CHICAGO (Reuters) – During a recent visit to my dentist, we talked about his frustrations with Medicare. “It’s amazing – they managed to remove teeth from the human body.”
Here’s what he meant: Traditional health insurance doesn’t cover most dental care. This surprises many people at the time of retirement. Studies have shown that more than half of workers between the ages of 50 and 64 are unaware that Medicare does not cover preventive dental care or more expensive and complex procedures.
But dental care is an essential part of overall good preventive health. Research shows clear links between poor oral health and chronic diseases such as diabetes, as well as pain, chronic infections and reduced quality of life.
Many seniors simply pay for dental care out of pocket — the average amount of out-of-pocket expenses for Medicare-enrolled people who needed dental care in 2016 was $607, according to the Health Care Research and Quality Agency. Health, a research arm of the US Department of Health. and Human Services.
But the expenses can be much higher if you need a crown, a bridge or a root canal, for example.
With fall Medicare enrollment season in full swing (reut.rs/2yj24dB), now is a good time to consider your dental options.
Traditional health insurance will only pay for dental treatment in very limited circumstances – it must be deemed necessary as part of a covered procedure, for example a tooth extraction necessary for radiation therapy. But many Medicare Advantage plans — the managed care alternative to traditional health insurance offered by private insurance companies — include dental coverage.
Advantage plans typically include prescription drug coverage and an out-of-pocket spending cap. But they often include some level of coverage for vision and hearing care — and 63% of Advantage enrollees had access to dental coverage in 2017, according to Avalere Health. Among Advantage recipients with dental benefits, more than half were covered for x-rays, oral exams and cleaning; a smaller number were covered for restorative procedures.
Many Advantage plans that cover dental care require no copayment for preventive services, according to Avalere data, but cost sharing increases sharply for surgery, restorative services and periodontal procedures.
And they typically cap annual benefit payments at $1,000 to $1,500, notes Beth Truett, chief executive of Oral Health America, a nonprofit group that advocates for better dental health. “Advantage plan coverage typically mirrors many of the lower-reimbursement plans that cover people while they work,” she said.
On average, only 5% of patients reach these maximums in any given year, according to Evelyn Ireland, executive director of the National Association of Dental Plans. But if you do, the prices insurers negotiate with providers in your plan network can reduce out-of-pocket expenses, she notes. “In dental PPOs, prices can be up to 30-40% lower than actual charges,” she said. For example, the plan’s negotiated rate for one crown could drop the price by $1,200 to $800, she said.
For traditional Medicare enrollees, individual dental plans offer another way to be covered. For example, in Illinois, a Delta Dental PPO offered by AARP for $72 per month will cover most preventive services; it has an annual deductible of $50 and an annual cap on benefits of $1,500.
And some Medigap supplemental policy providers — for costs not covered by original Medicare — offer add-on options for dental and vision care, or discount programs to help customers save money on out-of-pocket expenses.
Low-income seniors who lack the resources to pay for care out-of-pocket or purchase commercial insurance face the most limited options. Medicaid is an important source of dental coverage for low-income elderly and disabled people who are also enrolled in Medicare (known as dual eligible).
Federal law does not require states to cover adults through Medicaid, but most states have some level of adult dental benefits, Ireland said. And expanding Medicaid eligibility under the Affordable Care Act more than doubled the number of adults covered by Medicaid, to 65 million in 2017, she notes.
PUSH FOR REFORM
US Senator Bernie Sanders of Vermont has proposed adding a dental benefit to Medicare Part B as part of his “Medicare for All” legislative proposal. The American Dental Association has estimated that integrating a comprehensive dental benefit into Part B—using the program’s existing cost-sharing rules—would cost the federal government $32.3 billion (in 2018 dollars) ; the base premium paid by enrollees is expected to increase by $14.50 per month.
Ireland doubts that a full dental benefit will be added anytime soon. His group is part of a coalition lobbying Medicare to expand coverage for medically necessary dental care, which could be done by administrative authority. “We’re talking about the idea of an overall benefit, but right now we’re focusing on things that we think we can accomplish in the short term.”
(Views expressed here are those of the author, columnist for Reuters.)
Reporting and writing by Mark Miller in Chicago; Editing by Matthew Lewis