(The opinions expressed here are those of the author, a columnist for Reuters.)
By Mark Miller
CHICAGO, Nov 15 (Reuters) - During a recent visit to my dentist, we got talking about his frustrations with Medicare. “It’s amazing - they have managed to eliminate teeth from the human body.”
Here is what he meant: traditional Medicare does not cover most dental care. This comes as a surprise to many people at the point of retirement. Studies have shown that more than half of workers aged 50-64 are unaware that Medicare does not cover preventive dental care or more expensive and complex procedures.
But dental care is a critical part of overall good preventive healthcare. Research shows clear links between poor oral health and chronic disease such as diabetes, as well as pain, chronic infection and reduced quality of life.
Many seniors simply pay for dental care out of pocket - the average out-of-pocket expense among Medicare enrollees who needed dental care in 2016 was $607, according to the Agency for Healthcare Research and Quality, a research arm of the U.S. Department of Health and Human Services.
But expense can run much higher if you need a crown, bridge or root canal, for example.
With Medicare fall enrollment season in full swing (https://reut.rs/2yj24dB), this is a good time to consider your dental options.
Traditional Medicare will pay for dental care only in very limited circumstances - it must be deemed necessary as part of a covered procedure, for example a tooth extraction needed in preparation for radiation treatment. But many Medicare Advantage plans - the managed-care alternative to traditional Medicare offered by private insurance companies - do include some dental coverage.
Advantage plans usually include prescription-drug coverage, and cap out-of-pocket expenses. But they often include some level of coverage for vision and hearing care - and 63 percent of Advantage enrollees had access to dental coverage in 2017 according to Avalere Health. Among the Advantage beneficiaries with dental benefits, more than half were covered for x-rays, oral exams and cleaning; a smaller number were covered for restorative procedures.
Many of the Advantage plans that cover dental work require no copayments for preventive services, Avalere data shows, but cost-sharing rises sharply for surgery, restorative services and periodontal procedures.
And they usually cap annual benefit payments at $1,000 to $1,500, notes Beth Truett, chief executive officer of Oral Health America, a nonprofit group that advocates for better dental health. “The coverage in Advantage plans typically mirrors many of the lower-reimbursed plans that cover people while they are working,” she said.
On average only 5 percent of patients hit these maximums in any given year, according to Evelyn Ireland, executive director of the National Association of Dental Plans. But if you do, the prices negotiated by insurers with providers in your plan network can bring down out-of-pocket expenses, she notes. “In the dental PPOs, the prices can be as much as 30 to 40 percent below the actual fees,” she said. For example, the plan-negotiated rate for a crown might bring the price down from $1,200 to $800, she said.
For traditional Medicare enrollees, individual dental plans offer another way to get covered. For example, in Illinois a Delta Dental PPO offered through AARP for $72 per month will cover most preventive services; it has a $50 annual deductible and an annual cap on benefits of $1,500.
And some providers of Medigap supplemental policies - for costs not covered by original Medicare - offer add-on options for dental and vision care, or discount programs to help customers save money on out-of-pocket costs.
Low-income seniors lacking the resources to pay for care out of pocket or to buy commercial insurance face the most limited options. Medicaid is an important source of dental coverage for low-income elderly and disabled people who also are enrolled in Medicare (so-called dual-eligibles).
Federal law does not require states to cover adults through Medicaid, but most states have some level of adult dental benefit, Ireland said. And the expansion of Medicaid eligibility under the Affordable Care Act has more than doubled the number of adults covered by Medicaid, to 65 million in 2017, she notes.
PUSHING FOR REFORM
U.S. Senator Bernie Sanders of Vermont has proposed adding a dental benefit to Medicare Part B as part of his "Medicare for All" legislative proposal. The American Dental Association has estimated that integrating a comprehensive dental benefit into Part B - applying the program’s existing cost-sharing rules - would cost the federal government $32.3 billion (2018 dollars); the base premium paid by enrollees would need to increase by $14.50 per month.
Ireland doubts that a comprehensive dental benefit will be added anytime soon. Her group is part of a coalition lobbying Medicare to expand coverage of medically necessary dental care, which could be done through administrative authority. “We are talking about the idea of a comprehensive benefit, but for now we are focusing on things we think can be accomplished in the near term.”
(Reporting and writing by Mark Miller in Chicago Editing by Matthew Lewis)