Research shows that good oral health is vital to overall health. For seniors, poor oral health can contribute to heart disease, diabetes, undetected oral cancers, and other illnesses. However, many Medicare beneficiaries have no dental coverage. High out-of-pocket costs for dental care mean many forgo or delay visiting the dentist. As a licensed Medicare agent, you play an important role in helping your clients understand the importance of oral health and finding dental coverage that fits their needs.
New CMS Ruling
Recognizing the impact dental health has on the outcomes of certain medical procedures, CMS recently released a ruling – effective January 1, 2023 – which states Medicare will cover “medically-necessary” dental procedures when integral to treating certain medical conditions.
The ruling covers the following:
- Dental exam and treatment as part of a comprehensive workup prior to organ transplant surgery, cardiac valve replacement, or valvuloplasty.
- Reconstruction of a bridge when performed as a result of, and at the same time as, the surgical removal of a tumor.
- Extraction of teeth to prepare the jaw for radiation treatment for neoplastic disease.
- A dental splint when performed in conjunction with treatment for a covered medical condition.
Medicare will provide payment on an outpatient or inpatient basis. Coverage includes associated services, such as X-rays and anesthesia.
Finding the Right Dental Benefits for Your Clients
Other than the “medically-necessary” coverage mentioned in the new CMS ruling, Original Medicare does not offer any dental benefits. Some Medigap plans cover some out-of-pocket expenses. Furthermore, some Medigap insurers offer the option to bundle their coverage with an additional dental policy or dental discount. Some private insurers also offer standalone dental plans.
For most seniors, Medicare Advantage (MA) plans are the best option for dental coverage. In 2021, 94% of MA enrollees were in a plan that offered some type of dental benefit. The cost and extent of benefits depend on the carrier and plan.
Dental coverage can be structured in a variety of ways:
- Preventative services only, such as cleanings and X-rays covered in full, usually twice a year. Most insurers require members to see an in-network dentist. Most Medicare Advantage plans, even $0 premium plans, include this coverage.
- Preventive services are covered in full, plus coverage for some additional procedures – such as fillings and extractions, for which members pay a coinsurance. Coinsurance amounts can vary and can be as much as 50%. Members must usually see an in-network provider. There is an annual dollar cap on how much the insurer will pay, which varies by insurer.
- Direct reimbursement requires members to pay their dental provider upfront and submit receipts for reimbursement. Many insurers allow members to see the dentist of their choice, regardless of the network. There is an annual dollar cap on how much the insurer will pay, which varies by insurer.
- Optional supplemental dental benefits offer members additional dental benefits for an extra premium each month. This coverage may include procedures such as crowns, implants, and dentures, for which members usually pay a coinsurance. There is an annual dollar cap, which varies by insurer. It’s important to note that some plans do not allocate the annual dollar amount in one lump sum. For example, a plan may allot a $3,000 annual cap quarterly in $750 increments.
You can help your clients find the right plan by understanding their specific needs and situation. It’s important to know:
- If the particular dentist that clients want to see is in the network.
- If a plan covers a particular procedure. Since plans are specific about what procedures they cover, it’s important to check the details.
- If clients can afford any additional charges. For reimbursement-type coverage, can clients afford to pay out of pocket and wait for the reimbursement?
Just like with medical coverage, you should re-evaluate your clients’ dental coverage each year to see if anything has changed. When you take the time to assess your client’s needs and help them make the right decisions for their health and well-being, you become a valued partner in their healthcare decisions. As a valued partner of Western Asset Protection, your success is our business. Reach out to us with any questions you may have.