A friend texted me recently about his neighbor.
“I am reaching out for Jerry. He has free dental through his Medicare Advantage plan. He has no top teeth left and needs dentures. His dentist quoted him $1,800. He had some fillings and such earlier this year and there was no bill. He wants to know why now, almost $2,000?”
Medicare coverage of dental services
Before figuring out Jerry’s situation, let’s review some basics about Medicare.
- Medicare does not cover routine dental care, preventive services, most dental procedures such as fillings and tooth extractions, or dental devices like dentures and braces.
- Medicare can cover medically necessary dental procedures that are an integral part of a covered service, such as reconstruction of a jaw following an accident.
- Effective in 2023, Medicare pays for diagnostic and treatment services to eliminate a dental infection prior to or with, an organ transplant, bone marrow transplant or cardiac valve replacement. (Previously, Medicare covered only the exam.)
- Medicare also covers extraction of teeth to prepare the jaw for radiation treatment and reconstruction after tumor removal.
What to know about Medicare Advantage dental care
- Most Medicare Advantage plans (98%) offer dental benefits, included in the plan’s premium.
- The coverage can vary. Some plans offer only preventive dental services, such as oral exams, cleanings, dental X-rays, and fluoride treatments. Other plans provide comprehensive dental to maintain and treat problems, including fillings, extractions, and root canals. Many offer a mix of the two services.
- Plans can set a maximum limit, the most it will pay in a calendar year for covered services. In 2021, the average limit was $1,300.
- Many plans offer an opportunity to upgrade the services for an additional cost. For example, paying a monthly premium of $35 can increase the plan’s maximum limit and/or add more covered services.
If your Medicare Advantage plan offers dental coverage, know these important points.
- Check the plan’s directory to find a dentist. In-network care is always your best option. If the plan covers out-of-network services, you may pay more.
- Review the Evidence of Coverage (EOC) for benefits, coverage criteria, exclusions or limits on the frequency and dollar value of treatments. For instance, some plans cover dental implants.
- Pay attention to any rules. One popular plan’s EOC notes if the care you need will cost more than $300, you or your dentist should submit a pretreatment plan. This would confirm that the services are covered and provide an estimate of the cost.
- Find out the plan’s annual maximum limit. If you need extensive dental treatments, get a quote first.
- Investigate how the payment works for these services. If you use network providers, the plan may pay them directly. Some plans have a reimbursement allowance. You can see any provider, but you would have to pay the bill and then submit receipts.
- Evaluate the cost and benefits of a plan upgrade. Would paying more on a monthly basis provide the coverage you need?
Back to Jerry. I checked the Evidence of Coverage for his plan, available on the plan’s website. He has coverage for exams, cleanings, fillings, crowns, bridges, root canals, and partial and complete dentures with a limit of $1,000. The dental work Jerry had done earlier in spring likely reached that limit so he needs to pay for procedures going forward this year or postpone whatever he can until next year.
Medicare’s Open Enrollment Period is around the corner, October 15-December 7. It’s a great time to review your Medicare Advantage plan’s benefits, costs and coverage, and check out what other options they offer. However, your medical care and medications should be your priority.
And remember, “free dental care” is free only up to the plan’s maximum limit.
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