As an independent insurance broker who focuses on helping Medicare beneficiaries find the right plan that suits their needs and budget, I’m often asked if Dental Insurance is covered by Medicare.
First, I will define what I am talking about when I say Medicare. Original Medicare includes parts A and B. Medicare Advantage plans are, for the most part, HMO’s, and usually have no monthly premiums. Advantage plans require that the beneficiary choose a primary care physician and a medical group; and referrals are needed before going to a specialist. There are also Medicare Supplement plans, aka Medi-Gap plans, that have monthly premiums and allow you to go to any doctor or hospital that accepts payments from Medicare.
Generally, original Medicare doesn’t pay for any dental services such as cleanings, fillings, dentures, etc. However, there are some unique exceptions, such as the following:
- Oral exams that are done in the hospital before heart valve surgery or a kidney replacement procedure.
- Tooth removal and dental services that are required in order to treat another, non-dental disease.
- Dental services that are required to treat certain types of cancer.
- Jaw surgery and repair caused by a traumatic accident.
Eighteen years ago, when I first became an independent insurance broker, I cannot recall any Medicare plans that offered Dental Insurance. In fact, in the first half of the 20th century, there was no such thing as Dental Insurance. It wasn’t until the 1950’s that unions introduced dental care to their members and families.
Today, most of us can enjoy Dental coverage. In 2019, Delta Dental companies covered more Americans than any other dental carrier. Over 78 million people are covered by Delta Dental plans across all 50 states, Puerto Rico, and the U.S. Virgin Islands.
Most Medicare Advantage plans either offer the option to purchase certain HMO and PPO Dental plans, have embedded HMO Dental plans, or give cash-back for dental services rendered. Only two Medicare Supplement plans offer Dental plans: The GX and FX plans.
What does a Dental HMO (DHMO) plan look like and what does it cost?
DHMO refers to the Dental Health Maintenance Organization plan. A person who participates in a DHMO plan can visit a dentist within the DHMO network and can receive discounted health coverage, including preventive visits and restorative care.
The DHMO’s have monthly premiums that are significantly lower than PPO Dental plans. I had a plan which cost $8.95 a month. PPO Dental plans begin at around $49.00 per month, per person.
A DHMO plan will offer discounted dental services to the participants within the DHMO network. Be it routine visits or more extensive tooth procedures like root canals or extractions, a DHMO plan will take care of all end-to-end processes within a more affordable range. There are usually no claims to file and no annual limits.
The disadvantage of a DHMO plan is that it’s sometimes hard to find a dentist who takes DHMO plans.
Advantages of the Dental PPO plan:
- Visit any dentist: One of the biggest advantages of DPPO plans is the ability to visit any dentist and receive full or partial coverage for their services. However, it is advisable to visit a dentist within the DPPO network, as it will save you the most money.
- No Referrals: The participant under the DPPO plan does not need to choose a primary dentist nor does one need to get a referral before visiting a dentist or specialist.
- No Co-Pay: The participants of a DPPO won’t have to pay a co-pay for visiting a dentist. On visiting the dentist in the DPPO network, the DPPO will file all the claims for the participant. But in case a participant chooses a non-network dentist, the participant will probably have to file their own claim.
Disadvantages of a PPO plan:
- Higher costs: A disadvantage of a DPPO plan is that the participants pay an annual deductible for their routine dental services. The monthly premiums are much higher than DHMO’s. Ex: $8.95/mo. for DHMO’s vs. $49.95/mo. for DPPO’s.
- Coverage: After meeting the deductible, the DPPO will cover most of the dental costs; but these plans pay less if one visits a dentist outside the plan’s network.
- Annual maximum: All DPPO’s have an annual maximum that it will pay. The participant has to pay the remaining cost for the dental services; but at a discounted rate, determined by the standard plan. I think the biggest disadvantage is that the annual maximum can be as low as $1000. One root canal costs about $1500. Also, many DPPO plans have 6-12 month waiting periods before they’ll pay even a penny for the more complicated services such as root canals, crowns, or dentures.
Although I have yet to find a Dental Insurance plan that I love, I think having either a DHMO or DPPO is better than having no coverage at all. Some dentists have their own in-house payment plans. Others will negotiate costs with you. Any way you look at it, good dental care is expensive; necessary, but expensive.
In support of you,
Quote of the month: “Some tortures are physical and some are mental, but the one that is both is dental.” ~ Ogden Nash
P.S. – To learn more retirement options or if you have any questions about Medicare, contact me at email@example.com or call 949-677-7631.