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.
Although original Medicare does not cover routine dental care, it does provide limited coverage for 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 plans provide the same benefits as original Medicare, they will typically cover the same types of oral surgery.
This article explains the Medicare coverage of oral surgery and dental care, 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.
If an individual requires oral surgery, various parts of Medicare may provide some coverage, including original Medicare, Medicare Advantage, Medicare Part D prescription drug coverage, and Medigap.
Original Medicare, which consists of Part A and Part B, does 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 to improve their general health or boost the likelihood of a good outcome from 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 to take place in the hospital for their safety. For example, a doctor may recommend that people with a severe heart disorder undergo this procedure in the hospital even though the extraction is not related to their heart condition.
In these cases, Medicare Part A covers the hospitalization but not the cost of the dental procedure.
Medicare Advantage, also known as Part C, is an alternative to original Medicare.
Private health insurance companies administer these plans, which provide the same benefits as parts A and B. However, Part C deductibles, copayments, and coinsurance are often different from those of original Medicare.
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 should check whether their Medicare Advantage plan covers the costs. By contacting the plan provider, an individual can minimize their out-of-pocket costs.
Prescription drug coverage
Medicare Part A or Part D may cover someone’s prescription drugs.
If an individual needs medication during a hospital stay, Part A will cover the cost. After a doctor discharges a person from the hospital, their Part D plan covers any approved drugs that a doctor prescribes.
People with original Medicare can add Part D prescription drug plans to their coverage for an additional premium. Unlike original Medicare, private insurance companies administer Part D plans.
Many Medicare Advantage plans include Part D prescribed medication coverage, but not all do. People should check the extent of their coverage with their plan provider.
If someone has original Medicare, they can choose to add a Medicare supplement insurance policy to their coverage. However, these Medigap plans cannot supplement Medicare Advantage plans.
As with Medicare Advantage plans, private health insurance companies administer Medigap policies.
If a person with original Medicare were to undergo an approved oral surgery, their Medigap plan might help pay the Part A and Part B deductibles, copayments, and coinsurance. However, these plans do not help pay toward routine dental care costs.
Original Medicare does not pay for services relating to the care, treatment, and removal of teeth. These services include routine cleaning, checkups, fillings, tooth extractions, and dentures.
The coverage also excludes the replacement of teeth or structures that directly support the teeth. Examples 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
For example, if a doctor were to remove all of a person’s teeth to treat oral cancer, Medicare would cover the removal of the teeth on the basis of it being medically necessary to treat cancer. However, the coverage would likely not extend to dentures to replace the teeth, which Medicare classes as a secondary service.
The out-of-pocket costs associated with oral surgery depend on someone’s specific Medicare coverage. Medicare Advantage plans and Part D plans differ, so people should check with their plan provider to confirm the costs.
Original Medicare consists of Part A, which is hospitalization insurance, and Part B, which is outpatient medical insurance. Each part may involve different out-of-pocket costs.
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 2021 are:
- $1,484 deductible for each benefit period
- $0 coinsurance for the first 60 days of a benefit period
- $371 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.
If a person needs extra support covering dental costs, some programs may help. These include the following:
- Medicaid is a state-run program that sometimes offers dental benefits to those with limited resources.
- The Bureau of Primary Health Care supports community health centers across the United States that receive federal funds. It also provides free or reduced-cost dental care. A person can call for help toll-free on 888-275-4772.
- Dental schools and dental hygiene schools may offer low cost dental care.
Original Medicare does not cover oral surgery that a person needs solely for dental health. However, it may cover oral surgery that someone needs for their general health under certain circumstances.
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 that the individual chooses.
As Medicare offers only limited oral surgery coverage, a person should check whether their plan provides coverage for the treatment they need before proceeding.