Dental & Vision Coverage under Medicare Part B?

Dental Coverage Medicare Part B
Not a whole lot

Medicare does not cover generally cover dental, oral surgery, chipped teeth, extractions, dentures or implants, accidents, routine care or most dental procedures such as cleanings, fillings, tooth extractions or dentures. In rare cases, Medicare Part B Doctor Visits will pay for certain dental services.  Medicare Part A Hospital will pay for certain dental services that you get when you are in the hospital. ^{Learn More: medicare.gov/dental}

Some Medicare Advantage plans may include dental benefits.

• Anthem MediBlue Plus
• United Health Care
• Blue Shield 65 Plus – Inspire HMO 2022

We did not in our research find any coverage under Medicare for Accidents! Scroll down for FAQ’s

Medicare #will pay when

• Expanded coverage for medically necessary dental procedures in Medicare. Coverage of some services
  • specifically, elimination of infection preceding an organ transplant and certain cardiac procedures — will begin in 2023,
  • while coverage of dental services linked to head and neck cancers will start in 2024. ^CDA.org *
• you receive an oral examination in the hospital because you will be having a kidney transplant or in a rural or federally qualified health clinic before a heart valve replacement;
• you have a disease that involves the jaw (like oral cancer) and need dental services that are necessary for radiation treatment;
• you had a facial tumor removed and had ridge reconstruction (reconstruction of part of the jaw) as part of that procedure;
• you need surgery to treat fractures of the jaw or face; See TMJ below
• you need dental splints and wiring as a result of jaw surgery.

While Medicare may pay for these initial dental services, Medicare will not pay for any more follow-up dental care after the underlying health condition has been treated. For example, if Medicare paid for a tooth to be removed (extracted) as part of surgery to repair a facial injury you got in a car accident, it will not pay for any other dental care you may need later because you had the tooth removed.

Medicare will pay for some dental-related hospitalizations, for example, if

• you develop an infection after having a tooth pulled;
• you require observation during a dental procedure because you have a health-threatening condition.
  • Medicare will cover the costs of hospitalization (including room and board, anesthesia, and x-rays). It will not cover the dentist fee for treatment or fees for other physicians, such as radiologists or anesthesiologists.

While Medicare may pay for in-patient hospital care in these circumstances, Medicare will never cover any dental care specifically excluded from Original Medicare (i.e., dentures), even if you are in the hospital.

Learn more ⇒

• medicare inter active.org/
• medical necessity Medicare dental work
• CMS General Explanation
• Justice in Aging – Oral Health for older Americans
• Medical Loss Ratio – Insurance Companies must pay out 80% of what they take in in premiums.  If they are going to pay for Dental Implants, how much do they have to charge?

Exclusions

• partnership for solutions.org
• Coverage Determinations cms.gov   –
• Dental Exam prior to Kidney Transplant 260.6
  
• Medicare Policy Benefit Manual cms.gov
• Exclusions  cms.gov
  

#TMJ, Temporo Mandibular joint caused by  trauma
(such as a blow to the face),

might be covered under Original Medicare

Treatment efforts for TMJ are directed toward:

1) reduction of pain,

2) improvement of dysfunction,

3) slowing the progression of the joint disease.

Temporomandibular joint arthroplasty is usually attempted after all nonsurgical methods of treatment have failed.

Conservative therapy is the mainstay in treating TMJ. This therapy may include behavior change, oral medications for pain, anti-inflammatory injections, and orthotic devices. Surgical treatments, often irreversible, may be recommended for difficult or unresponsive cases.

Learn more ⇒

• Our webpage on Medical Necessity
• William Square Dental.com on TMJ
  • 
  • Photo Courtesty of Willams Square Dental

FAQ

• Question Will Medicare pay for implants if the cause of the loss of teeth was due to a severe and life threatening #infection, primary cause.
• Answer:
  • How to Determine Medical Necessity
    • Dentists may ask specific questions to determine whether dental implants are medically necessary or not. Some of these include:
      • Has the patient suffered a traumatic injury to the area?
      • Is the condition the result of an infection, such as ulcers, diabetes, or GERD?
      • If patients can answer “yes” to one or both of these questions, they may be eligible for coverage.
      • Ultimately, however, they will need to consult with their provider to confirm if the treatment will be covered.
      • In some cases, dental implants will be covered by insurance policies. Issues resulting from trauma or infections that require dental implants will usually be covered by these insurance plans. However, there are many factors to consider, and patients will need to reach out to their insurance providers to find out what can and cannot be covered.  Harden Dental *
    • Medical insurance will pay for a procedure if it’s a necessary treatment for a diagnosed medical condition.
      • For instance, if tooth problems have made it impossible for a patient to eat solid food, that person has stepped over the line from a dental to a medical issue. As insurers become more concerned with systemic illnesses and whole-body health, they’re more likely to understand that dental practices play an important roll on a patient’s medical team.  Dentistryiq.com *
    • How To Know When Health Insurance Will Cover An Oral Procedure  Insurica.com * 
  • adicalgonquin.com/medicare-dental-implant-benefits/
  • kff.org/medicare/medicare-coverage-of-dental-services
  • Medically Necessary Dental Services   NIH
  • cms.gov/medicare/dental
  • Clinical Guidelines
    • See also our webpage on implants
    • outsource strategies.com/when-a-dental-procedure-is-considered-medical-and-billable-to-a-medical-insurance/

FAQ’s

• Question How do I go about finding a participating dentist and optometrist, for the Blue Cross add on to their Medicare Advantage Plan
  • Answer Let’s take a look at the Anthem MediBlue Plus MAPD plan page. Hopefully, I already have the list or search engine listed, if not, thanks for your question, it helps build the website for what my clients & visitors really want to know. Have you signed up for a member portal? Here’s a brief tour.
  • Here’s the Find A Doctor search feature. Select Liberty Dental as that is what the Evidence of Coverage shows on page 80. Then use the Liberty Dental Provider Finder. Put in your zip code, individual MAPD plan and get a list of participating dentists.
  • Here’s the Blue View Vision Provider Search Engine.
• Question  I am thinking of changing dentists. The last time I looked into dental insurance with my old dentist it really didn’t work out as she was pretty much a private pay dentist. (She did take delta dental but somehow I don’t think the numbers worked out at the time.)
  • I am thinking of going to a dentist who takes most ppo plans. I am pretty sure I have no dental coverage at present. (I would appreciate your double checking on that since I just switched to medicare with a supplement and am not sure everything that is covered.)
    • 1. Is dental insurance a good deal for me? I.E.
    • 2. how much would it cost and how much would it save me?
  • I would appreciate it if you could let me know my options.
• Answer … you have Part D Rx with Blue Cross, along with Plan F supplemental to Medicare. See Medicare & You for details on Medicare Coverage.
  • In general none of these plans cover dental, although there is coverage for accidents and thus the Plan F would pay it’s share too.
  • In general, we do not recommend dental. There are annual limits of say $1,000 to $1,500. When I earned my Bachelor’s Degree in Insurance, we were taught that Insurance was for unexpected major financial losses that one could not budget for. I don’t believe dental falls into that category. Take a look at Long Term Care, Life Insurance & Estate Planning. Many of the Medicare Advantage Plans (HMO) offer dental as an option.
  • To get a comparison of dental plans, full details and enrollment we suggest you use our affiliate website of Dental for Everyone.
• Question Dental Coverage is way too expensive and the coverage is terrible.  I can’t believe Medicare doesn’t cover it!
• Answer  Medicare only has so much money to fund benefits. The $170 you pay for Part B Outpatient or say $33 for Part D Rx only pays 25% of what it costs Medicare to provide the benefits to you.
  • Heck, check out the Part D Rx survey price comparisons we did for a client with MS Multiple Sclerosis
  • The retail annual cost of her Rx is $20k – Part D would pay $15k and she’s only paying around $35/month for coverage. Where does the rest of the money come from?

  • Here’s our webpage on MLR Medical Loss Ratio   Basically, Insurance Companies have to collect $1 to pay out 80c in benefits.  Here’s a You Tube video I did to explain MLR

  • Here’s a graph from the Kaiser Foundation showing the costs and what percentage is actually being paid, when you pay your Medicare premiums.

  • Here’s a video we did on the value and benefits of Dental Coverage

  • Being as the maximum payouts are say $1,500/year… I don’t want to sound like I’m on my high horse, but that’s not what I went and got a degree at San Diego State in Insurance for. IMHO there are other coverages that are more financially devastating to be insured against.

  • I do agree that Oral Health is very important… Funding it, well that’s beyond my pay grade. I will point out that in the past month, other people have been upset with the limitations of dental coverage. I myself have double the # of times/day I brush and floss. I should be using the water pic too.  More details & graphs above

MORE FAQ’s

• Can you please send me Some info on a dental ins?
• Something comprehensive that takes care of root canals.
• And something where I can use the ins right away, if possible?
  • See above, follow the links and check out the optional dental plan on page 10 of the Inspire Summary of Benefits.
  • If you want to do a Zoom meeting – schedule it here https://steveshorr.com/intro/set-a-meeting/
  • I reworked this page to update and make it easier to read. Please review and then schedule a Zoom meeting to go over it. steve shorr.com/set-a-meeting/
• When can you sign up for the Dental plan?
• Do you need to wait until the general enrollment of insurance plans?
  • One can sign up for the 65 plus dental plan at any time of the year, per page 62 of the Blue Shield 2017 Confidential Agent Training.
  • See above for the online link to enroll
  • You might also want to check out Dental for Everyone dental for everyone.com  which also has year around enrollment.
• I live in Orange County California and have vision coverage under Blue Shield 65 plus.
• I cannot find a list of eye doctors that will take my insurance.
• Can you help me with that?
  • We just updated this page to include the provider finder, above. Use the check box on type of doctor to put in Ophthalmology.
  • We would be happy to be your broker of record. There is no charge. Blue Shield pays us to help you, when you appoint us.  Email us for the form [email protected] 

2021 #Budget Bill to Add Dental???

H.R.502 – Medicare Dental Benefit Act of 2021

HR 4311 Medicare Dental, Vision, and Hearing Benefit Act of 2021 

2022 US Government Budget – Improving Medicare, Medicaid, [Medi Cal]  and ACA Coverage. Medicare, Medicaid, and the ACA marketplaces provide critical coverage to tens of millions of Americans, but should be strengthened through measures like improving access to dental, hearing, and vision coverage in Medicare, making it easier for eligible people to get and stay covered in Medicaid, and reducing deductibles  for marketplace plans [Covered CA].

House lawmakers to CMS: Expand dental coverage in Medicare now 7.5.2022 

****

S. 97/H.R. 502, would repeal the statutory exclusion on Medicare coverage of dental care and dental prostheses, while creating a specific dental benefit under Medicare Part B.

Specifically the bill:

• Repeals the statutory exclusion on Medicare coverage of dental care and dental prostheses.
• Expands Part B benefits to cover dental and oral health services, including
•  
• routine cleanings and exams,
• fillings and crowns,
• major services such as root canals and extractions,
• emergency dental care, and
• other necessary services.
• Provides for payment of dental prostheses, including crowns and full and partial dentures.
• Gradually phases in benefits over an 8-year period.
• Ensures adequate reimbursement for dental providers who serve low-income enrollees.
• Requires that the United States Preventive Service Task Force (USPSTF) include at least one oral health professional. ^Barragan *
• Coverage likely to be similar to what is included now in Medicare Advantage MAPD… note MAPD plans generally have the option to add more dental benefits…
• • Anthem MediBlue Plus
  • Blue Shield 65 Plus – Inspire HMO 2021
    • Dental & Vision
  • United Health Care

References & Links

• NPR — Democrats Hope To Beef Up Medicare With Dental, Vision And Hearing Benefits
• Kaiser Foundation – Medicare and Dental Coverage: A Closer Look
• The Hill.com Add Dental & Vision to Medicare
• give Medicare the power to negotiate for lower drug prices, add new benefits to Medicare  Adding dental, hearing and vision benefits to Medicare. Making new investments in home and community-based services to “help seniors, persons with disabilities and home care workers,”  Extending a boost to ACA income-based subsidies that were included in the American Rescue Plan Act. The boosted subsidies are set to expire after the 2022 coverage year.   fierce health care.com/add-new-medicare-benefits

See also our pages on dental for under 65

• Blue Cross Dental
• Blue Shield Dental & Vision
• Health Net Dental & Vision
• Dental & Vision for Adults and Mandatory Pediatic as an essential benefit

• Child Dental & Vision
• Covered CA & More
• FAQ’s – Explanations – Technical Info
  • Dental Implants
  • No Coverage – Big Claim – Buy Coverage now???
• Vision

There is NO Pre existing condition clause in Medicare or Medicare Advantage Plans

Instant Dental Quotes

Federal Law on Medicare – Part A  law.cornell.edu/

Part B  aw.cornell.edu

(D)in the case of inpatient hospital services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth, the individual, because of his underlying medical condition and clinical status or because of the severity of the dental procedure, requires hospitalization in connection with the provision of such services;  ^{law.cornell.edu/}

medicare.gov/dental-services

VISION FAQ’s

• What does Medicare Part A & B pay for vision?

  • Medicare doesn’t cover eye exams (sometimes called “eye refractions”) for eyeglasses or contact lenses.
  • Some Medicare Advantage Plans (Part C) offer extra benefits that Original Medicare doesn’t cover – like vision, hearing, or dental.
  • Eye exams, if you have diabetes
  • Glaucoma tests
  • Macular degeneration tests and treatment .medicare.gov/coverage/eye-exams-routine
  • Part A doesn’t cover unless it’s a medical problem/emergency.
    • Medicare Part A is intended to serve individuals strictly as a hospital insurance. If you are admitted to the hospital because of an accident involving your eyes, your plan benefits would apply; otherwise, you are responsible for all costs associated with routine vision corrections and eye exams. Oftentimes, individuals with Medicare Part A enroll in a private, individual vision insurance plan for coverage.
  • Medicare Part B is a medical insurance plan. As such, coverage applies to some vision care, but only when you have a medical condition that involves your eyes or affects your vision. Medicare Part B does not cover routine eye examinations and vision correction. That means prescription glasses and contact lenses will not be covered by your plan, unless you have had a necessary cataract surgery.
  • Medicare Part B does cover annual glaucoma screenings for high-risk patients. These include individuals with diabetes or a family history of glaucoma, African-Americans over the age of 50, and Hispanics over the age of 65. Medicare Part B also covers cataract surgery, prosthetic eyes and special treatments for macular degeneration, but a 20% coinsurance cost typically applies to many of these treatments. ^{vsp.com/medicare-vision-coverage}
    • See Medicare Benefits Booklet
    • medicare.gov/eyeglasses-contact-lenses
    • medicare.gov/eye-exams-for-diabetes
    • CMS.Gov on Cataract Surgery
    • Though Medicare will cover both laser and traditional cataract surgeries, they do not yet cover New Technology Intraocular Lenses (NTIOLS). For instance, Medicare may not cover you if you need multifocal or toric lenses, though they will cover monofocal lenses.  READ MORE >>> 
      • inter mountain nv.org/ does-medicare-pay-for-cataract-surgery-how-to-qualify
      • n vision centers.com/cataracts/medicare
      • medical news today.com/does-medicare-cover-cataract-surgery#exclusions

How is #Cataract Surgery – Placement covered by Medicare?
Private Insurance?  Medi Cal?

• Eyeglasses & contact lenses
  • Medicare doesn’t usually cover eyeglasses or contact lenses.  However, Part B covers corrective lenses if you have cataract surgery that implants an  intraocular lens. Corrective lenses include one pair of eyeglasses with standard frames  or one set of contact lenses.
• Costs
  • You pay 100% for non-covered services, including most eyeglasses or contact lenses.
  • After you meet the Part B deductible, you pay 20% of the Medicare-approved amount  for corrective lenses after each cataract surgery with an intraocular lens. You pay any additional costs for upgraded frames. Medicare will only pay for contact lenses or eyeglasses from a supplier enrolled in Medicare, no matter if you or your supplier submits the claim.
• Things to know
  • Medicare covers cataract surgery if it’s done using traditional surgical techniques or using lasers.
• Eyes
  • See “Artificial eyes & limbs” on page 13.
• CMS.gov Cataract Surgery
  • It’s basically 80% and you pay 20%, which can be covered under Medi Gap
    • Anthem Blue Cross
    • Blue Shield – Medi-Gap – Any Medicare Provider
    • UHC AARP Medi Gap
  • or a Medicare Advantage Plan.
    • Anthem MediBlue Plus & SNP
    • Blue Shield 65 Plus – Inspire HMO
    • Scan
    • United Health Care

  • Coverage Indications, Limitations, and/or Medical Necessity

    • Cataract is defined as an opacity or loss of optical clarity of the crystalline lens. Cataract development follows a continuum extending from minimal changes in the crystalline lens to the extreme stage of total opacity. Cataracts may be due to a variety of causes. Age-related cataract (senile cataract) is the most common type found in adults. Other types are pediatric (both congenital and acquired), traumatic, toxic and secondary (meaning the result of another disease process) cataract.

    • Most cataracts are not visible to the naked eye until they become dense enough (mature or hypermature) to cause blindness. However, a cataract at any stage of development can be observed through a sufficiently dilated pupil using a slit lamp biomicroscope. In settings where this instrument is unavailable (e.g., skilled nursing facility), a direct ophthalmoscope can be used to assess the degree to which the fundus reflectivity (red reflex) is impaired by the ocular media. There is no scientifically proven medical treatment for cataracts.

    • In general, cataract surgery is performed to alleviate visual impairments attributable to lens opacity. There are uncommon situations when lens extraction becomes medically necessary for anatomic rather than optical reasons.

      • These include lens induced angle closure (e.g., microspherophakia) and lens subluxation (e.g., Marfan syndrome). In other situations, cataract extraction might be medically indicated with relatively less opacity because of intolerable optical imbalance. Most commonly, this would be due to surgically induced anisometropia (a significant difference in refractive errors between the eyes) or aniseikonia (a difference in magnification as a result of prior lens extraction in the one eye). Some patients may elect lens removal and replacement primarily for refractive benefits to reduce their dependence on spectacles. Such elective procedures are not medically necessary and are called “refractive lens exchanges” to distinguish them from medically indicated cataract surgery. Finally, advanced cataracts may need to be removed to properly visualize, treat, and monitor retinal disease, apart from the patient’s visual symptoms and potential.

      • READ MORE CMS.Gov  – Very extensive and goes into Medical Necessity etc. *

    • Aetna Clinical Bulletin Cataract
  • Further Reading
    • CMS Coverage Guidance – including Medical Necessity
    • Forbes on if Medicare covers Cataracts
    • Medicare.Gov Eyeglasses, etc.
    • Medicare Clinical Bulletin Medical Necessity Cataracts
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