A Guide to Medicare Dental Coverage8 minute read

8 minute read

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Updated for July, 2019

Approximately one in four seniors aged 65 and over (23 percent) have gone five years or more since their last dental visit, according to the National Institute of Dental and Craniofacial Research (NIDCR). Additionally, 16 percent of individuals in this age range consider their oral health as “poor.”

dentist and senior patient looking at an X-ray

The American Dental Association (ADA) adds that individuals 60 and over often face some rather unique dental concerns. For instance, there are more than 500 medications that cause dry mouth, some of which are prescribed for high blood pressure, high cholesterol, Parkinson’s, and Alzheimer’s disease. This is important because the ADA cites dry mouth as a “common cause of cavities in older adults.”

Other oral health concerns that appear more often in older adults include gum disease and mouth cancer, according to the ADA.

Unfortunately, having Medicare doesn’t always help with this issue. According to Medicare.gov, this federal health insurance program typically does not cover dental care, procedures, or supplies.

Medicare doesn’t provide benefits toward regular cleanings or services designed to treat and/or correct problematic oral issues, such as fillings or tooth extractions.

Medicare also does not generally offer benefits for dental devices, including dentures and dental plates.

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

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

One exception to the dental exclusions under Original Medicare’s parts A and B is Medicare Advantage. Commonly referred to as Part C, these types of policies are offered by private insurance companies and are intended to cover all of the same basic expenses participants receive under the Original Medicare plan.

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 Organizations)
  • 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.

Medical Billing
PACE is another type of Medicare program that provides some level of dental coverage.

PACE is short for “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,” according to Medicare.gov.

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 for PACE, participants 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

Whether you need dental services not covered under a Medicare plan or you don’t qualify for Medicare coverage options that would pay for some or all of your dental care needs, you always have the option of purchasing a stand-alone dental plan.

If you do this, the Wisconsin Dental Association (WDA) makes it clear that you do not need dental insurance in order to receive dental care. Also, if the cost of dental coverage is most concerning to 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.

If the former is less than the latter, dental insurance may not be the best financial decision for you. The 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 WDA explains that 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 a major dental issue 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 expense.

Also, take the 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’ll mistakenly go to an out-of-network provider and incur even more dental costs.

Finally, 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. At a minimum, 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, simply by knowing how much your new plan will cover and how much you’ll have to pay on your own.

Medicare does have rather limited dental health coverage, but other options exist that can potentially help offset these types of expenses. Medicare Advantage, PACE, and stand-alone dental policies are three to consider.