In the course of your practice, retired patients seeking dental insurance have probably approached you. How can you point them in the right direction? Except as described below, Medicare doesn’t cover most dental services. So if retirees want dental insurance, they must seek other options.
What Dental Care Does Medicare Cover?
Medicare covers dental care only when it’s deemed medically necessary, such as pulling teeth after an injury or treating fractured jaws. Medicare Part A (hospital insurance) does cover limited dental services if a patient receives them in a hospital and if they’re necessary to help perform a covered, non-dental procedure or medical service.
But Medicare doesn’t cover routine dental care such as cleanings, fillings, root canals, implants, or dentures. Medicare also won’t cover follow-up treatment for services covered for medical necessity. For example, while Medicare will cover dental extraction in preparation for radiation therapy, it declines to pay any replacement costs for the extracted teeth.
What Dental Coverage Does Medicare Advantage Offer?
Medicare Advantage plans, also known as Part C Medicare, enable patients to obtain Medicare benefits through a private health insurer. However, Medicare Advantage plans often charge a premium in addition to a Medicare Part B premium. They also may include other costs and limits, but they may offer some patients advantages, depending on the patients’ circumstances.
For example, some Medicare Advantage plans cover routine dental care. If patients already have a Medicare Advantage plan, they should ascertain what dental services may be covered. If they don’t and they’re considering a Medicare Advantage plan, dental coverage should be one of the factors to consider.
To give your patients more information on Medicare Advantage plans, including finding and comparing plans in their area, direct them to the Medicare Advantage website.
What about Individual Dental Plans?
A patient buys an individual plan as an individual, not as a member of a group. But these plans offer coverage for family members as well. Individual dental plans are available from a number of sources:
- Patients may buy one directly from an insurance company.
- Brokers or agents may offer retiree individual plans.
- Patients may be able to buy an individual dental plan from an association of which they’re a member, such as AARP.
Patients may be able to buy a dental plan from an Affordable Care Act health insurance marketplace (exchange). Some state and federal marketplace medical plans include dental benefits for adults. A few state-run marketplaces sell standalone dental plans without requiring the purchase of a medical plan. If your state operates a marketplace, the state will appear on this list. Patients should check with their state’s marketplace for details.
If no state marketplace is available, patients can use the federal marketplace, healthcare.gov. Your patients may be able to buy standalone dental plans through the federal marketplace, but they’ll also have to purchase a medical plan. And, there are no subsidies to help them pay for standalone dental plans on federal or state exchanges.
For general information on dental plans and how to choose one, direct your patients to our guide, Dental Plans.
Can Veterans and Their Families Get Dental Coverage?
If some of your patients are retired service members or family members of one, or if they fall within certain other military-related groups, they can enroll in the TRICARE Retiree Dental Program. Its monthly premium can be deducted from their retirement pay. Exams and cleanings are free, and dental accident coverage is 100%. For other covered services, patients pay a percentage, and the plan pays the rest. Annual deductibles and annual maximums are included. For orthodontic care, a lifetime maximum applies. For more information, click here.
Medicaid
While state Medicaid programs are not required to provide dental benefits, they are allowed to. Many states do provide dental benefits, but the details differ from state to state and from year to year. Ask your patients to contact their state Medicaid agency here to learn more or to apply for Medicaid coverage.
Dental Discount Plans
Dental discount plans are not insurance, but a method of obtaining lower prices for all dental care, including routine dental care. For a yearly fee, patients gain access to a network of dentists who have agreed to offer discounted rates to members who pay the full discounted rate for each service. The amount of the savings (discount) varies by the plan.
Estimating Dental Care Costs
Encourage your patients to use our FH Dental Cost Estimator to identify estimated costs for specific dental procedures in your area, which can help patients paying a deductible, uninsured patients, or those consulting a dentist not in their dental plan network. With this information, patients can budget for needed dental procedures and plan for the future.
Robin Gelburd, JD, is the president of FAIR Health, a national, independent nonprofit with the mission of bringing transparency to healthcare costs and insurance reimbursement. FAIR Health oversees the nation’s largest repository of private healthcare claims data, comprising more than 24 billion billed medical and dental charges that reflect the claims experience of over 150 million privately insured Americans. Follow on twitter @FAIRHealth.
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