Will Medicare Pay For Oral Surgery – Dental benefits are not generally covered by Medicare, except in limited circumstances, and many people on Medicare do not have any dental coverage at all. Some Medicare beneficiaries have access to dental coverage through other sources, such as Medicare Advantage plans, but the scope of dental benefits, when covered, varies widely and is often quite limited, which can result in high out-of-pocket costs among those with serious dental needs or unmet a need
Policymakers are now debating options to make dental care more affordable by expanding dental coverage for people on Medicare. President Biden’s 2022 budget request includes as part of the president’s health plan “improving access to dental, hearing and vision coverage in Medicare.” Senate Democrats recently announced a deal to include Medicare expansions, including dental, vision and hearing, as part of the budget reconciliation package, although details of the deal have not yet been released. In 2019, the House of Representatives passed the Elijah E. Cummings Lower Drug Costs Now Act (H.R.3) which would add a dental benefit to Medicare Part B, along with a vision and hearing aid, in addition to provisions to reduce prescription drug costs. . Earlier this year, Representative Doggett, joined by 76 members of the House of Representatives, introduced the Medicare Dental, Vision, and Hearing Benefit Act (H.R. 4311) which would cover these benefits under Medicare Part B.
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In light of these ongoing policy discussions, this report provides new data on the share of Medicare beneficiaries with dental coverage, the cost of a dental visit in the past 12 months, and out-of-pocket expenses for dental care. It also takes a closer look at the scope of dental benefits offered to Medicare Advantage enrollees in individual plans in 2021. We focus on Medicare Advantage plans because they have become the primary source of dental coverage among Medicare beneficiaries. Our analysis draws from multiple datasets, including the Medicare Current Beneficiary Survey for information on dental visits and out-of-pocket dental costs and the Medicare Advantage Enrollment and Benefit files for data on individual Medicare Advantage plans. To present a more detailed picture of dental benefits beyond what is available in these data sets, we examine dental coverage offered by 10 geographically dispersed Medicare Advantage plans offered by different insurers with relatively high enrollment that offer dental benefits (see Methodology and Appendix for more information).
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Nearly 24 million people, or about half of all Medicare beneficiaries (47%), had no form of dental coverage in 2019 (Figure 1).
The remaining Medicare beneficiaries have access to dental coverage through Medicare Advantage plans, Medicaid, and private plans, including employer-sponsored retirement plans and individually purchased plans.
In 2019, 29% of all Medicare beneficiaries had access to some dental coverage through Medicare Advantage plans (including 3% of beneficiaries also eligible for Medicaid who had access to dental coverage through a Medicare Advantage plan). Another 16% had coverage through private plans. About 11% of Medicare beneficiaries had access to dental coverage through Medicaid (including those mentioned who also have coverage through Medicare Advantage plans). With the increase in Medicare Advantage enrollment, a growing share of Medicare beneficiaries have access to some dental coverage through their Medicare Advantage plan, so the share of all Medicare beneficiaries with some dental coverage would likely be higher in 2021.
A preliminary analysis of the 2016 Medicare Current Beneficiary Survey (MCBS) and other data sources indicated that nearly two-thirds of people on Medicare (65%) had no dental coverage that year. However, due to a data collection and processing issue later identified by CMS, the estimates for private dental coverage derived from the MCBS were lower than they should have been of unknown magnitude. CMS resolved this issue in 2017. Because of this and other methodological changes in our analysis, as explained in the methodology, estimates of the number of people on Medicare with dental insurance cannot be trended using our 2016 estimate.
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Lack of dental care can exacerbate chronic diseases, such as diabetes and cardiovascular disease, contribute to late diagnosis of serious illnesses, and lead to preventable complications that sometimes result in expensive emergency room visits.1 Limited or no dental coverage and cost concerns contribute. to Medicare beneficiaries before routine and other dental procedures.
In 2018, half of Medicare beneficiaries did not have a dental visit (47%)—with even higher rates reported among those who are black or Hispanic (68% and 61%, respectively) (Figure 2).
When we looked by race and gender, we found that a greater proportion of black and Hispanic women (64% and 59%, respectively) went without any dental visits in the past year than white women (40%). The same pattern exists among men: a greater share of black (74%) and Hispanic (64%) men than white men (44%) went without a dental visit.
Low-income beneficiaries are much less likely than higher-income beneficiaries to report a dental visit in the previous year. Nearly three-quarters (73%) of Medicare beneficiaries with incomes of less than $10,000 a year have not visited a dentist, compared to 25% of beneficiaries with incomes above $40,000.
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Health status was also correlated with dental care. Nearly two-thirds (63%) of all beneficiaries in fair or poor self-rated health had a dental visit in the past year, compared to 41% of beneficiaries in excellent, very good or good health.
These relatively low rates of dental use are not attributable to a drop in utilization caused by the COVID-19 pandemic, as they are based on 2018 data, the most recent year available, which was before the pandemic.
Most beneficiaries who received dental services in 2018 (88%) paid out-of-pocket for their care. Among all beneficiaries, the average expenditure on dental care was $454 in 2018, although this includes a large number of beneficiaries who did not have any dental care that year. Among the roughly half of all Medicare beneficiaries who used any dental services, the average expense for dental care was $874 in 2018. One in five beneficiaries who used dental services spent more than $1,000 out-of-pocket on dental care. maintenance, including one in ten who spent more than $2,000 (Figure 3).
Medicare Advantage plans may provide additional (“supplemental”) benefits that are not covered under traditional Medicare, such as dental, vision, hearing and fitness benefits. The cost of these benefits can be covered by rebate dollars. Plans may also charge additional premiums for such benefits. In 2021, 94% of Medicare Advantage enrollees in individual plans have access to some dental coverage. The majority (86%) of these Medicare Advantage enrollees have access to a plan with broader coverage, while 14% had access to preventive coverage only. Preventative dental coverage under Medicare Advantage plans generally includes oral exams, cleanings, dental x-rays and sometimes fluoride treatments. More comprehensive benefits cover a range of services, including restorative services (eg, fillings), endodontics (eg, root canals), periodontics (eg, scaling and root planing), prosthodontics (eg, dentures, dental implants), and oral surgery .
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Virtually all Medicare Advantage enrollees in plans that offer access to dental benefits (including if they have to pay a premium for those benefits), have access to preventive services, including oral exams (100%), cleanings (100%), and x- rays (99%), although fewer enrollees have access to fluoride treatment (59%).
Service Limits. Medicare Advantage plans typically limit the frequency of obtaining certain covered services during specified time frames. For example, almost all enrollees (88%) are in plans that have frequency limits on the number of cleanings, with the most common limit being twice a year. For other services, such as x-rays, the frequency limits vary more according to plans. For example, 36% of enrollees are in plans that limit the number of x-rays to a specified time frame, with the most common limit being once a year.
Covered Services (Other than Preventive). Among enrollees in plans that offer access to more comprehensive services, the type of services covered varies by plan: 96% of enrollees are in plans that offer restorative services, such as fillers; 83% are in plans that cover withdrawals; 76% are in plans that cover periodontics and/or prosthodontics; 64% are in plans that cover endodontics, such as root canals; and 60% are in plans that cover diagnostic services and/or non-routine services. However, we did not examine frequency limits for more comprehensive services because these service categories encompass a variety of treatments, and it is not always clear what an individual plan covers in each of these service categories.
As part of the prosthodontics service category, some beneficiaries may have access to coverage for dentures, a commonly needed service among older adults. As of 2018, nearly 14% of adults 65 and older are edentulous, meaning they have no natural teeth. We were unable to determine specifics on dental coverage based on the analysis of national data, so we looked at the ten illustrative plans in more detail. Five of the ten plans specified that they covered dentures (partial and full) and each of these plans limits dentures to 1 set every 5 years (Appendix Table 1). Among these five plans, cost sharing imposed on beneficiaries for dentures ranges from no copay to a $500 copay, and 50% to 70% coinsurance. Everyone
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