Original Medicare does not cover routine dental care or oral surgery for the general health of the teeth. However, Medicare may approve coverage for oral surgery in special cases.
While original Medicare does not cover routine dental care, it does provide limited coverage of certain types of oral surgery.
Approved procedures and surgeries include those related to a covered health condition, such as tooth extractions before jaw cancer treatment.
As Medicare Advantage provides the same benefits as original Medicare, they will typically cover the same types of oral surgery.
This article explains the oral surgery and dental care covered by Medicare plans, discusses the out-of-pocket costs that may apply to approved oral surgery, and looks at other options that may help a person with dental expenses.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Original Medicare Part A and Part B do not cover dental care or oral surgery that a doctor or dentist performs primarily for tooth health.
However, it does provide some coverage if a person needs dental care for their general health, or if an individual needs dental care to try and increase the chance of a good outcome of another approved service.
Surgery and dental care must be medically necessary. Examples include:
- oral examinations before a heart valve replacement or kidney transplant
- tooth extraction before radiation treatment for jaw cancer
- reconstruction of the jaw after removal of a facial tumor
- surgical repair of a jaw fracture or injury
Sometimes a person may need a simple dental procedure in a hospital for their safety.
An example of this would be if someone with a severe heart disorder needed a tooth extraction.
The extraction is not related to their heart condition, but a doctor recommends that it take place in a hospital.
In these cases, original Medicare will provide coverage for the hospitalization, but not the cost of the dental procedure.
Original Medicare does not pay for services relating to the care, treatment, and removal of teeth. This includes routine cleaning, checkups, fillings, tooth extractions, and dentures.
The coverage also excludes the replacement of teeth or structures that directly support the teeth. Examples of this include:
- the removal of diseased teeth in a jaw with an infection
- the removal of the teeth to prepare for dentures
- secondary services, such as dentures
Example of a secondary service
The fitting of dentures may be classed as a secondary service as a doctor may need to remove all of a person’s teeth to treat oral cancer.
Medicare covers the removal of the teeth because it is medically necessary to treat cancer.
Coverage is not usually available for the dentures, as this would be the secondary service.
Original Medicare consists of Part A, hospitalization insurance, and Part B, outpatient medical insurance.
Most of the costs related to an approved oral surgery fall under Part A.
Out-of-pocket expenses can change each year, but Part A associated costs for 2020 are:
- $1,408 deductible for each benefit period
- $0 coinsurance for the first 60 days of a benefit period
- $352 per day coinsurance for days 61–90 of a benefit period
A benefit period begins when a person first enters a hospital and ends after they have not received inpatient hospital care for 60 consecutive days.
Medicare Advantage, also known as Part C, is an alternative to original Medicare.
Private insurance companies offer the plans, which provide the same benefits of parts A and B but deductibles, copayments, and coinsurance can often be different.
Some Medicare Advantage plans also include coverage for routine dental care, but the extent of the coverage can vary.
As Medicare only covers oral surgery in some instances, a person who needs a procedure may want to check that Medicare Advantage will cover the costs. By contacting the plan provider, an individual can ensure their out-of-pocket costs are minimized.
If a person needs medications during a hospital stay for a covered oral surgery, the cost falls under Part A.
After a doctor discharges a person from the hospital, their Part D plan would cover any approved drugs a doctor prescribes.
Part D refers to prescription drug plans that are available to people with original Medicare. Private insurance companies administer Part D plans.
Many Medicare Advantage plans include Part D prescribed medication coverage, but not all do.
If an individual with a Medicare Advantage plan needs medication after being discharged from a hospital, their policy may cover the costs.
Medigap plans are Medicare supplement insurance policies available to people who have original Medicare but not to those who have Medicare Advantage.
Like Medicare Advantage plans, private health insurance companies administer Medigap policies.
If a person with original Medicare had an approved oral surgery, their Medigap plan might help pay parts A and B deductibles, copayments, and coinsurance.
These plans do not help pay routine dental care costs.
If a person needs extra support covering dental costs, some programs may help. These include:
- Medicaid: a state-run program that sometimes offers dental benefits to those with limited resources
- The Bureau of Primary Health Care: supporting community health centers across the United States that receive federal funds, providing free or reduced-cost dental care (a person can call them toll-free on 888- 275-4772)
- Dental schools and dental hygiene schools: which may offer low-cost dental care
Original Medicare does not cover oral surgery that a person needs solely for dental health.
However, Medicare does cover oral surgery that someone needs for their general health, under certain conditions.
Medicare Advantage may also cover some types of medically necessary oral surgery.
For an approved surgery, the related deductible, copayment, and coinsurance costs may differ depending on the plan an individual chooses.
Since Medicare offers only limited oral surgery coverage, a person may consider checking their plan to find out they have coverage for the treatment they need.