By Danielle Kunkle
It seems hard to believe that Congress didn’t include dental care when designing Medicare. The reason is partly because health insurance itself was quite different back then. When health insurance began to surface between the 1920s and the 1950s in America, dentistry was not included in the standard bundle of benefits. Medicare was formed shortly after that in 1965, and the American Dental Association also opposed inclusion of dental benefits under Medicare, fearing a fixed-fee schedule as well as government interference in the profession of dentistry. Even today, dentistry isn’t technically a branch of medicine.
While Medicare will cover medically necessary limited dental care, it does not cover the routine care that you and I have to come think of as dental and vision coverage.
Let’s take a look at what’s covered and what isn’t and what your options are for getting coverage.
When it comes to dental care, Medicare covers only medically necessary dental. The scope of this coverage is extremely limited. For example, if you are involved in an accident that breaks your jawbone or teeth, and an oral surgeon needs to be involved in the repair, Medicare Part B may cover this. We sometimes also see limited coverage involving treatment of head and neck cancer that involves the removal of teeth.
However, Medicare does not consider any routine care to be medically necessary. That means that the following items are not usually covered on their own:
Just because Medicare doesn’t’ cover these items doesn’t mean you won’t need this care. In fact, many would argue that dental care is even more necessary for people over 65 than for younger people. This means that every year millions of Medicare beneficiaries explore their options for dental care.
The most common way that Medicare beneficiaries get care for their dental needs is through standalone dental plans. There are many insurance companies that offer these plans. Some plans are simply discount plans where if you use the plan’s network, the providers in that network give you access to special discounted rates at the time of service. This option is usually good for people who need immediate care for major services because there are usually no waiting periods.
Other companies offer HMO or PPO plans where the insurance company will actually pay out benefits for your care. Most individual dental plans have annual maximum coverage of $1000 – $1500. Often there is a small annual deductible and then preventive care is covered at 100% while basic and major services are covered at lesser percentages. Since these plans actually pay benefits, they are often more expensive than the discount plans.
There are also some plans that offer a type of reimbursement coverage. You can see your own dentist and submit your bills to the insurance company to be reimbursed up to a certain amount for covered services. It’s worth noting that many of these plans also offer packages that cover not just dental, but also routine vision and hearing services since Medicare doesn’t cover those items either.
It’s easy to find all of these types of plans by simply typing “individual dental plans” or “senior dental insurance” into your internet browser and then perusing the various plans listed.
Another way to get some dental benefits is to enroll in a Medicare Advantage plan that includes routine dental coverage. Medicare Advantage plans (also called Part C plans) are private health insurance plans that offer your Medicare Part A and B benefits through their own networks. The insurance companies who sell these plans can include some value-added benefits in the coverage such as routine dental or vision care.
Included benefits are generally preventive in nature or may only cover up to a certain dollar amount each year. This means that the benefits are probably not as extensive as what you would find inside a standalone dental plan.
You will often be asked to use the plan’s dental network, and that network may not include your current dentist. We also often see benefits that are limited to preventive care only inside Advantage plans. Each company has different coverage, so if you are considering Medicare Advantage, review the plan’s Summary of Benefits to see if any dental care is included.
You also may find some Medicare Advantage plans that do not include routine dental but have riders available for purchase that will add in dental or vision care. Consult with a Medicare insurance broker to see what insurance companies in your county are offering inside their plan designs.
While Medicare itself doesn’t cover routine dental, it’s good to know you have some options for getting the dental care you need.
Danielle Kunkle is the co-founder of Boomer Benefits, an insurance agency specializing in Medicare-related insurance products. They help baby boomers New to Medicare learn about their benefits and coverage options across 47 states.
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