Medicare is federal health insurance generally available to people aged 65 or older and certain younger people with disabilities. The core of this program, known as Original Medicare (Parts A and B), typically does not cover routine dental care services.
Original Medicare Dental Coverage
The general rule is that Original Medicare does not pay for services “in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth”. This exclusion means that standard procedures like routine cleanings, fillings, dentures, or most tooth extractions are not covered benefits. Beneficiaries are responsible for the full cost of these common dental services.
There are exceptions where Medicare Parts A (Hospital Insurance) and B (Medical Insurance) will provide coverage. Coverage is limited to services that are medically necessary to treat a covered medical condition. This may include certain dental procedures performed in a hospital setting due to the severity of the procedure or the patient’s underlying medical status.
Medicare may cover an oral exam required before a major medical surgery, such as a heart valve replacement or an organ transplant. Diagnostic and treatment services to eliminate an oral infection are covered if they are considered “inextricably linked” to the success of a covered medical service, like chemotherapy or radiation treatment for head and neck cancer. Additionally, services like jaw reconstruction following an accident or the stabilization of teeth related to reducing a jaw fracture may be covered.
Dental Coverage Through Medicare Advantage (Part C)
For most beneficiaries in California seeking routine dental coverage, Medicare Advantage (MA), or Part C, plans are the most common solution. These plans are offered by private insurance companies approved by Medicare and must cover everything Original Medicare covers. However, most MA plans bundle additional benefits, including dental, vision, and hearing coverage, which Original Medicare does not provide.
The dental benefits offered through Medicare Advantage plans can vary significantly from one plan to another and often depend on the specific county in California. Many plans include basic preventive services at little to no cost, such as routine check-ups, cleanings, and X-rays.
If more comprehensive coverage is needed, such as for crowns, root canals, or dentures, beneficiaries often have options to purchase supplemental dental riders. These optional supplemental plans may involve an additional monthly premium but offer expanded benefits, sometimes including services like implants. Many MA dental plans have a yearly limit on how much they will pay for covered services, such as a $1,500 maximum annual benefit amount.
Medi-Cal Dental Program (Denti-Cal)
Californians who meet certain low-income and resource requirements may be eligible for the state’s Medicaid program, known as Medi-Cal, which includes comprehensive dental benefits through the Denti-Cal program. Full-scope Medi-Cal beneficiaries are automatically enrolled in the Denti-Cal program, bypassing the limitations of Original Medicare for dental care. This program is governed by state regulations and federal Medicaid regulations (Title XIX of the Social Security Act).
Denti-Cal covers a wide range of services for eligible adults and children. Covered services for adults include diagnostic and preventive care like examinations and cleanings, along with restorative procedures such as fillings and root canals. The program also covers tooth extractions, crowns, and complete or partial dentures.
For children who qualify, Denti-Cal provides even more extensive coverage, including orthodontics in certain medically necessary cases. For beneficiaries who qualify for both Medicare and Medi-Cal, known as “dual eligibles,” the Medi-Cal dental benefit can work in coordination with any dental coverage provided by a Medicare Advantage plan.