A Guide to Medicare Dental Coverage

The American Dental Association (ADA) adds that individuals 60 and over often face some rather unique dental concerns. For instance, there are more than 500 medications that cause dry mouth, some of which are prescribed for high blood pressure, high cholesterol, Parkinson’s, and Alzheimer’s disease. This is important because the ADA cites dry mouth as a “common cause of cavities in older adults.”

Other oral health concerns that appear more often in older adults include gum disease and mouth cancer, according to the ADA.

Medicare and a Lack of Dental Coverage

Unfortunately, having Medicare doesn’t always help with this issue. According to Medicare.gov, this federal health insurance program typically does not cover dental care, procedures, or supplies.

Medicare doesn’t 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?

Original Medicare’s Part A Dental Coverage

Under Original Medicare Part A, participants may be covered for certain dental services received while in the hospital. These include any “emergency or complicated dental procedures” deemed necessary at the time, according to Medicare.gov.

The Centers for Medicare and Medicaid Services (CMS) explains that while blanket dental exclusions for Part A coverage are made under Section 1862 (a)(12) of the Social Security Act—an act that hasn’t been amended since 1980, according to the CMS—one example of an emergency or complicated procedure that is often at least partially covered is jaw reconstruction needed as a result of an accidental injury.

Another instance in which Medicare Part A would pick up a portion of a typical dental care cost is if an extraction is needed to prepare a patient for radiation treatments as a result of jaw-related neoplastic diseases. Healthline says that this category of conditions are diseases involving the growth of tumors, both cancerous and noncancerous in nature.

According to the CMS, Medicare will also contribute toward oral examinations needed before kidney transplants or heart valve replacements in certain situations. Specifically, this type of expense would likely be covered under Medicare Part A if the hospital’s dental staff performs the exam.

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 won’t 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 Advantage Dental Policies

One exception to the dental exclusions under Original Medicare’s 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:

• HMOs (Health Maintenance Organizations)
• PPOs (Preferred Provider Organizations)
• PFFS (Private Fee-for-Service) Plans
• SNP (Special Needs Plans)

The type of plan chosen depends on what benefits you’d like to receive, the cost of the plan, and any coinsurance or copayments that would apply.

Dental Coverage Through PACE

PACE is another type of Medicare program that provides some level of dental coverage.

PACE is short for “Programs of All-Inclusive Care for the Elderly” and is designed to help participants “meet their health care needs in the community instead of going to a nursing home or other care facility,” according to Medicare.gov.

With PACE, contracts are made with area specialists and healthcare providers to provide participants care for dentistry, as well as other services they likely need. These include adult day primary care, laboratory services, meals, nursing home care, nutritional counseling, occupational or physical therapy, prescription drugs, and more.

To qualify for PACE, participants must meet four minimum requirements:

1. Be at least 55 years of age
2. Live in a PACE service area
3. Need nursing home-level care
4. Be able to live safely with PACE’s help

A Stand-Alone Dental Plan

Whether you need dental services not covered under a Medicare plan or you don’t qualify for Medicare coverage options that would pay for some or all of your dental care needs, you always have the option of purchasing a stand-alone dental plan.

If you do this, the Wisconsin Dental Association (WDA) makes it clear that you do not need dental insurance in order to receive dental care. Also, if the cost of dental coverage is most concerning to you, it helps to compare how much you would pay out-of-pocket for your typical dental expenses versus how much you would pay for a dental care policy.

If the former is less than the latter, dental insurance may not be the best financial decision for you. The one exception, of course, is if you’re facing more complex—thus, more costly—dental procedures. In this case, it may be more beneficial to purchase a policy that helps offset some of those added expenses.

The WDA explains that the ideal dental plan contains provisions for three categories of treatment:

1. Preventative, diagnostic, and emergency services such as cleanings, x-rays, and other oral wellness services. Coverage is usually around 100 percent.
2. Basic restorative dental care such as fillings, oral surgery, periodontal treatment, and root canal therapy. Coverage is generally 80 percent.
3. Major restorative dental care such as crowns, bridges, dentures, and orthodontics. Coverage is typically somewhere around 50 percent.

Be aware that individual dental policies often come with a waiting period for more extensive procedures. Therefore, if you’re purchasing the insurance to cover a major dental issue that you expect to occur in the near future, be sure to look for this provision to ensure that it will, in fact, pick up the expense.

Also, take the time to see which dental health professionals in your area accept the insurance you’d like to buy. This limits the likelihood that you’d have to change dental providers, but it also reduces the chance that you’ll mistakenly go to an out-of-network provider and incur even more dental costs.

Finally, review your selected dental policy thoroughly so you know exactly what it covers and how much you can expect to pay for the services you’ll need. At a minimum, this can help you decide which policy is best suited to you based on your specific oral health needs. It can also help you budget appropriately, simply by knowing how much your new plan will cover and how much you’ll have to pay on your own.

Medicare does have rather limited dental health coverage, but other options exist that can potentially help offset these types of expenses. Medicare Advantage, PACE, and stand-alone dental policies are three to consider.