Everything you need to know: Medicare Dental Coverage

ADA, The American Dental Association said that individuals 60 and over face some rather unique dental concerns. Approximately one in four seniors have gone five years or more since their last dental visit and 16 percent in this age range consider their oral health as poor. Also, for instance, there are more than 500 medications that cause dry mouth, some of which were prescribed for high blood pressure, high cholesterol, Parkinsons's and Alzheimer's disease. This is now the common cause of cavities in older adults.

Unfortunately, Medicare doesn't always help with this issue. In fact, according to Medicare.gov, this federal health insurance program typically does not cover dental care, procedures, or supplies. They don't provide benefits toward regular cleanings or services designed to treat and/or correct problematic oral issues, such as fillings or tooth extractions and they don't generally offer benefits for dental devices, including dentures and dental plates.

So, what does Medicare cover when it comes to dental health care?

Medicare will contribute toward oral examination needed before any surgical procedures, such as kidney transplant or heart valve replacement in certain situations.

Original Medicare's Part A Dental Coverage

Under Original Medicare Part A, participants may be covered for certain dental services received while in the hospital. These include any emergency or complicated dental procedures deemed necessary at the time. 

CMS, The Centers for Medicare and Medicaid Services explains that while blanket dental exclusions for Part A coverage are made under Section 1862 (a)(12) of the Social Security Act- one example of an emergency or complicated procedure that is often at least partially covered is jaw reconstruction needed as a result of an accidental injury.

Another instance is if an extraction is needed to prepare a patient for radiation treatments as a result of jaw-related neoplastic disease. Healthline says that this category of conditions includes diseases involving the growth tumors, both cancerous and non-cancerous in nature. 

Medicare will also contribute toward oral examinations needed before kidney transplants or heart valve replacement, as said earlier. Specifically, this type of expense would likely be covered under Medicare Part A  if the hospital's dental staff performs the exam.

Medicare Part B Dental Benefits

On Medicare Part B, if the physician conducts the examination needed prior to kidney transplant or heart valve replacement, then Part B benefits will apply according to CMS. However, when it comes to Medicare Part B, there are two specific sets of services that will not be covered.

• First involves services used to care, treat, remove, or replace teeth to structures supporting the teeth. For example, pulling teeth prior to getting dentures.
• Second include those related to teeth and their supporting structures, unless those services are needed to effectively treat a non-dental condition.

In this kind of situation, the dental service must be performed at the same time as the covered service in order for Medicare to pay its portion. It must also be performed by the same healthcare professional who performed the covered service whether that person is a physician or dentist.

Medicare Advantage Dental Policies

Many Medicare Advantage plans do offer dental coverage, according to Medicare.gov, though the exact benefits provided varies based on the plan chosen. 

Additionally, these plans can be:

• HMOs (Health Maintenance Organization)
• PPOs (Preferred Provider Organizations)
• PFFS (Private Fee-for-Service) Plans
• SNP (Special Needs Plans)

The type of plan chosen depends on what benefits you'd like to receive the cost of the plan and any coinsurance or copayments that would apply.

PACE DENTAL COVERAGE

This is another type of Medicare program that provides some level of dental coverage.

PACE means Programs of All-Inclusive Care for the Elderly and is designed to help participants meet their health care needs in the community instead of going to a nursing home or other care facility. 

With PACE, contracts are made with area specialists and healthcare providers to provide participants care for dentistry, as well as other services they likely need. These include adult day primary care, laboratory services, meals nursing home care, nutritional counseling, occupational or physical therapy, prescription drugs, and more.

To qualify, you must meet four minimum requirements:

1. Be at least 55 years of age
2. Live in a PACE service area
3. Need nursing home-level care
4. Be able to live safely with PACE's help

STAND-ALONE DENTAL PLAN

Whether you need dental services not covered under a Medicare plan or you don't qualify for coverage options, always remember that you always have the option of purchasing a stand-alone dental plan.

If you do this, the Wisconsin Dental Association makes it clear that you do not need dental insurance in order to receive dental care. If the cost of the dental coverage concerns you, it helps to compare how much you would pay out-of-pocket for your typical dental expenses versus how much you would pay for a dental care policy. But if the former is less than the latter, dental insurance may not be the financial decision for you. One exception, of course, is if you're facing more complex, thus more costly dental procedures. In this case, it may be more beneficial to purchase a policy that helps offset some of those added expenses.

The ideal dental plan contains provisions for three categories of treatment:

1. Preventative, diagnostic, and emergency services such as cleanings, x-rays, and other oral wellness services. Coverage is usually around 100 percent.
2. Basic restorative dental care such as fillings, oral surgery, periodontal treatment, and root canal therapy. Coverage is generally 80 percent.
3. Major restorative dental care such as crowns, bridges, dentures, and orthodontics. Coverage is typically somewhere around 50 percent.

Be aware that individual dental policies often come with a waiting period for more extensive procedures. Therefore, if you're purchasing the insurance to cover major dental issues that you expect to occur in the near future, be sure to look for this provision to ensure that it will, in fact, pick up the expenses. 

Take time to see which dental health professionals in your area accept the insurance you'd like to buy. This limits the likelihood that you'd have to change dental providers, but it also reduces the chance that you'd mistakenly go to an out-of-network provider and incur even more dental costs.

Review your selected dental policy thoroughly so you know exactly what it covers and how much you can expect to pay for the services you'll need. This can help you decide which policy is best suited to you based on your specific oral health needs. It can also help you budget appropriately. 

Medicare does have rather limited dental health coverage, but other options exist that can potentially help offset these types of expenses. Medicare Advantage Plan, PACE, and Stand-Alone Dental Policy are three to consider.