Dental Coverage Explained

Medicare dental is incredibly confusing and frustrating. It’s hard to know what type of coverage (if any) to get in retirement. This article breaks down the ins and outs of dental insurance for individuals on Medicare.

Let’s start with what Medicare does and does not cover.

Medicare does cover dental procedures if they are linked with qualified medical conditions such as oral cancer. Essentially if you need a procedure to reconstruct your mouth, Medicare will pay for it. Aside from that, coverage is slim to none. 

Medicare doesn’t cover routine dental care such as cleanings, checkups, x-rays, bridges, root canals, fillings, crowns, dentures or periodontal work. For those services, you’ll have to pay out of pocket, purchase a discount card, and/or purchase a Medicare Advantage plan with dental or an individual dental plan. 

Let’s break down your options: 

1.Pay cash

If you have a good relationship with your dentist, he or she may give you a good cash discount on services. The idea is that cash today may be better than waiting down the road for insurance to pay.  

However, given the low cost of reimbursement from insurance in certain areas of the country, dentists may not be willing to give cash discounts since they can earn more money for people who are uninsured.  

Our survey of 100 dentists in the Northeast yielded price ranges of $60-120 for routine cleanings. A good ballpark to pay out of pocket for routine care (2 cleanings, x-rays, checkups) is somewhere around $300/year.  

If your teeth are pretty healthy, this may save you more money in the long run since you can put the money you would’ve otherwise spent on a dental plan in the bank for a rainy day (or extra gifts for your grandkids).

2. Discount Cards

Discount cards are a popular alternative given the cost of dental care. This is how discount programs work: A company (often times an insurance company) goes out to dentists promising more patients if they agree to a lower fee and join a network through signing a contract. The company then turns around and sells the right to use that contract to the consumer for typically a yearly fee of somewhere between $100-200. This fee does not buy you insurance, but rather the negotiated discounts to the dentist.

One thing to make sure of is that your dentist accepts the discount cards. We’ve run into situations where someone purchases a card with their dentist listed as part of the “network” only to find out that their dentist has never heard of the discount card and will not honor it. These discount cards can save you money, but just make sure you’re purchasing from a reputable source and a brand name that you know.  

3. Medicare Advantage

Medicare Advantage (or Part C) is the all-in-one solution for Medicare. Advantage plans are administered by private insurance companies and combine hospital, outpatient, and oftentimes drugs as well as extra benefits such as vision, hearing, fitness, and dental benefits.  

Not all Advantage plans are required to have all the extra benefits but some of them do offer dental as either part of the plan or as an add-on. Depending on where you live, plans can differ drastically. Most embedded dental plans offer basic services such as cleanings, check-ups, and X-rays. However, we’ve also seen extremely robust plans that include major services such as crowns, bridges, and root canals.

If the Medicare Advantage plan that you choose has robust dental benefits, you may not need to purchase a separate dental plan. However, we do see that many robust embedded dental plans have a restrictive dental network so make sure that your dentists are covered. Also, note that dentists can choose to leave the network anytime during the year even though you’re locked into the plan. 

4. Buy an individual dental plan 

Individual dental plans typically allow you to have the greatest flexibility. Certain plans will allow you to use both in-network and out-of-network dentists (for a higher cost). With individual dental plans, the key is to know the price ranges and what you’re getting. 

Typically there are 2 main categories of dental plans:

ones that only cover basic services (cleanings/checkup/x-rays/fillings/etc) and ones that also cover major services (periodontics, root canals/bridges/crowns/etc).

Typically, the average price range for a basic dental plan is around $20/month versus $40-60/month for more robust ones. 

However, dental plans (even the robust ones) typically do not cover 100% of services.  Usually, they’ll cover you 100% for routine needs such as cleanings, checkups, and x-rays. For major services, you’ll usually have to pay somewhere around 20-50% of the cost. There’s also a maximum amount that a plan will pay yearly. That amount is somewhere between $1000-$2000.  This means that if you had a $3,000 crown and your plan’s maximum is $1,000, your plan will only pay up to $1,000 and you’ll be responsible for the extra $2,000. 

Also, dental plans may require a waiting period.  A waiting period is the amount of time that you’ll have to pay and be on the plan before the plan will start covering you for major procedures.  Typically waiting periods are between 6 months to 1 year.  

This means that you’ll have to pay for the plan for 6 months to 1 year before any major services are covered. Sometimes the waiting periods are waived if you did not have a lapse in dental coverage. 

Finding an individual dental plan can be complicated. If you have any questions about dental coverage, please reach out to us at help@doctorschoiceusa.com or 1-800-656-0894.