.
What are the different plans under Medicare?
Original Medicare comprises two plans: Medicare Part A and Medicare Part B. Original Medicare pays for much, but not all, of the cost for covered health care services and supplies.
Medicare Part A, also known as, “hospital insurance,” covers hospital stays and inpatient treatment. It only covers the treatments which are deemed to be medically necessary. This shows that the doctor has concurred that the treatment is required to treat any ailment or condition. Medicare Part A comprises inpatient medical care such as Home health services inclusive of long-term care facilities and inpatient rehab, hospice, hospital care, nursing home care, and skilled nursing facility care. The home health services mentioned cover nursing care, physical therapy, and occupational therapy. The skilled nursing facility care covered by Medicare Part A covers meals, supplies, and nurse-administered injections. Medicare Part A administers care for the comfort of terminally ill individuals who no longer want to pursue treatment for their illness any. How much Part A covers for these services depends on which type of facility you stay in, whether you’ve met the deductible (which resets for each new stay), and how long your stay lasts.
Whilst Medicare Plan A covers most of the inpatient services, Medicare Part B covers outpatient medical services. They give the following services:
- Ambulance services
- Doctor’s office visits
- Durable medical equipment which includes equipment such as wheelchairs, walkers, and bathtub transfer benches
- Blood work and lab tests
- Mental health and substance abuse treatment.
- Outpatient surgery
Medicare Part B also covers a variety of preventive care services, such as tobacco cessation therapy, annual wellness visits, nutrition therapy, flu shots, diabetes screenings, cancer screenings, HIV and STD screenings, and preventive care. Part B covers 80% of costs for covered services, leaving 20% of the expense to be paid by the patients themselves.
Medicare Advantage, also known as Medicare Part C was created in 1997. Insurance companies rather than the federal government administered this plan, unlike the Original Medicare plan. These insurance companies offer supplemental benefits along with the benefits that are offered by the Original Medicare. They incorporate hospital and medical insurance in the Advantage plan.
Additional benefits incorporated in the Advantage plan include:
- Prescription drug coverage:
Almost all Medicare Advantage plans offer prescription drug coverage, unlike the Original Medicare plan
- Dental, vision, and hearing:
Medicare Advantages plan covers treatments even if they are deemed to be medically unnecessary by the doctors and the health professionals. Though, Most Medicare Advantage plans differ in the amount of coverage for these alternatives.
Many Advantage plans have no or low deductibles and no premiums. Another benefit of Medicare Advantage is that most plans place limits on the maximum cash-based costs you can incur during a plan year. Besides that, studies have shown that switching to a Medicare Advantage plan can save you money on lab administrations and clinical equipment. If you choose a Medicare HMO plan, you may see more investment funds on healthcare administrations provided by your HMO network.
Some plans offer long-term savings, plan adaptability, and better consideration, whereas others can prompt fewer supplier alternatives, extra expenses, and challenges in one’s way of life.
What’s more is that a few organizations offer other health-related advantages under their Medicare Advantage plans, like gym memberships, clinical transportation, and food delivery. Considerable Medicare Advantage plans also offer the accompanying advantages:
- some home healthcare services
- hospice care
- doctor’s visits
- preventive care
- SilverSneakers fitness memberships
Medicare Part D, also known as the Medicare prescription drug benefit, is an optional health insurance program provided by the U.S Federal government.
They introduced Medicare Part D in 2006 because both Part A and B lacked any outpatient drug coverage. It is a discretionary program that helps cover the expense of prescription drugs.
As Medicare beneficiaries are eligible for prescription drug insurance, therefore, Medicare Plan D aids them in paying for self-administered prescription drugs. If you have Original Medicare, then you are eligible to enroll for Part D. Otherwise, you can sign up for Medicare Part C, which also includes some prescription drug coverage.
They offered part D through private insurance companies either as a stand-alone plan, for those enrolled in Original Medicare, or as a set of benefits included with your Medicare Advantage Plan. This insurance covers a fraction of the medication cost. Most beneficiaries pay a month-to-month premium and different cost-sharing liabilities, for example, copays and deductibles.
The Medicare drug plans, including Medicare drug plans and Medicare Advantage Plans, have their catalog of what drugs are covered, called a formulary. This plan incorporates both brand-name prescription drugs and generic drug coverage.
The formulary incorporates almost 2 drugs in the most commonly recommended classifications and classes. These aides make sure that people can get the prescription drug they need regardless of the ailment they face. If Part D’s formulary does not comprise of the particular drug you require, in that case, an alternative or the comparative drug must be used. If your prescriber deems the alternatives to be unsatisfactory, then an exemption can be requested. Otherwise, you may have to pay out of pocket for the drug or file an appeal.
A Medicare drug plan updates its drug list during the year, according to the directions provided by Medicare. They update the list when drug treatments change, new drugs are delivered, or new clinical data opens up. All Part D plans should incorporate at least two drugs from most classes and should cover all drugs accessible in the following classifications:
A drug category is a group of drugs that treat the same symptoms or have similar effects on the body. All Part D plans must include at least two drugs from most categories and must cover all drugs available in the following categories:
- HIV/AIDS treatments
- Antipsychotic medications
- Anticonvulsive treatments for seizure disorders
- Immunosuppressant drugs
- Anticancer drugs (unless covered by Part B)
Part D plan also covers most of the vaccines, excluding the ones that the Medicare Part B plan has covered. Part D also excludes drugs and medicines that the law has banned. Following is a list of a few drugs that are excluded from Medicares’ coverage. There are certain kinds of drugs that are excluded from Medicare coverage by law. Medicare does not cover:
- Drugs used to treat anorexia, weight loss, or weight gain Part D may cover drugs used to treat physical wasting caused by AIDS, cancer, or other diseases
- Fertility drugs
- Drugs used for cosmetic purposes or hair growth: Drugs used for the treatment of psoriasis, acne, rosacea, or vitiligo are not considered cosmetic drugs and may be covered under Part D
- Drugs that are only for the relief of cold or cough symptoms
- Drugs used to treat erectile dysfunction
- Prescription vitamins and minerals (except prenatal vitamins and fluoride preparations)
- Non-prescription drugs (over-the-counter drugs)
Prescription drugs used to treat the aforementioned conditions may be covered if they are also used to treat other conditions.
Medicine for the relief of cold symptoms, for example, may be covered by Part D if prescribed to treat something other than a cold, such as shortness of breath from severe asthma, as long as the FDA has approved it for such treatment.
If your doctor prescribes a non-cancer medication on your plan’s formulary for a reason other than the FDA-approved use, your medication will most likely not be covered unless the use is listed in one of three Medicare-approved drugs compendia (medical encyclopedias of drug uses). When deciding whether to cover a drug for cancer treatment, your drug plan will consult these and other compendia as well as peer-reviewed medical literature. Your Part D plan may also deny your drug because it does not meet the FDA’s Drug Efficacy Study Implementation (DESI) standards. DESI assesses the efficacy of drugs that were previously approved solely based on their safety. Part D does not cover drugs that are found to be less than effective by DESI evaluation.
What are the eligibility criteria for Medicare?
Original Medicare is divided into two parts: hospital insurance and medical insurance. Hospital insurance, also commonly known as Part A insurance deems you to be eligible if you are age 65 or older and you or your spouse worked and paid Medicare taxes for at least 10 years. You can get Part A at age 65 without having to pay premiums if:
- You are receiving retirement benefits from Social Security or the Railroad Retirement Board.
- You are eligible to receive Social Security or Railroad benefits but you have not yet filed for them.
- If you or your wife neglected to pay the Medicare taxes during the period of your employment and you are of age 65 or older, then you may be able to buy Part A, provided that you are a citizen or permanent resident of the United States.
If you are under age 65, you can be eligible for Part A premium-free if either you are a kidney dialysis or kidney transplant patient, or conversely, for the past 2 years, you have been entitled to Social Security or Railroad Retirement Board disability benefits for 24 months.
While there are certain conditions under which you can avail Part A without paying any premium, none exist for the medical insurance, also known as Part B. Everyone must pay for Part B if they opt for it.
A person eligible for Part A is advised to Join Part B, but Part B has its own set of requirements. To qualify for Part B, your income must be at least $91,000 or double the amount in the case of a couple.
Enroll in both Parts A and B. In most situations, your enrollment window lasts seven months, starting three months before your 65th birthday and ending three months after. While you can join in Part B three months after turning 65, it’s advisable to do so early to avoid coverage gaps. Remaining ineligible for Part B may mean waiting until the next general Medicare enrollment session.
If you don’t enroll during your initial window, you won’t lose eligibility for Part B, but your premium will go up 10% each year you’re eligible but don’t enroll. Part B can be postponed if you or your spouse is already covered by a current employer’s plan. The General Enrollment Period (GEP) for Medicare A and B runs from January 1 to March 31 each year, with a late enrollment penalty if applicable.
The monthly premium for Part A is deducted from your Social Security, Railroad Retirement, or Civil Service Retirement check.
If you do not get any of these payments, Medicare sends you a bill for your Part B premium every 3 months.
If you qualify for Medicare, they require you to choose between Original Medicare and Medicare Advantage. Research has found that 4 in 10 choose to opt for Medicare Advantage plans, and enrollment in these plans has risen faster than overall Medicare enrollment.
For Medicare Advantage, you must have both Medicare Part A and Part B, and you can choose a plan during your first enrollment period, which is the seven months after the month you qualify for Medicare.
Most Medicare Advantage plans provide Part D prescription drug coverage. End-stage renal disease (ESRD) patients are eligible for Medicare, but not most Medicare Advantage plans. The 21st Century Cures Act changed this in 2021. By 2021, ESRD patients can choose from the same Medicare Advantage plans as other seniors.
Prescription drug coverage under Medicare Part D requires either Medicare Part A or B or both. You can enroll in Medicare Part D at the same time as Parts A and B.
Most beneficiaries of Medicare Advantage have Part D pharmaceutical coverage (89 percent of all Medicare Advantage plans include Part D coverage in 2022). Some MSA plans and some PFFS Medicare plans do not cover Part D. If your MSA or PFFS doesn’t offer Part D coverage, you can buy a stand-alone plan to augment it.
Enrolling later may cause higher rates unless you had creditable coverage from another plan during the period in which you delayed Part D enrollment.
What are dental benefits?
Dental benefits are the insurance that covers dental care. Most insurance companies treat dental insurance as a separate entity from medical insurance. Certain employers offer benefits packages that cover both medical and dental insurance.
The dental plans categorize the dental procedures into three: preventive care, basic procedures, and major procedures. The majority of the dental plans cover 100% of preventive care, which includes annual or semiannual office visits for cleaning, X-rays, and sealant procedures. Basic procedures include treatments for gum disease, extractions, fillings, and root canals. The patients pay most policies and fund 80% of the basic procedures. The policies for major procedures cover only 50% causing the patient to pay more out-of-pocket expenses than for other procedures. These major procedures include bridges, inlays, dentures, and dental crowns.
Each policy has its way of categorizing procedures as preventive, basic, and major, for instance, some policies categorize root canals to be basic procedures and cover most of the cost whereas others treat them as major procedures, so you must understand what is covered when comparing policies.
Most insurance companies treat dental insurance as a separate entity from medical insurance. Certain employers offer benefits packages that cover both medical and dental insurance.
Here is a list of the dental procedures that various dental insurance cover:
- diagnostic services, including:
- radiographs (X-rays)
- preventive services, including:
- restorative services, including:
- endodontic services, including root canal treatments
- periodontal services, including deep scaling
- removable prosthodontic services, including:
- partial dentures
- complete dentures
- oral surgery services, including extractions
- orthodontic services, including braces
- adjunctive services, including:
- general anesthesia
Does Medicare cover Dental Benefits?
As mentioned before, Medicare health insurance has different plans. Each of these plans has its own set of coverage and eligibility. Likewise, the dental coverage they provide also differs from one another.
Dental Coverage with Original Medicare
Original Medicare -Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) – does not cover dental services you need for the health of your teeth, including but not limited to:
- Routine checkups
- Dentures (complete or partial/bridge)
- Tooth extractions (having your teeth pulled) in most cases
Medicare may cover some specific dental expenses that are needed to protect your overall health with emergencies or certain surgeries. Medicare does not pay for follow-up dental care or dental-related hospitalizations.
Medicare will pay for dental services that are an integral part either of a covered procedure (e.g., reconstruction of the jaw following accidental injury), or for extractions done to prepare for radiation treatment for neoplastic diseases involving the jaw. Medicare will also make payment for oral examinations, but not treatment, preceding kidney transplantation or heart valve replacement, under certain circumstances. They would cover such examinations under Part A if performed by a dentist on the hospital’s staff, or under Part B if performed by a physician.
Medicare also covers some dental-related hospitalizations. For instance, Medicare may cover observations required during a dental procedure provided you have a health-threatening condition.
In this case, Medicare will cover the cost of hospitalization, such as room, anesthesia, and x-ray. It will not cover the dentist fee for treatment or fees for other physicians, such as radiologists or anesthesiologists. Further, while Medicare may cover inpatient hospital care in these cases, it never covers dental services excluded from Original Medicare, even if you are in the hospital.
Dental Coverage with Medicare Advantage
Good dental health is essential for your teeth, overall health, and overall quality of life. Routine dental checkups, such as cleanings and x-rays, as well as other basic and major dental services, are not covered by Original Medicare Part A or Part B. The good news is they included these benefits in many Medicare Advantage plans.
Most Medicare Advantage plans provide routine dental coverage, with a $0 copay for preventive services with in-network dentists. Plans will provide varying levels of dental care, ranging from preventive and diagnostic services to more comprehensive dental coverage. In some areas, you can change your plan to get dental coverage through a Dental Rider for an additional monthly premium.
Preventive & Diagnostic coverage includes:
- Dental exams
- Routine Cleanings
Comprehensive coverage includes some or all of:
- Deep cleanings
- Crowns and bridges
- Root canals
- Partial and complete dentures
- IV sedation and general anesthesia
- Dental implants
Does Medicare Cover Dental Implants?
According to the Centers for Disease Control, a dental implant is a structure in the mouth that acts as an anchor to the jawbone. It serves in place of a failed natural root. It’s attached to a replacement tooth or bridge.
Original Medicare- Part A and Part B- do not cover routine dental care, which includes dental implants as well.
However, certain Medicare Advantage plans may include dental implants and other routine dental services.
Medicare Advantage (Medicare Part C) equips people with the means to use Original Medicare coverage through a private health insurance company that Medicare has approved.
As mentioned before, Medicare Advantage plans must provide the same benefits as Medicare Part A and Part B, and many plans include other coverage, such as routine dental care and prescription drug coverage.
A single dental implant can cost from $3,000 to $6,000. Many basic dental insurance plans don’t cover implants and those that do come with limits and exclusions. With that in mind, many consumers choose dental insurance that covers dental implants. If you opt for Medicare Advantage plans for dental implants or any other dental services, be mindful of the cost it may incur on top of the Advantage plan’s existing premium. You may also want to consider dental insurance (outside of Medicare) from a private insurance company. Some dental insurance plans might cover some costs of dental implants.
Alternative and Low-Cost Dental Options
According to a study conducted by Kaiser Family Foundation, 50% of Medicare patients lack dental coverage.
Only 29 percent of those with coverage have it through a Medicare Advantage plan, and they spent an average of $874 out of pocket in 2018. One in five of them spends more than $1000 on dental coverage each year.
A Medicare Advantage plan can be costly for dental coverage. If the Medicare Advantage plan is not as suitable for you, you can get the care you need through a low-cost alternative. We have listed some alternatives below:
- Dental schools:
If you have a dental school or a dental hygienist school in your locality or your town, then you may have found a low-cost solution to your problem. Dental Hospitals may offer free or low-cost care because the dental professionals in training require some practice. To explore, if there are any dental schools nearby, you can visit the American Dental Association and the American Dental Hygienists’ Association websites.
- Charitable organizations:
Dental Lifeline and Dentist from the Heart can help you find free dental care. A nonprofit organization such as Authority Health assists older adults, in particular, in finding affordable dental coverage.
- Free or low-cost dental clinics:
Certain clinics provide dental services at a lower cost. Association of State and Territorial Dental Directors comprises a directory of low-cost clinics available in each state. Some dental clinics offer low-cost services to help people in need. You may want to check out the Association of State and Territorial Dental Directors to locate options in your state.
Just like Medicare, Medicaid is also a federal public health insurance program that allows US citizens with a set income range and assets to avail themselves of Medical care. More than 12 million Medicare beneficiaries are also Medicaid eligible. While dental coverage varies by state, Medicaid may be a resource for your dental needs.
Alternatively, if your dentist is willing to negotiate rates, you could try and set up a payment plan that suits your financial needs.
The benefits of good dental care are undeniable, but it’s hard to come by affordable dental care. Now that you have read the article, you must be familiar with Medicare and the different dental benefits you can avail of from them. If you still think Medicare isn’t the right choice for you, we’ve provided you with some of the low-cost dental care options as well. Picking the right means for your dental health can benefit your health and your finances. To pick the right option, survey the prices of all the alternatives and your expenses carefully, and choose the option that gives you a lot of benefits for the right amount of value.