Joanne (00:00):

Does Medicare cover routine dental services? If not, what options do you have? We will help answer these questions in today's episode.

Cameron (00:06):

But before we start, my name is Cameron Giardini and together with my co-host Joanne Giardini-Russell, we operate Giardini Medicare, which is an independent insurance agency based out of Southeast Michigan. Although we are based in Michigan, we do work virtually over the phone to directly help consumers in about 13 different states to find the right Medicare coverage for them. If we do not work in your state, we will connect you with another trusted independent agent that will be able to help you find the coverage you want. And if you choose not to work with us or anybody that we know, we still know that the information in today's podcast will help you with a successful and stress-free transition to Medicare.

Joanne (00:41):

We'll talk about understanding how dental insurance options when you're on Medicare will likely have different costs and coverages compared to the employer-provided dental insurance that you may have used in the past. We'll talk about how Medicare Advantage versus Medigap coverage will likely impact your dental coverage options. We'll talk about how to find dental insurance and what to look for, and we will not be discussing dental options from any retiree coverage or those that are specifically for dual-eligible people, meaning those people qualifying for both Medicare and Medicaid.

Cameron (01:12):

Yeah, all good points to mention. Just keep that in mind when we're going through this episode that is what we will cover. Of course, starting off we need to figure out what does Original Medicare cover when it comes to dental? Original Medicare, again, is part A and part B of Medicare, and it covers very, very little when it comes to routine dental services. So I'll go through a brief list here. It's probably not an inclusive list. There are some really funky ways that Medicare may cover certain dental procedures, but I'll go through some examples here. And this is according to Medicare Interactive. Of course, we will link to all our sources in the show notes. Here's what Medicare might actually cover in regard to dental. One is an oral exam before a kidney transplant in a hospital. 

Cameron (01:57):

You can also get an exam in a rural clinic before having a heart valve transplant is when you can do. You can also get dental services for radiation treatment for certain jaw-related diseases. This is going to be typically oral-related cancers. You may also get partial jaw reconstruction after the removal of a facial tumor. You may get surgery to treat fractures to your jaw or face and you may get dental splints and wiring after jaw surgery. Now if you listen to that list and you're like me, you're probably realizing that a lot of those services are not typically what comes to mind when you think of dental coverage. You’re probably thinking cleanings, x-rays, exams, the basic stuff, and that is not going to be covered by Original Medicare as you can tell. So just to back that up, I'll have Joanne go over some stats about original Medicare and dental coverage

Joanne (02:43):

All right, overall Medicare dental statistics, are exciting. So, on an additional note, there have been proposals that have been introduced in the past to add more comprehensive routine dental coverage to Original Medicare. Most recently there was the initial draft of the Inflation Reduction Act. It did not make it through and we are not aware of any imminent proposals that are likely to make this happen. So please prepare as though none of those things will happen anytime soon.

Cameron (03:10):

Yeah, don't pay attention too much to the political news as far as dental or anything else being added to Medicare. Whatever happens, is going to happen at the end of the day.

Joanne (03:17):

Exactly. It's been out there for years and years and nothing has happened yet. So let's talk about some stats. This is from the Kaiser Family Foundation. 47% of Medicare beneficiaries did not have dental coverage as of 2019. At that time, this was roughly 24 million people in 2018. The average cost for those that used dental services was $874 a year, 20% of the individuals that are receiving dental services spent over $1,000 a year, and 10% spent over $2,000 a year in 2018. Again, 47% of all Medicare beneficiaries did not have a dental visit during that year. Low-income individuals are much more likely to not seek dental treatments. 73% of beneficiaries with income less than $10,000 did not visit a dentist versus 25% of those with income above $40,000 not going to the dentist.

Cameron (04:14):

Yeah, and I just wanted to highlight again what Joanne said about the average cost of dental procedures. I find it interesting that 90% of those eligible for Medicare were in the thousand-dollar out-of-pocket or less range. So when we talk about getting dental coverage and ensuring yourself for the most part, again, this is of course averages and you can be higher than this, but you're really looking for about a thousand dollars or less of dental services in a given year. So I always think that's good to remember

Joanne (04:40):

It was lower than I thought when I saw that stat, truly. 

Cameron (04:42):

Yep, definitely. Now one of the options you would have with Medicare as far as getting dental coverage is if you go with a Medicare Advantage plan. So, before we get into how you can get dental coverage with a Medicare Advantage plan, we'll talk about some of the dental coverage trends and statistics when it comes to Medicare Advantage plans so you can get a better idea of what you might be looking at. In 2023, there were 97% of Medicare Advantage plans offered some level of dental coverage. So this coverage can vary greatly like we have talked about in the past, and it can go from just a couple of cleanings and x-rays all the way up to implants and more major procedures. They're not all created equal, but it's very common to get dental coverage provided by a Medicare Advantage plan. And of course, these statistics are coming from the Kaiser Family Foundation, and I'll read through them now.

Cameron (05:27):

In 2021, 86% of Medicare Advantage enrollees they have access to a plan with extensive coverage that includes fillings, endodontics, periodontics, oral surgery, et cetera. And the other 14% only have access to plans with preventive coverage. So if people are out there saying, oh, if you get an advantage plan, it's really just the bare bones dental coverage, it's probably not true because again, 86% had access to at least one plan with more extensive coverage. So yes, it used to be weaker coverage in the past, it's only growing as the years go on. Also, Medicare Advantage plans with more extensive coverage, almost always have coverage capped. That is basically the maximum amount the plan would spend towards your dental services each year. And in 2021, that annual limit was $1,300 on average across those plans providing these benefits. However, 8% of plans went up to $2,000 to $5,000 in dental coverage built into the plan.

Cameron (06:24):

And just so you know, if you do get extensive coverage built into your Medicare Advantage plan, it is most common that the cost-sharing for more of those major procedures is going to be 50% coverage. Now some do cover 100% of the cost, but just remember, although you have thousands of dollars of dental potentially built into your plan, it doesn't mean you won't spend anything out of pocket to meet that full amount. Again, dental coverage just seems to be strengthening as the years go by. These numbers that we are presenting are from 2021, but we can tell you just firsthand in Michigan, we have noticed even in the last two years that these coverages have only grown. So I would imagine all of these numbers to be higher than they were just two years ago.

Joanne (07:01):

And again, remember that those are numbers that people have access to. It doesn't necessarily mean all of the plans in your area are going to be as rich or not as rich. So just remember its zip code driven.

Cameron (07:11):

Exactly. Yep. So then along those lines, finding a plan is going to also come down to your zip code and your location. So, Joanne, you can talk about what to consider when finding a plan for dental coverage.

Joanne (07:22):

All right, so this is really important to kind of run through. You're going to look at different styles of coverage. You've got HMOs and PPOs in terms of coverage levels. And this is going to dictate typically whether you can use your coverage at an out-of-network dentist. However, if you have out-of-network coverage, when possible, it is almost always better to be with an in-network dentist. Always remember too that networks can vary even among plans with the same company. So don't just call a dentist and say, Hey, do you take company X? If you do, call a dentist, and specify the network for example, a plan might use Delta Dental, check with your broker, use the online search tool, which is common, or call member services to confirm that a dentist is in the plan network.

Cameron (08:00):

And just real quick to highlight that. As Joanne mentioned, the plan might use a different network than the actual name of the plan itself. So in a lot of cases in Michigan you'll have a company, an insurance company that uses Delta Dental for their dental network. So you're actually trying to figure out which Delta plan the dentist takes instead of the insurance company's name. Just good to think about

Joanne (08:19):

And it's not always easy to find FYI. No, they make it a little tricky sometimes. So do your homework, please really check those networks. Also, you're going to want to ask yourself which dental benefit is most important to you. You know, do you need implants? Do you need thousands of dollars of coverage or are you okay with just having the basics like exams, cleanings, and x-rays, do you want 100% coverage or are you going to be okay with 50% coverage? Figure out what you're actually looking for as you're doing some of the homework to get the insurance coverage for dental. Also, you want to understand that Medicare Advantage plans are yearly contracts, and they can change in the future year. They can change on January 1st. It could be for the better, could be for the worst. 

Cameron (08:59):

They probably will change.

Joanne (09:00):

Yeah, they usually do and they could go either way, but they are annual contracts, and often Medicare Advantage plans don't have waiting periods, which is a really great selling feature. A lot of standalone plans will have a 6-month or 12-month wait pretty easily. Medicare Advantage options won't have that.

Cameron (09:14):

And a waiting period, just so you know, is basically saying once you sign up for our plan, we might not cover a certain procedure for the first 6 months or 12 months on the policy. So if you sign up for a plan right away, it probably won't cover implants immediately. It might take 6 months or 12 months. So that's a benefit of the advantage plan is you're usually not subject to that wait like Joanne was saying.

Joanne (09:33):

Definite perk there. And then last but not least, we always go back to the zip code feature, right? Your dental options with a Medicare Advantage plan are going to depend on your county and what is offered in your county. So just because you're talking to your friend in Florida, they're not going to have maybe the same benefits available to your friend in Las Vegas.

Cameron (09:49):

Yeah, exactly. As with everything with Medicare Advantage plans, they're very county-specific and then that's even more so than just the state. So I'll do a recap here of Medicare Advantage dental coverage. Just remember these services can range from preventative services like cleanings and exams all the way up to major services like crowns and implants. It's all going to depend on the plan. Even if plans do have more comprehensive dental coverage, you may still have to pay a percentage out of pocket. So keep in mind a lot of these plans won't have full 100% coverage, although you just must have a little give and take when it comes to getting these dental benefits. Some plans with enhanced dental coverage can actually be purchased in addition to what your plan is providing. So some plans will offer basic coverages or a little bit of coverage and you can actually purchase at a higher premium to get more enhanced dental with your plan.

Cameron (10:35):

This is usually a little bit better than comparing it to the price if you had to go get dental insurance by yourself. And then also when you're first starting Medicare, just try not to base your Medigap versus Medicare Advantage decision just on dental coverage. Yes, it is a part of the puzzle, but remember with Medigap plans, you do have an open enrollment period for the first six months that you're 65 or older and first enrolling in part B, typically this is the one time you can get Medigap plans without health questions. So make sure you are still comparing both options before just fixating on the dental and choosing a Medicare Advantage plan because of that. Basically, have the dental coverage be a cherry on top of a plan you already like with Medicare Advantage instead of making that the sole reason you choose that route. And then also if you see really high levels of dental coverage being offered, understand that's usually for dually eligible people, meaning those eligible for both Medicare and Medicaid, those are what's going to be advertised because they get you to call in, they get you to click on stuff, but that's probably not what is actually out there for most individuals. So, what about Medigap and their dental options? Joanne can talk about that.

Joanne (11:37):

Well, we've got Medigap and individual dental trends and statistics. We'll go over some of these. So let's talk about individual dental loss ratios. Loss ratios according to Telos actuarial study are about 60% for individual dental insurance. This means that dental insurance companies spend about 60 cents on claims for every $1 that they collect in premiums from their policyholders. So that's a really important number to note.

Cameron (12:02):

It's a really good reminder for people that you should expect to really not break even every single year when it comes to dental insurance. I don't know why, but I'm sure Joanne, you can attest to this as well, when it comes to dental coverage, a lot of people try to profit off their dental coverage. It's kind of the one thing where people hate to lose any money. If you spend $500 in premium, you always want to get $600 or more out of it, but there are some years you may not need those extra dental services and you might end up losing money just like any other insurance. So that's the point that we're trying to make with that loss ratio that on average these dental companies are paying out way less than they're taking in premiums.

Joanne (12:37):

It is one of the weirdest insurance products though because people really do get mad when their dental doesn't pay out and we hear it all the time, whether it's your work coverage or your Medicare, all of them, they complain that dental doesn't pay out. Individual dental plans typically have a deductible ranging from $50 to $100 per year and the benefits are often designed as 100% for preventive services. For example, the cleanings and the exams and things like that. 80% for basic services, an example of basic service would be fillings, and root canals, and 50% for major services such as bridges, crowns, and implants. Remember Original Medicare is going to cover very limited dental services. As mentioned earlier in the episode, Medigap plans, they're only designed to cover the same services that Medicare does cover.

Joanne (13:20):

So don't expect that your Medigap plan is going to cover dental procedures either. They're always going to follow Original Medicare. If Medicare does not pay for the dental, which typically is the case. Your Medicare Supplement also known as Medigap will not either. So, just always remember cleanings, fillings, and crowns are not going to be covered ever by Medicare in your supplement. Also, remember that there is no penalty from Medicare for not having dental insurance. Some people think these penalties are going to accrue if they don't buy dental insurance, but it has nothing to do with it. Medicare doesn't care if you buy dental insurance.

Cameron (13:52):

Exactly. Yep. We're talking about individual dental options to go with Medigap because again, Medigap plans cover what is remaining the 20% after Medicare pays. So, if Medicare doesn't pay for the dental, neither will Medigap. Here are some common dental options for those with Medigap plans or Medicare supplements you can basically go with an exclusive dental insurance plan provided by a Medigap policy that you enroll in only if that company is offering a plan like that. I know here in Michigan we have one or two insurance companies that will provide a plan that you can purchase at an additional price. So, you still pay more for it, but at an additional price, you can purchase a dental vision, possibly even a hearing package that will be available to you only if you sign up for their Medicare Supplement as well. Now keep in mind that this coverage is still at an added premium. I just want to stress that it is not usually included at no cost.

Joanne (14:46):

And do remember it is always going to be linked to that Medicare supplement. It's not that you can stay with that carrier for three or four years and then take your dental policy with you. You need to remain with that carrier.

Cameron (14:55):

Yeah, it's typically only available to people that are also enrolled and stay enrolled in that Medigap plan. Now, aside from those exclusive dental plans provided by some companies, you can always pay cash for dental. That's just kind of what it sounds like. You know, you pay cash, maybe you get a discount, but that is what some of our clients do choose to do. You can also get a dental discount plan. Usually, you would purchase these through a company or they're provided in-house or they might be provided in-house by your actual dentist. They might say, for this set amount we'll cover cleaning x-rays exams for the year at this rate. So if you've ever seen Susie Orman advertising dental coverage, it's pretty much a dental discount plan. Not saying they're bad, but just understand that these are not insurance plans. So usually, you pay about $100 per year for a dental discount plan, and then just like it sounds, you get discounted procedures at the in-network dentist.

Cameron (15:45):

If a crown's normally $800, it might be $500 with the dental discount plan. And I'm just throwing out those rough numbers there and keeping in mind that they must be in-network dentists. That is the restriction with the discount plan versus just using cash typically. Then also you can just do individual dental insurance. So, this is not a Medicare dental insurance plan, it's just dental insurance that is available to any adult. Usually, they are for people from age 18 to 90, you know, it's just any adult that's trying to purchase their own individual dental. You can look for a plan but we will talk about this in more detail very shortly. So, the biggest thing here is just thinking long-term about these dental options. Again, if you choose a plan, like Joanne was saying, just because it has dental coverage as a Medigap policy where you can purchase that added coverage, it may change in the future, and you'll likely have to medically qualify if you want to change to a new Medigap carrier.

Cameron (16:34):

So, not only will your premiums change, but some of these plans could just say we're no longer offering that dental coverage. It's totally up to them. It's typically a group policy, it's not available to you as an individual. So there are some different rules that they might play by. Individual dental insurance is I think what most people think about when they think I'm going with a Medigap plan and I'm trying to find dental insurance. So, we're just going to recap that and think about more things to consider. So I'll have Joanne start and we'll go over that.

Joanne (16:59):

Yeah, the coverage styles of all these dental insurances can really vary. Some work as reimbursements at any providers. Some are HMOs, some are PPOs, and some pay a set amount based on the procedure you receive. Just keep in mind that when it comes to all dental insurance, that having a plan with your dentist in the actual plans network will likely result in the most bang for your buck. I'm going to flip this to Cameron because he's good at explaining that not all PPOs are created equally. I'm going to like Cameron's launch into that piece right here.

Cameron (17:30):

Yeah, I don't want to get too technical. I know we've already talked a lot about dental insurance, which you probably didn't think you'd listen to anything for 20 minutes about dental, but here we are. Just keep in mind, not all PPO plans are created equally. People think I'll just get a PPO if my dentist will take it out of network. No big deal. So easiest way to think about this is there are usually two types of PPO plans. There are called MAC plans and UCR plans. Now, all that you need to know for that is a MAC plan is typically going to base reimbursements based on in-network rates. So if you go to an out-of-network dentist, the plan is still going to reimburse that smaller amount they would normally pay an in-network dentist. Long story short, it's probably not the best way to go if you're trying to go see an out-of-network dentist with a PPO plan. So just make sure you're figuring out which plan you have versus usual and customary. Let's say most dentists in your area charge about $1000 for this procedure, we'll pay you about 80 to 90% of that. So, you're getting $800 to $900 towards that procedure paid to the dentist. Now you'll pay a percentage of that, but again, UCR plans are going to have a higher reimbursement typically out of network with a PPO. So hopefully that's not too confusing. If you have any questions, you can always ask us or ask your dental provider.

Joanne (18:39):

Good job. It does get confusing. Okay, also remember your employer's not paying a portion of your dental coverage anymore. Be prepared for potential sticker shock. Everybody is really shocked at how much dental can cost. Monthly premiums are always going to be dependent on the plan and the coverage, but most plans are really ranging from $30 to $60 a month based on our experience. I talked to someone today that's paying $120 for two people and that was just for the dental portion if you want to add hearing and other things, that's even extra. Typically, this coverage can also be added at any time. So again, there is no penalty, and you can buy it at any time. You do not need to wait for the fall. That open enrollment period that everybody thinks you only can touch your Medicare.

Cameron (19:26):

Please, don't wait until the fall.

Joanne (19:27):

Don't wait. It's just, it's too busy <laugh>, please do it now. But also remember that most plans are going to have a waiting period. However, if you have left employer coverage recently, you might be able to waive that if you've had prior coverage and show proof of that. So, think of those things when you might want to time your dental purchase in the next couple of years, you're likely better off having a plan in place sooner than later because you can't prepare for that crown or root canal. We have had people call us from dental offices with a hole with no tooth and they want coverage for that day to start and it's impossible, okay? It's not going to happen. So please don't do that. The most common cost sharing for major procedures is 50% and plans have coverage limits typically that are going to range from $1,000 to $5,000 a year.

Cameron (20:10):

Yep, you got it. We'll just do a quick recap of Medigap dental coverage and then we're getting to the end of this. So, some Medigap plans, do offer dental coverage at additional premiums only for those people that are enrolled in their Medigap plans. Just like always, don't make this the only reason you would choose that Medigap plan over another. And keep in mind that there are other options ranging from paying cash to purchasing an individual dental policy. All these insurance products, like always, are going to be unique to your geographic location. So just check what is available in your zip code. Understand that dental insurance you purchase on your own is likely not going to be as financially appealing when comparing it to being offered through your employer that paid a large chunk of those premiums in the past. And of course, just like Joanne had talked about, don't wait to enroll when you need treatments right away.

Cameron (20:55):

If you think you need dental coverage in the near future or at any time in the next few years, it's better to get it sooner than later. So aside from medical coverage, concerns about dental coverage are often one of the main factors that consumers consider when trying to decide between Medicare Advantage and Medigap coverage. Hopefully, the information in today's episode will help you make a more informed choice between the two. But just remember that dental is one piece of the big Medicare puzzle. So, make sure you listen to our Medigap versus Medicare Advantage episode to learn more about those two very important options. As always, please leave us a review on your podcast app and subscribe so you can listen to future episodes. You can also find more Medicare content from us by going to YouTube and searching Giardini Medicare. And finally, if you have any questions about today's show, you can email us at info@gmedicareteam.com. Thank you.