Q: I am wondering about dental coverage. My current employee plan includes dental coverage, and once I retire I will be on Medicare. I can't find any information on dental coverage that Medicare gives to individuals. What can you tell me about dental coverage?
A: The quick answer is, no, Medicare does not cover dental care, but this is not completely accurate because Medicare always has exceptions and exclusions for the rules. Medicare gives limited dental coverage in limited situations and it does not usually cover routine dental care. Medicare will not pay for dentures under any circumstances.
I will now give you some examples of how and when Medicare will cover dental evaluations and treatments. This information is taken from the www.Medicare.gov website.
If dental services are required to protect your general health, or if you need the dental care in order for other Medicare-covered services to be successful (or approved), Medicare does cover those services. A few examples: an oral exam is required to check for gum disease prior to a kidney transplant or heart valve replacement; a facial tumor has been removed and reconstruction of the jaw is required as part of this procedure; a disease (like oral cancer) is present that requires treatment as part of the preparation for radiation; surgery is needed to treat fractures of the face or jaw; or you need dental splints or wiring as a result of jaw surgery. Remember that in all these situations Medicare will not pay for dentures. Medicare will pay for these limited initial dental services; it will not pay for any more follow-up dental care.
Medicare will pay for some dental-related hospitalizations. An example is if after having a tooth pulled, you develop an infection that requires hospitalization. Another example is if you require hospitalization for a dental procedure due to a health-threatening condition. In this situation, Medicare will pay for the hospitalization costs including the dentist's fees for treatment.
I would now like to talk about other alternatives you can get for your dental needs. There of course are dental insurance policies you can purchase. These usually cost approximately $20 to $40 monthly and give you limited coverage for your routine check-ups and sometimes coverage for more expensive procedures. Be sure to look into these policies thoroughly before purchasing one. Make sure your dentist participates and ask the office how payment is handled. Do you pay for the visit and then get reimbursed by the insurance company? Is there a co-pay and how much? What exactly does it cover and how often? In some situations, if you put that same dollar amount in an envelope in your desk, and use that money to pay for the cost of the visit, you would be money ahead. But as with all insurance policies, you are insuring against the big expensive procedures that we don't always see coming. But many of these dental insurance policies have limited or no coverage for those expensive procedures. Often people ask me about crowns, implants, etc. These dental plans may only cover a percentage (30 percent or 50 percent of the cost) or a limited dollar amount ($500 per year).
The next paragraphs describe other ways of covering the cost of dental care. If you qualify for Medicaid coverage, Medicaid does cover dental services. You must be low income and have limited money/assets to qualify, but Medicaid does provide dental coverage at a participating dentist's office. There are also dental clinics in some areas of the country that can provide free or reduced-cost services. Dental schools also provide low-cost dental care. This allows students to gain experience working on real people, and they always work under the supervision of experienced and licensed dentists.
Some Medicare Advantage Plans (HMO and PPO plans) provide dental coverage in their package of benefits. Each plan is different, and your dentist needs to accept the plan as well. Remember that when looking at Medicare Advantage Plans you need to consider the doctors and hospitals that participate, as well as the drug coverage provided. I wouldn't recommend choosing a Medicare Advantage Plan based on the dental coverage it provides. That is definitely an added benefit, but it should not be the primary reason for choosing that plan.
Earlier I talked about some companies that sell stand alone Dental Insurance Plans. Two immediately come to mind. A partnership between AARP and Delta Dental offers two plans in our region: PPO A or PPO B. My quotes for premiums were low; they are running about $42 to $60 per month per person. These plans have a maximum coverage amount of $1,000 or $1,500, respectively. So you pay $42 per month for coverage, and they limit their liability to up to $1,000. In one year you have paid $504 in premiums. This plan could save you some money, but also remember you have to go to a participating dentist to see a real benefit.
Humana also offers two dental insurance plans. One is specifically designed for veterans, and if you are a veteran, that may be worth looking into. You do not have to be hooked up with VA Services to enroll in this dental plan. (If you were enrolled in VA Services they would cover your dental needs.)
The second Humana plan offered does not require you to be a veteran and may be a useful product with regard to cost and coverage of procedures. My concern with the plan is that we don't currently have too many dentists that participate with the plan in our region of the country. That may improve over time.
I also do want to talk about VA dental benefits. If you are enrolled in the VA Health Care System, you have an ID card which allows you to use VA physicians and pharmacies, and you can also get Dental Care there. This can be a wonderful way to have your dental care needs met. You may have to travel to Erie, Pa., or Buffalo to have your dental work done, but it is covered in full. Not all veterans qualify for these benefits, so check with your local Veterans' Services Agency to see if you qualify.
When I talk with individuals aging into Medicare, dental insurance is usually mentioned at least briefly. Many of us are used to this benefit being part of our employee plans and expect Medicare to cover it at as well.
Medicare, as you can see, is not dental insurance for most of us. That may be something we want to lobby for coverage in the future.
If you would like to reach Janell Sluga directly with questions, please call 720-9797 or email her at email@example.com.