Medicare Dental Coverage and Supplemental Dental Benefits

Medicare dental benefits – available to those 65 years of age and older, those with disabilities and those with chronic kidney disease – are meager by any measure.

What Medicare Dental Coverage Pays For

Dentists routinely rate Medicare’s oral health benefits as none, or next to zero, since they are limited to services deemed medically necessary, such as a dental exam prior to kidney transplantation or heart valve replacement, extractions performed in preparation for radiation treatment involving the jaw or jaw reconstruction following accidental injury.

Medicare does not cover routine dental care or most dental procedures such as cleanings, fillings, tooth extractions or dentures.

However, efforts in Congress, particularly the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, have created incentives for Medicare-managed plans (not subject to the strict regulations of Medicare itself) to offer enhanced dental benefits.

Medicare will pay for some dentistry-related hospitalizations; for example, if you develop an infection after having a tooth pulled or you require observation during a dental procedure because you have a health-threatening condition. In such cases, Medicare will cover the costs of hospitalization and your dentist’s treatment fee.

Medicare will never cover any dental care specifically excluded from Original Medicare (i.e., dentures), even if you are in the hospital.

Medicare Parts A and B

Medicare coverage is divided into two parts.

Part A is a hospital insurance program. If you are eligible, you can enroll without charge. However, if you are not covered by Social Security, you must pay part of the premium. When you apply for Social Security, you automatically apply for Medicare. However, if you apply for Medicare, you are not automatically applying for social security.

Part B is a medical insurance program covering charges from doctors, surgeons and other outpatient providers, as well as fees for medical supplies. If you are eligible for part A, you have the option of selecting supplemental part B coverage. To take advantage of part B, you must pay a monthly premium. In most cases, if you obtain routine care from out-of-network providers, neither Medicare nor a Medicare Advantage HMO plan will pay for the costs.

You do not have to be retired to enroll in Medicare. You are eligible for Medicare starting at age 65. When you apply for Medicare you are automatically eligible for both Part A and Part B. But even if you keep working after you turn 65, you should sign up for Medicare Part A. If you have health coverage through your employer or union, Part A may still help pay some of the expenses your group health plan does not cover.

You may wish to wait to sign up for Medicare Part B if you or your spouse are working and have group health coverage through your or your spouse’s employer or union. You would have to pay the monthly Medicare Part B premium, and the Medicare Part B benefits may have limited value to you as long as your group health plan is the primary payer of your medical bills.

Medigap (Supplemental Insurance) Policy

Medigap (supplemental insurance) is health insurance sold by private insurance companies to fill the “gaps” of your original Medicare plan coverage. Medigap policies help pay some of the healthcare costs that your original Medicare plan does not cover. If you are enrolled in the Medicare plan and also have a Medigap policy, then Medicare and your Medigap policy will each pay their shares of your covered healthcare costs.

Insurance companies can only sell a “standardized” Medigap policy. You may be able to choose from up to 12 different standardized Medigap policies (Medigap Plans A through L). Medigap policies must follow federal and state laws. A Medigap policy must be clearly identified on the cover as “Medicare Supplement Insurance.” Each plan – Plan A through Plan L – has a different set of basic and extra benefits. Since costs can vary, it is important to compare Medigap policies. The benefits in any Medigap Plan A through L are the same for any insurance company. Each insurance company decides which Medigap policies it wants to sell.

In order to buy a Medigap policy you must have Medicare Part A and Part B, and you will have to pay the monthly Medicare Part B premium. You also will need to pay a premium to the Medigap insurance company. Medigap policies won’t cover any healthcare costs for your spouse; you and your spouse must each buy separate Medigap policies.

Medicare Dental Advantage Plans

Dental coverage is available at low, or sometimes no, cost to Medicare-eligible seniors who join a Medicare-sanctioned, state-regulated fee-for-service plan that provides dental and medical assistance. Known as Medicare Advantage plans, they are run nationwide by private health insurers in compliance with federal guidelines. Medicare Advantage plans now provide coverage for approximately nine million of the 44 million people in the Medicare population; up from about six million in 2006.

A Medicare Advantage Private Fee-for-Service plan works differently than a Medicare supplement plan (see above). Your doctor or hospital is not required to agree to accept the plan’s terms and conditions, and may choose to forgo treatment, with the exception of emergencies. Some Medicare Advantage plans may include dental benefits.

Dental plan members can choose from a large network of qualified providers. Some plans are flexible to the extent that you may choose any provider. Optional services (riders) are available to health plan members for an additional monthly premium, though not all optional services are available in all areas. Consult your Medicare Advantage plan to see what dental services are covered.

Medicare Advantage dental benefits vary among providers. Some have monthly premiums and an initial enrollment fee. Others have a co-payment for office visits and an annual dollar cap.

AARP Delta Dental Plans

The Delta Dental Insurance Company, one of the nation’s largest providers, in partnership with AARP, offers flexible private coverage in the form of two recently established programs available to AARP members (who must be age 50 or older to qualify) and their families.

Delta Dental Plan A

Plan A is a fee-for-service program providing comprehensive benefits through a network of 182,000 Delta Dental Premier providers – three out of every four dental practices in the country.

Enrollees also can save money by seeing one of Delta Dental’s 67,000 PPO dentists. They also can go out of network entirely – though that may equate to higher out-of-pocket costs.

With monthly fees averaging $56 for single (varying by state and available for single, two-person and family), Plan A is the higher priced of the two programs. It features a one-year mandatory enrollment period, phased-in benefits and a standard maximum benefit of $1,350 per year. It covers a wide range of preventive, diagnostic and treatment services, including emergencies. Diagnostic and preventive care is free of charge. After the first year, most major restorative services are billed at 50 percent.

Plan A offers first-year coverage for the following:

• Diagnostic and preventive care (Delta pays 100%)
• Periodontal maintenance cleanings (Delta pays 80%)
• Denture repair, rebase and relining (Delta pays 80%)
• Basic restorative (fillings) (Delta pays 50%)
• Oral surgery (Delta pays 50%)
• Root canals (endodontics) (Delta pays 50%)

Delta Dental Plan B

Plan B is less expensive, with a monthly fee averaging $41 for a single plan (varies by state and whether a single, two-party or family plan). It provides access to the same two networks of participating Delta dentists, though members may go out of network if they are willing to pay more.

Coverage for services under plan B is more basic, a waiting period is required before major restorative coverage kicks in and the maximum benefit ceiling is $1,000.

Plan B offers first-year coverage for the following:

• Diagnostic and preventive care (Delta pays 80%)
• Periodontal maintenance cleanings (Delta pays 50%)
• Denture repair, rebase and relining (Delta pays 50%)
• Basic restorative (fillings) (Delta pays 50%)
• Oral surgery (Delta pays 50%)
• Root canals (endodontics) (Delta pays 50%)

After 12 months, periodontics, crown and cast restorations, dentures (prosthodontics) and temporomandibular joint dysfunction (TMJ) treatment are covered at 50% for both Plan A and Plan B.

For a Delta Dental PPO in your area, call 1-866-583-2085; you can also use an online directory by visiting Delta Dental’s website (www.deltadental.com).

Tricare Retiree Dental Program

Delta Dental of California, a subsidiary of the same holding-company system that includes Delta Dental Insurance Company, administers the nation’s largest voluntary dental coverage plan, the Tricare Retiree Dental Program (TRDP).

Serving more than a million military retirees and retired civilian employees of the Department of Defense, as well as their spouse and children under 21, TRDP’s benefits cover a wide range of procedures, including diagnostic and preventive services, periodontics, endodontics, oral surgery and dental emergencies.

While care is available from any licensed dentist, optimal benefits are available from any of Delta Dental’s participating dental practices nationwide.

To find out if you or certain members of your family qualify for TRDP dental benefits, call 888-838-8737 or visit the website www.trdp.org.