Medicare Dental Coverage for Seniors
This article was updated on: 09/03/2017
When shopping for the best dental plans for seniors, you should consider what services and treatments you might need, the costs of the plan, and what the plan covers. The dental needs of seniors could depend on the condition of their current teeth and their dental history. For example, if you already have full dentures, you may be more concerned about getting checked for oral cancer than in cavity treatment or bridges.
Dental problems in seniors
According to the National Institute of Health (NIH), seniors may have the following dental problems (this list is not exhaustive):
- Dental carries (cavities): 93% of seniors 65 and older have had dental carries in their permanent teeth, according to NIH
- Tooth loss: seniors over age 65 have an average of 18.90 remaining teeth, according to NIH (Adults age 20 to 34 have 26.90 teeth on average)
- Gum disease: periodontal gum disease is the most common cause of tooth loss among seniors, according to NIH
- Oral cancer: According to the NIH oral cancer rates increase with age, peaking between ages 60 and 70.
- Facial pain/TMJD: Temporomandibular muscle and joint disorder (TMJD) is the most common cause of facial pain
Medicare dental coverage
Generally Original Medicare dental coverage is only for limited circumstances involving hospitalization. Original Medicare (Part A and Part B) generally doesn’t cover most dental care, including cleanings, fillings, tooth extractions, dentures, and dental plates. Hospital insurance (Part A) may pay for emergency or complicated dental procedures, for example the reconstruction of the jaw following an accidental injury, according to the Centers for Medicare & Medicaid services (CMS). According to CMS, Congress has not amended the dental exclusion since 1980, when it made an exception for inpatient hospital services when the dental procedure itself made the hospitalization necessary. If you have Original Medicare and want routine dental care, you will generally need to find a plan from a private insurance company.
Medicare Advantage plans may offer routine dental care. Medicare Advantage is another way to get you Original Medicare (Part A and Part B) benefits from a private insurance company. A Medicare Advantage plan may offer routine vision as well as prescription drug coverage. If you have a Medicare Advantage plan you have to continue paying your Part B premium. Medicare Advantage plans must cover everything that Original Medicare covers except for hospice care which is still covered by Medicare Part A. The extent of the Medicare Advantage dental coverage may vary from plan to plan.
Other dental coverage for seniors
As a Medicare beneficiary, you are free to shop for a stand-alone private dental plan for seniors. Some dental plan types are PPO plans* and others are indemnity plans. A PPO stands for preferred provider organization. This is a type of plan that contracts with dental providers to create a network of participating providers. If you want to use a dentist out of network, you usually can for an additional cost. An indemnity plan allows you to visit almost any dentist you like with the plan paying a portion of your total charges. Indemnity plans are also called “fee-for-service” plans.
Both PPO and indemnity plans may have no out-of-pocket maximums. This means that there is no limit on what you might pay from your own resources. These plans also may have an annual maximum benefit. This is the most the plan will pay for your dental services in a year.
Another thing to consider when looking for dental plans for seniors is the waiting period some plans may have for certain services. For example, a plan may set a 3-month waiting period for an extraction. This means that if you get an extraction a week after enrolling in that plan, you usually won’t be covered. Some services may have longer waiting periods, such as 15 months, before the plan covers that service. This is why it is best to not wait until you have a dental emergency to enroll in a dental insurance plan.
Dental plan costs and services
Dental plan costs could vary from plan to plan. Here are some costs you might pay:
- Premium: this is a monthly amount you pay your provider whether you use the plan or not
- Deductible: this is how much you pay out-of-pocket before your plan begins to pay.
- Coinsurance: this is a percentage of the cost of the procedure or service you must pay
- Copayment: this is a set dollar amount, say $20, that you must pay for a procedure or service
For services that are not covered, you may pay 100% the cost of that service.
If you have more questions about dental plans for seniors, I can help answer your questions. If you like, use the other links to request a phone appointment or an email from me. I’ll send you Medicare information tailored to your needs. To browse plans now, try the Compare Plans buttons on this page. Or, to get assistance quickly from a licensed insurance agent, feel free to call us. Call Medicare.com’s licensed insurance agents at 1-844-847-2660, TTY users 711; Monday through Friday, 8AM to 8PM ET.
*Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.
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