Dental coverage: What to expect from Medicare

Medicare wasn't designed to include coverage of routine dental care and coverage of expenses is limited. Here's what you need to know.

  • By
  • Contributor
  • July 16, 2015

For half a century, Medicare has provided comprehensive health insurance coverage to America’s seniors. But dental coverage isn’t included in Original Medicare or Medigap plans.

So even with a very solid health plan via Original Medicare + Medigap + Part D prescription drug coverage, dental care is an out-of-pocket expense. And that’s becoming an increasing challenge as the cost of dental care rises: From 1996 to 2010, out-of-pocket spending on dental care increased by 26 percent, after adjusting for inflation.

Dental crisis in United States

Nearly 70 percent of seniors have no dental insurance at all. That’s worrisome not just for oral health, but also for overall health. There’s a significant link between untreated dental disease and various other systemic ailments, including heart disease and diabetes.

Oral cancer is seven times more likely to be diagnosed in people over age 65, and routine dental check-ups are an excellent means of detecting oral cancer.

Yet more than one in five Medicare beneficiaries have not seen a dentist in the last five years.

A quarter of Americans age 65 and older are missing all of their natural teeth, although there is significant variation in tooth retention based on geographic area, income, and education level.

There is no doubt that we have a dental crisis in the U.S. Although the ACA deemed dental coverage for children to be an essential health benefit, there’s no requirement that adults have dental coverage, or that carriers provide it.

Coverage of routine dental care wasn’t built in

dental-plans-MRO-clickAnd Medicare was never designed to include routine dental care; Medicare’s coverage of dental expenses is limited to situations where the dental treatment is integral to other medical treatment (for example, an extraction prior to radiation treatment for oral cancer, or jaw reconstruction following an accident).
While health insurance plans generally pick up the tab for large medical bills, it’s rare to find dental coverage that doesn’t leave enrollees on the hook for significant bills if they need extensive dental work. This is generally true across a wide range of plan types, including Medicare Advantage dental coverage, stand-alone dental plans, and group dental plans for employees and retirees. Dental plans commonly have benefit maximums of $1,000 or $1,500 per year, and a single root canal can cost upwards of $1,500, while an implant can be as much as $7,500 per tooth.

But some coverage is better than nothing. Even with low benefit maximums, people who have dental insurance are more likely to receive routine preventive dental care, and are less likely to have untreated dental problems that get worse over time.

Sources of dental coverage

Roughly ten percent of retirees retain dental coverage from their former employer or a spouse’s employer. But there are other options available for seniors who don’t have access to employer-sponsored dental coverage.

Medicare Advantage is an alternative to Original Medicare for enrollees who want dental coverage. In 2010, 55 percent of Medicare Advantage plans included dental coverage. If you’re considering Medicare Advantage instead of Original Medicare + Medigap + Medicare Part D, be sure to familiarize yourself with the pros and cons of both options.

Stand-alone dental plans are available for purchase, and some carriers offer dental plans that are specifically designed for seniors. But again, it’s typical for them to have relatively low annual benefit maximums (here’s an example of such a plan, offered by Anthem for seniors in Virginia – the benefit maximums range from $500 to $1,250 per year, depending on the plan selected, and the premiums range from $216 to $624 per year, including vision coverage).

For low-income seniors who are dual-eligible for Medicare and Medicaid, limited dental benefits (including dentures) can be provided by Medicaid, but coverage varies considerably from state to state.

Legislative help on the way?

Two bills were introduced in the 2015 legislative session that would have added routine dental treatment to Medicare’s list of covered services (H.R. 1055 – the Comprehensive Dental Reform Act of 2015; and S.570 – a “bill to improve access to oral healthcare for vulnerable and underserved populations”).

Both bills were referred to committees but have not advanced to a vote; you can contact your elected representatives to urge them to support these measures if dental coverage for Medicare beneficiaries is important to you.

Programs that help

For seniors who have no dental coverage, a variety of programs can help them obtain dental care:

  • Dental schools will often provide treatment at a reduced price. (Here’s a list of accredited dental schools in the United States.)
  • For low-income seniors, dental care is available on a sliding fee scale at community health centers. You can use this tool to find a community health center near you.
  • The Dental Lifeline Network coordinates dental care nationwide for elderly, disabled, and medically fragile populations. More than 15,000 dentists donate their time to provide dental care for patients who would not otherwise be able to afford treatment.
  • Many dentists offer payment plans, or will refer patients to a credit source, often with low initial interest rates. Read the fine print though, because interest rates can reach credit card-levels after the introductory period is over.
  • Dental savings plans are readily available, without waiting periods or restrictions on their use. But they are not considered insurance, and they don’t pay anything on your behalf when you receive treatment. Instead, dental discount plans simply utilize a network of dentists who agree to charge a reduced rate for plan members. And although some discount plans offer significantly reduced rates for routine care like x-rays and exams, they typically provide only very small rate reductions for more extensive dental work.
  • Brighter is an online tool that self-pay dental patients can use to compare local dental prices and gain access to pre-negotiated rates.
  • And of course, some patients simply opt to receive dental care in a foreign country, finding it less expensive – even after accounting for travel costs – than obtaining dental care here in the US.

So while there are programs available to help seniors obtain affordable dental care, in most cases, Medicare beneficiaries must pay out-of-pocket for their dental care, and many simply forgo dental treatments altogether.

The ACA has substantially reformed our healthcare system, but dental coverage remains out of reach for many American adults, and that’s especially true for retirees who no longer have access to employer-sponsored insurance.