Medicare Dental Coverage & What Dental Services Are Covered By Medicare?

Is there dental insurance for Medicare? Many of you may be surprised that the short answer is no; Original Medicare does not cover dental in the traditional sense. During our working years, we often get dental as part of our employer coverage or as an add-on to a privately purchased health insurance policy. You’ll find that the situation with Medicare is very similar in that you can only get dental with a private insurance plan or as a stand-alone purchase.

Here, we will go over what’s covered for dental under Original Medicare, general helpful knowledge about dental plans, and how to get coverage with various Medicare insurance plans.

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 those on Medicare

If you only have Original Medicare, then you will have to purchase a dental plan from a private company. There are no specific dental plans for those on Medicare. Anything you find will be a universal style plan that is available to everyone. Any questions on age or birthday are used to adjust the rate and not necessarily to qualify you for the plan. 

You will have a good number of plans to choose from. Almost all of them will be a PPO option. There will be a lot of popular companies like Cigna, Humana, Anthem Blue Cross, Delta Dental, Metlife, and others that have great coverage options. There will also be plenty of lesser known companies out there with good coverage. It’ll depend on where you live, also known as your service area. There are a few HMO options out there. One of the most popular being the Delta Dental HMO plan. 

The question we often get is what is the best dental plan for seniors? “Best” is always a situational answer. We can say the best place to start is to ask your dentist which insurances they accept. They will often say that they take most PPOs. If you want to know which plans cost the least to the patient, ask to speak to the biller. They can often tell you the plans that come through with the lowest share-of-cost for the patient. You can then search those plans online and compare monthly costs and benefits. 

Dental plans for Medicare Supplements

A Medicare Supplement plan (aka Medigap) won’t specifically cover dental as part of your health plan. It will only cover what Original Medicare covers for dental. Many Medicare Supplement plans will often have a dental package that you can purchase as an add-on to your Supplement plan. 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 Supplement plan, and it’ll give you a single point of contact for all customer service needs for medical and dental. 

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