Indeed, many people are surprised to learn that Medicare does NOT cover routine dental care. We often have access to dental insurance coverage through our employer’s group health insurance plans during our working years. On those plans, we get benefits to cover the cost of our teeth cleanings and annual x-rays. We often also have coverage for more expensive things like crowns or root canals.
Medicare does not pay for anything related to keeping your teeth healthy, such as checkups or fillings. It also does not cover things like extractions or dentures in most cases. What you and I think of as “dental care” are things that Medicare considers “not medically necessary.”
Medically Necessary Dental Care
Medicare MAY cover dental work related to another health condition, or in other words, when medically necessary. An example of that would be if you need surgery to treat a broken jaw or if you have dental services ordered by an oncologist as part of your treatment plan for oral cancer. Another example might be an oral exam performed as part of a comprehensive workup before kidney transplantation.
Even in these circumstances, the prescribing physician must demonstrate to Medicare why this dental service is necessary. More on that later in this article.
Other than these few limited exceptions, everything else is pretty much not covered. Section 1862 (a)(12) of the Social Security Act defines a Statutory Dental Exclusion “where such expenses are for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth.” (You can read more on the statutory dental exclusion at the CMS.gov website.)
Dental Insurance Options for People on Medicare
So, what is a person on Medicare supposed to do for routine dental coverage? There are a couple of options.
Medicare Advantage Plans
Some Medicare Advantage plans cover a small amount of routine dental services. I hesitate even to mention this because Medicare Advantage plans can change their benefits each year. If you opt for a specific plan just because of some minor dental coverage, you will be upset if the plan drops that benefit next year. Also, dental coverage within a Medicare Advantage plan may only have a small network of dentists. Chances are that your family dentist may not be in the network. Never choose your Advantage plan based only on the fact that you want a little dental coverage. Always select your Medicare insurance for its medical benefits first. Then if that plan also includes even $100 worth of dental coverage, consider that a bonus.
Standalone Dental Insurance
A more reliable option is to purchase individual dental insurance. This is a private dental insurance policy through a reputable dental insurance carrier. You enroll in it separately from Medicare.
Dental insurance plans provide benefits for all the things you expect, like cleanings, x-rays, fluoride, fillings, and even crowns and root canals. While there are many individual dental insurance plans out there on the market, there is one that we like because it does not restrict you to a dental network.
It also offers coverage for routine vision and hearing, which are two additional things that Medicare does not cover. Benefits are available immediately, with no waiting period for preventive care.
Learn more about our Dental, Vision and Hearing plan here.
A standalone individual dental insurance plan like this one offers fuller coverage than the limited dental benefits that you can find in a Medicare Advantage plan. You can use the coverage for preventive care and basic care like x-rays, fillings, and extractions. Most importantly, it includes major coverage items like bridges, crowns, root canals, and dentures. Also, the benefit grows over time.
Dental benefits from an individual plan don’t change every year. Unlike Advantage plans, standalone dental plans don’t have to re-file their benefit plans with Medicare every year. You can also carry your family members on an individual plan if more than one person in your household needs the coverage.
Private Pay
Some individuals will privately pay for dental care. You can check with your dentist to see if they are willing to give you a discount for paying cash since that saves your dentist the burden of filing insurance claims on your behalf. My dentist gives me a 5% discount whenever I pay cash for my care. Yours might do the same…so it’s worth asking.
Does Medicare Cover Dental that is NOT routine?
Medicare defines “covered dental benefits” as medically necessary. If a dental procedure is an integral step of a covered procedure, Medicare will make payment. For example, let’s say you injure your jaw in an accident. Medicare may cover repair to your jaw. If the surgery to repair your jaw involves a hospital stay, Medicare Part A will cover the hospital stay, and Part B will cover the surgery.
Medicare will also cover dental exams required prior to major surgeries, such as transplants. Since your dental health can impact your overall health and ability to recover from major surgery, your doctor may order a preliminary dental exam before a heart transplant or kidney transplant. In this scenario, Medicare will cover the exam itself but may not cover the dental work you need to complete before the surgery.
What about cancer? Does Medicare cover dental work related to cancer treatment? The answer is: maybe.
People who undergo radiation treatment for head and neck cancer often suffer dental problems. Technically, Medicare should cover such dental work. In reality, though, many beneficiaries with medically-necessary dental procedures still find it difficult to get Medicare to pay for these procedures. They often have to file appeals to get someone to look at their claim more closely.
Does Medicare Cover Root Canals?
Original Medicare does not cover root canals. It also does not cover oral exams, extractions, fillings, dentures, teeth cleanings, or dental implants. Sometimes people wonder about root canals or dental implants since these procedures require surgery, but Medicare does not cover root canals or dental implants.
Remember that Medicare provides healthcare for injuries and illnesses, and medical conditions. Unfortunately, routine dental, vision, and hearing fall outside that umbrella. Preparing to make other arrangements for your dental care once you transition to Medicare is a good idea.
