Does Medicare Include Dental Benefits?

What Medicare does (and does not) cover can be a little confusing, especially when it comes to additional benefits like dental insurance. In the most basic sense, Original Medicare will not cover your trip to a dentists’ office or any of the services you have done there.

You may be wondering why Medicare does not provide any coverage for your oral health needs. Original Medicare Part A specifically covers any care you receive at a hospital and Part B handles the cost of doctor’s office visits. Unfortunately, both parts will not cover dental care except in extreme situations (which we’ll get to below).  That is because the guidelines for Original Medicare have a dental exclusion — a blanket rule that your Medicare benefits cannot be used for dental care. This means that no matter how expensive the dental procedure is or how badly you may need it, Medicare will not cover any of the cost if can be done at a dentist’s office.

Since its creation, Medicare has never provided dental care coverage. But in 1980, Congress did approve some exceptions to the rule for emergency situations where dental services are needed. These are often situations where you must have dental work done as part of a treatment plan for life-threatening health conditions, or if going without the dental service would deteriorate your health and cause additional, specific issues.

While many people would agree that going without dental care can cause future health issues, that is not enough to get Medicare to cover your oral health needs. The loophole to this dental exclusion rule is that qualifying dental services have to be done at a hospital or in-patient facility to be eligible for coverage — that is how Medicare can determine they are truly a necessity. At this point, Medicare Part A kicks in so that hospital staff can perform the services you need and you will be on the road to recovery.

But it is important to know that even if your dental care generally qualifies for Part A benefits, not every component of the services you need will be covered. If that sounds tricky, it is because Medicare is picky about what necessary dental care it will cover — you could say that your benefits will only cover the bare minimum. After a dentist or oral surgeon performs the procedure you need at a hospital or in-patient center, you may still be stuck with out-of-pocket costs for follow-up dental care.

Determining What is Covered: Primary and Secondary Services

If you are unsure about what dental services you can receive through Medicare, the best place to start is determining what kind of dental care you need. Most kinds of dental work fall into two categories: primary services and secondary services.

Primary services focus on the care and treatment of your teeth, gums and overall oral health. If you need teeth removed, replaced or repaired for any reason, this is considered a primary service regardless of what caused tooth deterioration or how bad tooth decay may be. Some example primary services are:

  • Having teeth pulled so that dentures can be fitted
  • Removing decayed teeth
  • Filings, bridges and crowns
  • Annual or biannual oral exams and cleanings

Primary services are not covered by Medicare. If you need to have any of these procedures, looking into a dental plan through Medicare Advantage or a private insurer is your most reliable option for lowering what you will pay out-of-pocket. The Medicare Specialists at PolicyZip are available to help you compare your coverage options and find the optimal level of benefits at the most cost effective price.

Secondary services can be described as the dental implements you need to support your teeth and oral health. In simpler terms, these are often needs like full or partial dentures or implants. Medicare will not cover the cost of these medical devices, no matter how much you need them.

If you are considering elective dental care such as teeth whitening or braces, Medicare will not cover the cost at all. In this case, it’s a good idea to identify an insurance provider who offers some kind of coverage for these kinds of care.

What Is — and Is Not — Covered With Necessary Services

If the dental work you need is much more serious that a primary, secondary or elective service and required by a doctor as part of a treatment plan for another condition, it likely falls into the medically necessary category. Some examples of necessary dental services are:

  • Oral examinations conducted at hospitals or in-patient facilities, especially before kidney transplant surgery, a heart valve replacement or a injury to your jaw or face
  • Tooth extraction before radiation treatments on your jaw (common in cases of oral cancer)
  • Surgery to fix face or jaw fractures or breaks
  • Dental splints and wiring related to jaw surgery
  • Facial and oral tumor removal
  • Jaw reconstruction
  • Hospital stays for oral infections after having a tooth pulled
  • Any hospital stay costs for beneficiaries who must be observed during dental treatments because of health-threatening conditions like heart or organ failure

In these cases, Medicare may choose to cover some of the cost of your dental treatments. Often, a necessary service — such as wiring after jaw surgery — will be covered. But the cost of follow-up treatments such as implants or dentures after teeth were pulled for radiation treatments is your responsibility. If you were hospitalized following dental care or during dental treatment, Medicare will cover related expenses like room and board and anesthesia. But it will not cover the cost of the dental treatment.

How to Get Dental Coverage

If you receive medically necessary dental work in a hospital, Medicare Part A will help cover the cost. In many cases, it may be beneficial for you to confirm your insurance benefits before receiving treatment to ensure you are not stuck with an unexpected bill afterwards.

If your dental needs are not considered medically necessary, you still have options. Enrolling in a Medicare Advantage plan that offers dental benefits can ensure you receive oral examinations and care at a level of coverage that fits your needs and wallet. Since Medicare Advantage plans are offered through private insurers, there are a variety of plans to choose from. You can connect with a Medicare Specialist at PolicyZip by calling (844) 205-7510 or filling out the form below to discuss these options.