Original Medicare and Dental Coverage

Original Medicare will only cover dental services when they are deemed medically necessary.


Now, medically necessary isn’t as broad of a term as we all would hope. It doesn’t mean, I have a tooth infection that can spread so it’s medically necessary. That still falls under comprehensive dental and not medical. Medically necessary can best be described as needed under your existing medical coverage. Examples of this include the following:

  • You get in a car accident and get a broken jaw and/or broken teeth. In this situation Medicare would cover any dental work needed as part of your original Medicare coverage.

  • As part of your oral cancer treatment, your oncologist schedules a few dental procedures. This would be covered by your Original Medicare as part of your cancer treatment.

  • It’s even possible to have some dental procedures covered as part of a comprehensive preparation for a kidney transplant.

The thing to note is that in each case, dental work is covered because it is part of a regular medically covered procedure, or a doctor is proving it necessary to proceed with another medical service.


Types of Dental Coverage for Those on Medicare


The types of dental plans available to those on Medicare are often similar or identical to any other dental plan. So, understanding the basics will help you make sense of what kind of coverage you might find out there.


HMO Medicare Dental Plans


HMO stands for health maintenance organization. These operate in exactly the same way their medical counterparts do. You will have to choose a primary dentist from a covered provider list. This dentist will manage your care. If a procedure is needed they will have to get an authorization approved from the insurance first. If they want to send you to a specialist, they will have to get a referral approved first. You will not be able to see a specialist or get a procedure done (even if it is covered) without first getting approval. There is no out-of-network coverage. If you go to an out-of-network provider, you’ll have to pay full price for their services.


There are some rules, though it’s good to note that there is a great trade off. These plans are often the lowest cost monthly. For example, Delta Dental has an option for a dental hmo plan that’s less than $10 a month, depending on some factors. Most services have flat co-pays that are predictable and upfront. Lastly, they have no annual maximum for coverage. You can get as many procedures done as needed, as long as you fulfill your co-pay each time.

The other benefit is that they often have no waiting period. A waiting period is when you cannot use certain services without first waiting a set amount of time. Often what this looks like is all major dental (crowns, dentures, etc.) cannot be covered until you have paid into the plan for a minimum of 6 months. This is common on many dental plans. To have no waiting period is a huge benefit for those looking to use their coverage right away.


PPO Medicare Dental Plans


PPO stands for preferred provider organization. These are also just like their medical counterparts. There is a network of primary dentists and specialists in which you will get preferred rates for covered services. There is coverage for out-of-network providers, however your share-of-cost will be higher. These plans are attractive because there are no approvals or referrals needed to receive services or see specialists. Know that there is a difference in coverage to compensate for this.


Many PPO plans will have a waiting period. This means you will not be able to get many services outside of a checkup and x-rays without first having to wait anywhere from 3-6 months. If you cannot wait 3-6 months, then this type of plan may not be fit for you.

The last major difference is coverage. Dental PPOs rarely have a co-payment structure, which you would pay a flat amount for a specific service. Most PPOs work on a coinsurance system, so you’ll pay a percentage of the work that is done. For example, many will ask you to pay 20% for minor dental work (fillings, extractions, etc.) and 50-70% for major dental (crowns, dentures, etc.). They will often have a maximum allowable coverage per year. This is the maximum dollar amount a health plan will pay for services within a year. This can range anywhere from $800 – $1500 on average. What this looks like in practice is this:

-Say you have a PPO with $1000 annual maximum. For any services you would pay your coinsurance amount and the health plan would pay the rest, up to $1000 within the year. Once their share has reached $1000, you will pay full price for any services for the remainder of the calendar year.


So, if you get a set of dentures and your coinsurance is 50%, here’s what that would look like. On average dentures are around $2000 or so. You would pay $1000 and the insurance would pay the other $1000. This would use up all of your coverage for the year. Any other services that year would be your full responsibility to pay.


Dental plans for Medicare Advantage plans


It is becoming increasingly common to see dental coverage included with a Medicare Advantage plan. The type of dental plan included will likely be an HMO dental plan. If your plan includes an HMO dental plan, be sure to check the dental network it offers. You will want to choose your dentist when you sign up or you will certainly be auto-assigned a dentist.


If your Advantage plan doesn’t include dental coverage, then it’s very likely you can purchase a dental policy as a separate add-on. Similar to the Supplement plans, these dental add-on plans are often priced pretty competitively and have comparable benefits with any private dental plan. We recommend taking a look at these plans first to see if they fit your needs. The billing will often be integrated with your Advantage plan, and it’ll give you a single point of contact for all customer service needs for medical and dental.


Dental plans for Medi-Medi


Those with both Medicare and Medi-Cal will have dental coverage through their Medi-Cal in the form of Denti-Cal. Denti-Cal operates like a PPO dental plan. Denti-Cal is not accepted everywhere. Only certain dentists will accept it. You will find that many private dentists do not accept Denti-Cal. Most Denti-Cal providers will be clinics and larger establishments. So, if you want to see a private dentist, please call first to confirm that they accept Denti-Cal.

It is possible to get more dental coverage to help supplement your Denti-Cal. Many Medicare Advantage plans will include a wrap around dental plan for your Denti-Cal at no additional cost. These plans will help add coverages that Denti-Cal would not normally cover by itself, like porcelain crowns and no limit on the number of major dental services you’re able to receive in a year. If your dentist takes Denti-Cal, it’s likely they will accept these plans as well.


Implants and Medicare


\It is becoming a popular practice for dentists to recommend implants when doing dentures. This is a good practice to help prevent bone loss in the future. The downside is that implants are almost never covered by dental plans. At best there are a few plans that will discount your implants anywhere from 5-15%. When it comes to implants, it may be a good investment for the future of your dental health, but you’re not likely to find the same kind of coverage assistance you’re used to.


Frequently Asked Questions About Dental Coverage


Is there a dental plan for Medicare patients? No, there are not dental plans specifically for Medicare patients only. However, you can enroll into individual dental plans available to most everyone.

How do I get dental care for Medicare? You can add it through most private Medicare plans or purchase a separate private dental plan.


What is the best dental plan for seniors?

The best dental plan will be an individualized answer and depend on your needs and dental preferences. An HMO may allow you more predictable coverage with no limits but will have a limited network. On the other hand, a PPO will allow freedom to go to most dentists while having a high share of cost with an annual limit.


Does Medicare cover dental in 2020? No, not in the traditional sense. Medicare will only cover dental when it is deemed medically necessary for an Original Medicare covered service. For example, if you are in a car accident and get dental damage, then Medicare will cover the dental work necessary to fix the damage.

Is dental coverage a part of health insurance?

When it relates to Medicare, dental is only covered in Medically necessary situations. Traditional dental insurance is not covered under Medicare.

Do any Medicare supplement plans cover dental?

Most Medicare supplement plans will allow you to add dental as a separate add- on purchase. They will not cover dental as part of the Supplement plan, other than the limited circumstances Medicare covers dental.

Can you get supplemental dental insurance?

If you already have dental coverage, you can’t always get supplemental dental insurance. You can generally only have one dental policy in force at a time.

How do I get dental insurance with Medicare?

In most cases you will need to purchase a dental policy separate from your Medicare. Many times you can get dental coverage from your Medicare insurance policy as an add-on or, in limited circumstances with Medicare Advantage plans, it will be included as part of the all-inclusive package.

What Medicare plans cover dental?

Some Medicare Advantage plans will have dental coverage included as part of their insurance package at no additional cost.

Is dental insurance for seniors worth it?

Yes, dental procedures like crowns and dentures can easily add up to over $2000 or more. If you wait until that bill shows up to get dental coverage, you may find yourself having to wait an additional 6 months to a year due to the waiting period many dental plans have for such services. Getting coverage early and getting regular check ups can keep costs down and ensure you get to keep your natural teeth longer.

How much is dental insurance for seniors?

Dental insurance can range anywhere from $5 a month all the way up to around $80 a month. It’ll depend on how much coverage the policy provides and what kind of policy it is. You will find that most policies average around $25-40 a month.

Does AARP have a dental plan for seniors?

Yes. AARP has dental plans administered through Delta Dental. They typically offer both PPO and HMO plan options depending on where you live. These plans are very competitive and reasonably priced. If you are an AARP member this would be a great place to start when looking for dental coverage.

Why doesn’t Medicare cover dental?

Dental insurance has long been separated as an ancillary coverage. This means it has been classified as extra, like hearing aids, chiropractic, etc. Dental has been separated from the medical field for quite some time, including their schooling. Dental school is not a part of medical school. We say all this to point out that in the eyes of insurance and everything classified as “medical,” that the dental field stands apart from that.

Does Medicare cover dental implants?

No. Medicare and even most dental insurance plans will not cover dental implants. Original Medicare will only cover dental work when deemed “medically necessary.” Essentially, in relation to an accident or other medical procedure.

Does Medicare cover oral surgeons?

Only when it has to do with a “medically necessary” procedure. For example, if you are in a car accident and need an oral surgeon, then you will have coverage for one. Now, if you need an oral surgeon for a tooth extraction, then you will not have coverage for that under Original Medicare and will need to get a separate dental insurance policy.

What is the best dental insurance for seniors on Medicare?

The best dental plan will be individualized and depend on your needs and dental preferences. An HMO may allow you more predictable coverage with no limits but will have a limited network. On the other hand, a PPO will allow freedom to go to most dentists while having a high share of cost with an annual limit.

Does Delta Dental accept Medicare?

Yes, Delta Dental will allow you to enroll into any of their plans regardless whether you have Medicare or not.

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