What Does Medicare Part B Pay For?
Although Medicare Part B pays for some routine dental work, most of the time it only pays for more serious dental problems, such as severe pain, infection, or problems that result in loss of teeth or permanent disfigurement. If you want a routine checkup, or to have your cavities filled, you need to buy private dental insurance.
Medicare Part B will help pay for dental care if your dentist confirms that you have a medical condition, such as:
Advanced periodontal (gum) disease.
Cancerous or precancerous conditions.
Dental injuries or trauma.
Severe infection in your mouth.
Tumors (benign or malignant).
Traumatic injuries to the face or jaw.
Periodontal (gum) disease is one of the most common chronic diseases in the U.S. Among adults age 65 and older, the prevalence of periodontal disease is around 60 percent.
Part B will also help pay for dental care if you need a tooth removed because you have a condition that threatens your overall health, such as:
Growths, such as tumors or cysts.
Soft tissue sarcoma.
Bone or joint infection.
Cluster of cysts.
Part B will also help pay for dental care if you need to have the root canal or center filled, or if you need any type of surgery to treat a dental condition.
Medicare Part B also pays for dental services that are considered medically necessary to keep your mouth and teeth healthy. This could include services like getting your teeth cleaned, taking care of oral sores or wounds, and taking care of dental infections.
How to Get Dental Care Under Part B
To get dental services under Part B, you must see a doctor within the first 12 months of enrolling in Medicare. You may also visit a dentist who accepts assignment from Part B. This means that the dentist has agreed to accept the approved amount as full payment for the service.
You can search for doctors and other providers who accept Medicare assignment, whether they are MDs, DOs, PAs, NPs, or dentists, on the Medicare website.
If you are receiving Part B and have vision problems, you will also be able to see a doctor who specializes in eye care.
If you live in an area with a shortage of Medicare-enrolled specialists, you will be referred to the next closest provider. You can search for doctors and other providers on the Medicare website.
If you would like to see a specialist from outside your area, you can use the "telehealth" option, which allows you to get services from doctors who are not in your area, through a video- and audio-conferencing system.
Service providers who do not accept Medicare assignment will charge you for the full cost of the services, and you will have to pay for these out-of-pocket.
How Much Part B Pays for Dental Care
Medicare Part B will pay for some routine dental services if they are medically necessary and are received from a doctor. Medicare will not pay for routine dental services if they are received from a dentist who does not accept assignment.
Medicare Part B will pay 80 percent of the approved amount, and you will have to pay the remaining 20 percent.
The approved amount is based on the 2004 fee schedule. The amount may change each year, so you will want to ask your doctor how much you will have to pay for any non-routine dental services.
The amount paid is subject to a deductible and coinsurance. The deductible applies to each benefit period, and the coinsurance applies to each service.
The deductible for a benefit period in 2018 is $185 and the coinsurance is $64.50.
During a benefit period, Medicare will pay 80 percent of the approved amount for covered services that are medically necessary. You must pay the remaining 20 percent, even if you get the service from the dentist who accepts assignment.
You must pay all of the coinsurance for a covered service if you get it from a dentist who does not accept assignment.
For example, if a dental X-ray costs $80, Medicare will pay $64.50 (80 percent), and you will have to pay $15.50 (20 percent).
The deductibles and coinsurance amounts are subject to change each year.
If you have to get a tooth extracted, the doctor who performs the procedure will have to report the amount he or she charges for the service, along with your other covered services, to make sure you are not charged more than the approved amount.
Monitoring Dental Care by Medicare
Medicare has the right to monitor the quality and appropriateness of dental services you receive. To help it do this, Medicare has created a structured program called the National Correct Coding Initiative (NCCI).
The NCCI uses codes to identify dental procedures, supplies, and equipment that are medically necessary. Medicare then uses these codes to decide whether a particular service is covered, and the amount it will pay for it.
To ensure that covered services really are medically necessary, Medicare randomly selects dentists from a sample of providers who have billed Medicare for dental procedures. If any of these dentists have billed Medicare incorrectly, Medicare has the right to require them to repay the amount of money they received.
Medicare also has the right to recoup the amount of money it paid for covered services if it determines that the services were not covered or not medically necessary.
Medicare Benefit Schedule for Dental Care
Medicare Part B will pay for a variety of dental services, including: