CHICAGO (Reuters) – During a recent visit to my dentist, we spoke about his frustrations with Medicare. “It’s amazing – they were successful in removing teeth from the human body.”
This is what he meant: traditional health insurance does not cover most dental care. This surprises a lot of people when it comes to retirement. Studies have shown that more than half of workers aged 50 to 64 are unaware Medicare does not cover preventative dental care or more expensive and complex procedures.
But dental care is an essential part of good preventative health care. Research shows clear links between poor oral health and chronic diseases such as diabetes, as well as pain, chronic infections, and reduced quality of life.
Many seniors are simply paying for their dental care out of pocket – the average spending of Medicare registrants who needed dental care in 2016 was $ 607, according to the Agency for Healthcare Quality and Research, a research arm of the US Department of Health. and Personal Services.
But the expense can be much higher if you need a crown, bridge, or root canal, for example.
As the fall Medicare enrollment season is in full swing (reut.rs/2yj24dB), now is a good time to consider your dental options.
Traditional health insurance will only pay for dental treatment in very limited circumstances – it must be deemed necessary as part of a covered procedure, such as a tooth extraction required for radiation therapy. But many Medicare Advantage plans – the managed care alternative to traditional health insurance offered by private insurance companies – include dental coverage.
Advantage plans generally include prescription drug coverage and out-of-pocket expense caps. But they often include some level of coverage for vision and hearing care – and 63% of Advantage enrollments had access to dental coverage in 2017, according to Avalere Health. Among Advantage recipients with dental care, more than half were covered for x-rays, oral exams and cleaning; a smaller number were covered for restoration procedures.
According to data from Avalere, many of the Advantage plans that cover dental care do not require a co-payment for preventive services, but cost sharing increases sharply for surgery, restorative services and periodontal procedures.
And they typically cap annual benefit payments at $ 1,000 to $ 1,500, notes Beth Truett, CEO of Oral Health America, a nonprofit group that advocates for better dental health. “Advantage plan coverage generally reflects many of the lowest reimbursed plans that cover people while they are working,” she said.
On average, only 5 percent of patients reach 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 that insurers negotiate with providers in your plan network can reduce out-of-pocket expenses, she notes. “In dental PPOs, the prices can be up to 30-40% lower than the actual costs,” she said. For example, the rate negotiated in the plan for a crown could drop the price from $ 1,200 to $ 800, she said.
For traditional Medicare registrants, individual dental plans offer another way to be covered. For example, in Illinois, a Delta Dental PPO offered by AARP for $ 72 per month will cover most preventative services; it has an annual deductible of $ 50 and an annual benefit limit of $ 1,500.
And some Medigap supplemental policy providers – for costs not covered by the original health insurance – offer supplemental options for dental and vision care, or rebate programs to help clients save money on reimbursable expenses.
Low-income seniors who do not have the resources to pay for care out of pocket or purchase commercial insurance face the most limited options. Medicaid is an important source of dental coverage for low-income seniors and people with disabilities who are also enrolled in Medicare (referred to as dual eligibility).
Federal law does not require states to cover adults through Medicaid, but most states have some level of adult dental benefits, Ireland said. And expanding Medicaid eligibility under the Affordable Care Act more than doubled the number of adults covered by Medicaid, to 65 million in 2017, she notes.
PRESS FOR REFORM
US 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 estimated that integrating full 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 registrants is expected to increase by $ 14.50 per month.
Ireland doubts full dental insurance will be added anytime soon. His group is part of a coalition lobbying Medicare to expand coverage for medically necessary dental care, which could be done through an administrative authority. “We’re talking about the idea of a global benefit, but for now we’re focusing on the things that we think can be accomplished in the short term. “
(The views expressed here are those of the author, columnist for Reuters.)
Reporting and writing by Mark Miller in Chicago; Editing by Matthew Lewis