Two common misconceptions about Medicare are that it doesn’t cover dental care and that beneficiaries need to pay all dental expenses out of pocket.
This may explain why even though most older adults have gum disease, roughly half of people with Medicare haven’t had a dental visit in a year, according to the KFF health policy research group. Poor oral health is associated with medical problems like heart disease, stroke, and cognitive impairment.
“Visiting the dentist regularly not only prevents dental complications from developing but also prevents minor oral health issues from progressing into larger ones,” noted the CareQuest Institute for Oral Health.
It’s true that Original Medicare’s Part B medical insurance doesn’t cover most dental work, including routine cleanings, fillings, tooth extractions, or dentures.
But there are numerous ways people with Medicare can get dental coverage aside from their employer or former employer:
- Most Medicare Advantage plans (private insurers’ alternatives to Original Medicare, also known as Medicare Part C) include dental insurance.
- Some Medigap plans (supplemental policies bought by people with Original Medicare) include dental, or sell separate dental policies.
- You can purchase an insurer’s dental insurance policy or dental discount plan on your own even if you have Medicare.
- If your income and assets are low enough to qualify for Medicaid, you may be able to get dental coverage through that program.
No matter which way you go, however, it’s important to understand a key difference between dental insurance and health insurance, which aims to prevent you from owing catastrophic medical expenses.
“If you buy dental insurance, you’re essentially buying maybe $1,500 worth of coverage with a certain co-pay,” says Dr. Mark Vitale, an American Dental Association spokesperson. “Forty-two years ago, when I went into practice, the maximum plan benefit ranged from $1,000 to $1,500. Fast-forward 42 years and it’s the same exact thing.”
When your dental expenses exceed a plan’s annual maximum, you pay them out of pocket. So, the coverage is helpful in defraying the cost of preventive care, like cleanings and X-rays, but often not great if you need something more significant like a root canal, a crown, or dentures.
“It can become extremely costly to have almost any invasive procedure,” says Dr. Lisa Simon, a dentist and physician at Brigham and Women’s Hospital in Boston. “Implants can go for $5,000 to $10,000 per implant. Dentures can be $4,000.”
Dr. Ira Lamster, former dean of the Columbia University College of Dental Medicine, says, “You have all these people who are 65 and older and I can tell you from my own experience, their teeth are going to need care. And there is no mechanism in place for comprehensive care for that group.”
A KFF report noted: “Absent a broader expansion of dental coverage under Medicare, people on Medicare who do not have a comprehensive source of dental coverage will continue to face relatively high out-of-pocket costs, particularly if they need extensive dental care that is unrelated to other covered medical services,”
Here’s a guide to your dental insurance options when you’re on Medicare:
Original Medicare and Medigap
Original Medicare only covers “medically necessary” dental services related to a covered medical procedure, such as an organ transplant, cardiac surgery, or chemotherapy. That’s pretty rare.
“It’s not what we think about as routine dental care,” says Bowen Garrett, a senior fellow at the Urban Institute.
Many people with Original Medicare also buy a supplemental Medigap policy which can sometimes be bought with dental insurance. In certain cases, vision and hearing coverage are included, since Original Medicare generally excludes those too.
“Most Medigap providers will offer a chance to enroll in their dental plan. Some will do it at a discount of 5% to 10% off,” says Chris Mihm, cofounder of Senior65.com, a health insurance agency specializing in Medicare.
“We’ve seen ones where the plan will cover most preventive benefits, but not some comprehensive benefits. We’ve also seen ones where they offer discounted rates for dental benefits through a specific network of providers,” says Meredith Freed, senior policy manager, program on medicare policy at KFF.
Occasionally, a Medigap policy is bundled with dental coverage and perhaps hearing too. For instance, Blue Cross Blue Shield of Illinois sells a Blue Dental Plus plan for Illinois residents. It has full coverage of preventive services and up to 50% of oral surgery, up to $2,000 annually.
Mihm says you’re often better off shopping for a dental plan on your own to find coverage rather than accepting the one a Medigap insurer offers.
“What if your dentist isn’t in the Medigap provider’s dental-plan network?” he says.
A Medigap insurer’s plan also may have longer waiting periods, lower annual maximums, and fewer dental services covered than a policy you could find on your own.
Medicare Advantage plans
Nearly all Medicare Advantage plans include dental coverage, which entices people to sign up or to switch from one Medicare Advantage plan to another during the open enrollment period ending March 31.
But dental coverage in Medicare Advantage plans is rarely generous.
A Mass General Brigham investigation found that only 8% of Medicare Advantage plans with a dental benefit met its research team’s quality standards. Just 4% of Medicare Advantage members with dental plans had a comprehensive dental benefit.
Many Medicare Advantage dental plans require 50% coinsurance for fillings, extractions, and root canals; more than half of enrollees with such coverage have annual limits of $1,000 or less, according to KFF.
In a recent JAMA Health Forum investigation, about one in eight Medicare Advantage members with dental coverage report a cost barrier to dental care compared with just 7% of people with other dental insurance.
“The dental benefit Medicare Advantage members have is not one that’s actually meeting their needs in any meaningful way,” says Simon, who cowrote the Mass General Brigham report.
George Dippel, president of the Deft Research firm that studies health insurance policies, says its survey of Medicare Advantage members found that dental coverage was “one of the top five largest dissatisfiers in Medicare Advantage benefits” this year.
One reason, Dippel noted: Some Medicare Advantage insurers have trimmed dental benefits lately.
Getting information about the breadth and quality of a Medicare Advantage plan’s dental insurance isn’t easy.
Medicare’s star ratings for the plans don’t apply to dental benefits. The agency’s Plan Finder tool has a green Dental check mark denoting Medicare Advantage plans with dental coverage, but it doesn’t provide many details.
“This is a situation where it’s really important to read the fine print because in some plans, dental coverage might just include an annual exam or X-rays but not more than that,” says Meredith Freed, of KFF. “Co-insurance for some plans can run up to 50%, which could be at least $1,000 out of pocket for some procedures.”
Simon advises going to the sites of Medicare Advantage plans you’re considering and comparing their dental benefits, annual maximums, and in-network dentists.
“This is all about doing your homework,” says Simon.
Medicaid
Adult dental coverage is an optional benefit in Medicaid, the federal-state health insurance program primarily for low-income Americans. So, each state can decide whether to offer it and which dental services are covered.
Only nine states provide what CareQuest calls an extensive dental benefit for adults on Medicaid. The others either don’t offer dental coverage, restrict it to emergencies or limit annual benefits to preventive care and annual maximums under $1,000.
Dental insurance plans and dental discount plans
To reduce out-of-pocket dental costs on your own, you could buy a dental insurance plan or a dental discount plan.
An insurance plan charges a premium (typically $30 to $60 a month) and covers certain types of dental care with an annual limit of $1,000 to $2,000. It has waiting periods before the insurance kicks in; co-insurance of 20% to 50% and, sometimes, an annual deductible of $50 to $100.
Generally, dental insurance plans offer two free dental visits a year. Some let you see any dentist in their network and pay extra to go out-of-network; others require you see their in-network dentists.
A discount plan is a membership plan that charges an annual fee of about $100 and shaves 10% to 60% off dental expenses at participating dentists. There are no annual dollar maximums, deductibles or waiting periods.
Read more from Fortune
Expanding Medicare’s dental coverage
There’s growing interest by health care analysts and dental groups to either expand dental coverage in Original Medicare, standardize dental coverage in Medicare Advantage plans, or make those plans’ dental benefits more transparent.
The Urban Institute’s researchers have written that “Medicare enrollees could benefit substantially from policies that would expand dental coverage. Spending burdens would likely be lessened for those with significant spending now, and more employees would likely obtain needed dental care.”
The American public wants broader dental coverage in Original Medicare, too.
Roughly nine in 10 voters polled by CareQuest—Democrats and Republicans alike—say they’d like to see a dental benefit added to Original Medicare.
Democrats in Congress favor this; many Republican legislators don’t. President Trump has not shared his view.
When Medicare was enacted in 1965, it excluded dental care because “we knew very little about how the mouth really integrated into the body,” says Lamster. “In the last 20 or 25 years, we’ve learned enormous amounts.”
The National Dental Association (NDA), comprised of minority dentists, wants to see comprehensive dental coverage in Original Medicare.
The group is also eager for more transparency from Medicare Advantage plans about their dental coverage. “We would like to see the plans explain to patients what they’re getting when they’re signing up for benefits,” says Dr. Cheryle Baptiste, president of the NDA.
The American Dental Association is working with the Trump administration to standardize Medicare Advantage dental benefits and make the plans’ coverage more apparent.
“If you try to buy [dental coverage in] a Medicare Advantage plan, it is very difficult to understand what it is you’re buying,” says Vitale.
Simon envisions a Medicare Advantage dental insurance system similar to the Affordable Care Act’s Marketplace, with its gold, silver, and bronze health insurance plans.
Lamster and Richard Manski (chair of the University of Maryland Department of Dental Public Health at the University of Maryland School of Dentistry) propose a hybrid approach to new dental coverage in Original Medicare.
“Our idea was to find a sweet spot between the competing ideologies, something that would make economic sense,” says Manski.
The Lamster-Manski proposal would have mandatory 80% coverage for a group of dental procedures including prevention and pain relief. Other dental care could be provided, with the amount of coinsurance, annual limits, and premiums varying based on the plans.
“Everybody in the Medicare program would get a basic set of dental services, but it wouldn’t cover everything. It wouldn’t cover implants or aesthetics,” says Lamster.
“The problem is, at least in the environment we’re in now, I don’t see that happening,” he added.
The Trump administration and congressional Republicans are looking for ways to reduce Medicare spending, not add to it.
“It’s not an easy time to be an optimist when it comes to expanding access to coverage,” says Simon.
