Page Reviewed / Updated - February 07, 2020
Written By: Lauren Thomas
Retirees have more Medicare options than ever before. In addition to Original Medicare, seniors have Medicare Advantage plans to choose from. Both types of plans have their own benefits, drawbacks and associated costs, and it can be difficult to decide which type provides the best coverage at the most affordable price. Understanding how these plans are similar to and differ from one another is vital in purchasing healthcare that provides needed benefits, including dental care.
Unlike Original Medicare, which is provided by the federal government and is the same for every member, Medicare Advantage is provided by private insurance companies. It offers the same benefits as Original Medicare but may also cover routine dental care.
To understand how Medicare Advantage differs from Original Medicare, it's important to understand how Original Medicare works. Medicare is a federal program that provides health insurance to those aged 65 and over, as well as people with disabilities. Benefits are divided into two parts, including Part A, which covers home health care and inpatient care, and Part B, which covers outpatient medical care.
Under Original Medicare, benefits come directly from the federal government. Pre-existing conditions are covered without limitations, and there is no waiting period. In most cases, Part A benefits are premium-free. Part B premiums are set by the federal government, and most people pay the same standard rate. There are no networks, so participants can use any healthcare provider that accepts Medicare, and they pay the same copay regardless of which provider they choose. In most cases, Original Medicare doesn't cover dental care.
Medicare Advantage, which is a popular alternative to Original Medicare, is not sold or managed by the federal government, but instead by private health insurance companies. These companies must follow rules and guidelines set by the federal government and provide the same services as Parts A and B. However, different Medicare Advantage plans feature different health provider networks, premiums, deductibles, copays and prescription drug pricing. Some plans include benefits like preventative dental care. All in all, Medicare Advantage works similarly to the private health insurance policies that are subsidized by employers or purchased on the individual marketplace.
Medicare Advantage plans cover everything included in Medicare Parts A and B and are able to offer additional coverage as well, such as routine dental services. Seniors who want dental services included in their coverage should carefully review the Medicare Advantage plans offered in their geographic region. Each plan has a "dental services" section in which covered dental services are listed. These may include:
If the dental services section says "Medicare-covered benefits," then the plan may not provide coverage beyond what is provided for in Original Medicare. In this case, the member would pay for the entirety of all routine dental services.
Medicare Advantage plans with comprehensive dental coverage generally have higher premiums than those that don't provide dental coverage. In most cases, members with dental coverage through Medicare Advantage pay a copay (a fixed dollar amount) or coinsurance (a predetermined percentage of the cost of service) in addition to their monthly premium for some services. The plan may also limit how often services may be performed. For example, a member's coverage may include one cleaning every six months, one extraction per year or one set of X-rays per year. Some members have annual dollar limits on what their plan pays out for dental care.
Eligibility requirements for Medicare Advantage are the same as Original Medicare. An applicant must be a U.S. citizen or legal resident for at least five consecutive years, and they must be at least 65 years old or eligible due to disability. They must be enrolled in Original Medicare or qualify for services. Additionally, they must live within their chosen plan's service area.Seniors who draw Social Security benefits are automatically enrolled in Original Medicare, but they can switch to a Medicare Advantage plan during the open enrollment period, which is between January 1 and March 31 every year. To find available plans and enroll in one that includes dental coverage, seniors should click here, specify that they want a Medicare Advantage plan and provide their zip code. Once available plans are listed, the applicant can view the plans one by one to find out which ones provide dental care.
While Original Medicare doesn't cover routine dental care, such as exams, cleanings, crowns, bridges and fillings, there are some situations in which dental services may be covered. If services are necessary for another Medicare-covered procedure, then they may be paid for by Original Medicare. For example, if a dental exam is required prior to a complicated procedure, like a heart transplant, it may be covered under Part A or Part B, depending on whether it is performed in an inpatient or outpatient setting.
To search for Medicare Advantage plans that provide dental coverage, seniors should go to the Medicare Plan Finder on Medicare.gov, input their zip code and specify that they want to see Medicare Advantage plans. Then, they should click on a plan's title, then its "benefits" tab. Medicare Advantage plans that provide dental coverage will have colored circles containing a D.
The simplest way for seniors to find out if their dentist accepts Medicare Advantage is to call the dental office and ask if their plan is accepted. The member can also review their plan's list of network providers.
A member's dental care provider can provide detailed information about what procedures are covered by the Medicare Advantage plan and how much the member will have to pay. Alternately, the member can review an electronic copy of their "Evidence of Coverage" notice, which outlines what the plan covers and how much the member pays.
While standalone dental insurance may be a financially economical option for some seniors, in many cases, it's better to purchase a Medicare Advantage plan that provides this coverage. All of the benefits provided in a Medicare Advantage plan are coordinated together, meaning that there is no separate premium for dental coverage. Additionally, out-of-pocket expenses paid out for dental care count towards the member's maximum out-of-pocket limit, beyond which Medicare Advantage plans pay 100% of eligible expenses. If a member has a separate dental plan, money they pay for services does not count toward their maximum out-of-pocket limit.