Does Medicare cover dental treatment?
LAWRENCE, Kan., U.S.: Medicare has a main rule that, once learned, will help you gauge what Medicare does and does not cover. This rule is that Medicare will only cover things that are medically necessary. Medicare does not consider routine dental treatments, such as cleaning, restorations, root canal therapy, extractions and oral examinations, as medically necessary. Therefore, more times than not, Medicare will not cover routine dental treatments.
However, in some cases, if you can prove to Medicare the medical necessity of particular dental services, it will approve a claim. Let’s look at a few examples below.
When are dental services covered?
If the patient has an underlying medical condition, Medicare may cover services and treatments that it usually would not. Therefore, if the patient requires dental care to diagnose or treat a medical condition, then Medicare is likely to cover it.
One example of this is an oral checkup before organ transplant surgery. If the patient is undergoing an organ transplant, an oral health examination may be required. Medicare will cover medically necessary dental services, such as an examination, before the patient’s organ transplant. Another example of this is if the patient has an injury to his or her jaw. If dental treatment is required for the overall treatment of the jaw injury, then Medicare is likely to cover it.
Remember that Medicare will not cover any dental treatment or services that are not medically necessary for the injury. Medicare may also cover medically necessary dental treatment if the patient suffers from oral cancer. If your patient requires a dental treatment or service that you feel should be considered medically necessary, you can submit documentation explaining to Medicare why you think it should be covered. Medicare may ultimately approve your claim.
Who pays if Medicare does accept the claim?
If Medicare does accept a dental claim, then Medicare Part B will provide the coverage. Under Medicare Part B, the patient pays an annual deductible of $185 (2019) and a 20% coinsurance. Medicare Part B will cover 80% of the bill after the $185 deductible.
If the patient has a Medigap plan, such as Plan G, that covers the Part B coinsurance, the only charge that the patient will have is the Part B deductible. The Part B coinsurance will be covered by the Medigap plan.
Keep in mind, Medigap plans only pay if Medicare pays. Therefore, if Medicare denies a dental claim, and the patient has a Medigap plan, that Medigap plan will also deny the claim.
Other dental coverage for seniors
Because Medicare usually does not cover dental services for its beneficiaries, seniors should obtain dental coverage through another source. Two popular ways seniors can obtain dental coverage are through Medicare Advantage plans and stand-alone dental plans.
Medicare Advantage plans usually include dental in their supplemental benefits. When a patient has a Medicare Advantage plan that includes dental coverage, the patient will pay a copay or coinsurance set by the plan. The Medicare Advantage plan will usually provide coverage for both preventive and comprehensive dental benefits.
Stand-alone dental policies are popular as well. People who choose Original Medicare often choose this type of coverage. There are even plans that include three benefits: dental, vision and hearing. Some of these plans do not have networks, so the patient can go to any dentist and still file an insurance claim.
Medicare rarely covers the dental treatments that you may feel your patients need, so you should always remind your patients on Medicare of this fact. If the patient receives a dental treatment from you and does not know that Medicare will not cover it, you will likely be the first person he or she calls to figure out what the problem is. It is better to cover all your bases beforehand.