On Medicare and Need Dental Work? Beware a Big Bill.
Ellen Phillips hasn’t eaten much solid food over the past year and a half. She has lost all of her upper teeth — badly infected, they had to be extracted in 2019. Her tongue is constantly swollen.
“I do well with Cheerios, applesauce and chocolate pudding, but I literally choke if I try to eat solid food, and that’s not how I should be eating,” said Ms. Phillips, 76, who is diabetic.
The extractions were a necessary prelude to needed heart surgery — dental infection or gum disease can allow bacteria to get into the bloodstream, causing surgical complications. The solution Ms. Phillips needs now includes extraction of her lower teeth and a set of implants that she said would cost at least $32,000.
But Ms. Phillips, of West Hartford, Conn., is enrolled in traditional Medicare — which pays for dentistry only in very limited circumstances. Her extractions were not covered, and she doesn’t expect Medicare will pay for her implants. Many Medicare Advantage plans, the managed-care alternative to traditional Medicare offered by private insurance companies, do include a limited amount of dental coverage. But none would come close to covering her needs.
Because of the anatomy of Ms. Phillips’s mouth, dentures are not an option, and as much as she would like to get the implants, the cost is prohibitive — especially since she is providing support to two adult sons whose livelihoods have been hurt by the pandemic. She retired nine years ago as the executive director of a nonprofit community health and home care agency.
“I’m sitting here not sure what to do next,” she said.
Coverage for dental, visual and hearing care has moved to the front burner this year as part of a broader discussion about Medicare expansion in Washington. President Biden proposed adding coverage for all three as part of the federal budget he unveiled last month. But adding coverage has been on the to-do list of Medicare advocates and progressive lawmakers for many years.
A study published in the journal Health Affairs last year noted that poor oral health was associated with higher rates of diabetes, cardiovascular disease and pulmonary infections. Vision loss and hearing loss are associated with a higher risk of falls, depression and cognitive impairment, and hearing loss with higher rates of hospitalization.
“These areas of health are really fundamental parts of our everyday living,” said Amber Willink, lead author of the study and an associate professor at the University of Sydney in Australia. “Good oral health, hearing and vision are things that we often just take for granted, but they are so fundamental to our daily needs, especially when it comes to improving and maintaining our health as we get older.”
The unmet need for such care in the Medicare population is high. Federal data shows that 19 percent of older adults have untreated tooth decay and another 19 percent have complete tooth loss. In 2016, 39 percent of Medicare beneficiaries reported having trouble seeing even with their glasses, and only 58 percent of those beneficiaries reported having had an eye exam in the previous 12 months. Two-thirds of Americans 70 and older have hearing loss.
Two-thirds of all people on Medicare don’t have dental coverage, according to the Kaiser Family Foundation. Among Medicare beneficiaries who used dental services, average out-of-pocket spending on dental care was $874 in 2018, and one-fifth spent more than $1,000 out of pocket, according to Kaiser.
For traditional Medicare to pay for dental care, it must be deemed necessary as part of a covered procedure — for example, a tooth extraction needed in preparation for radiation treatment. Likewise, the program does not cover hearing aids (which are notoriously expensive, often running into four figures) or exams, or most vision care.
Most Medicare Advantage plans offer some level of dental, vision and hearing care. Some plans charge additional premiums for these services, but often they come with no additional charge to beneficiaries. Instead, they are funded through Medicare’s complex Advantage payment system, which includes bonuses the government pays to plans based on quality ratings, and rebates, which are given in certain circumstances.
“Some of the savings must be spent directly on care for beneficiaries, and they go into these extra benefits,” said Allyson Y. Schwartz, president and chief executive officer of the Better Medicare Alliance, a Medicare Advantage research and advocacy group.
But the limits on what those plans cover vary widely. Among people in plans that offered both preventive and more extensive dental benefits, 43 percent faced annual dollar caps, typically around $1,000, Kaiser research shows.
“Some provide preventive and diagnostic services but don’t cover more expensive treatments,” said Tricia Neuman, executive director of the Medicare policy program at the Kaiser Family Foundation. “Others also cover pricier services, like implants, but have high coinsurance requirements or annual dollar limits. It’s better than nothing, but people with relatively skimpy dental coverage may be caught off guard when they see their bill.”
Some seniors buy a commercial, individual policy just for dental care, but these plans also leave them exposed to high out-of-pocket costs for the most expensive procedures. For example, a 66-year-old resident of New York City could choose between a basic ($24 per month) or premium ($48 per month) Delta Dental P.P.O. plan, both with a $50 annual deductible. The basic plan pays a maximum of $1,000 per year in care and the premium plan $1,500.
Low-income seniors are most likely to go without care. Medicaid covers dental, vision and hearing care for some low-income seniors, but states are not required to cover these services, and access to care is inconsistent across the country.
The median annual income for Medicare beneficiaries in 2019 was $29,650, according to Kaiser. The Health Affairs study found that 27 percent of low-income Medicare beneficiaries had visited a dentist in the previous 12 months, compared with 73 percent of high-income beneficiaries. And Kaiser reports that in 2016, 71 percent of Black Medicare beneficiaries did not visit a dentist in the previous year; nor did 65 percent of Latinos.
“Lower- and middle-income people, who may have comparable or greater needs, are going without needed dental care,” Dr. Neuman said. “The costs of some of these dental services are absolutely unaffordable for people living on a fixed income.”
The most serious financial risk comes with restorative procedures like the ones Ms. Phillips needs, said Wey-Wey Kwok, senior attorney at the Center for Medicare Advocacy, which has long urged more robust Medicare coverage of dental, vision and hearing care.
“It doesn’t cost private dental insurance plans a lot to cover preventive care like routine cleanings, exams and X-rays, which is why most cover that fully,” Ms. Kwok said. “The expense lies in restorative care, which is why plans minimize that risk by requiring greater cost-sharing, or imposing an annual dollar cap on coverage.”
For example, the median cost across the United States last year for a root canal and crown, extraction of four teeth and a partial upper denture was $4,800, according to a survey by the American Dental Association’s Health Policy Institute. The median cost for a patient needing periodontal treatment, three fillings and two crowns was $4,360.
What Can Be Done?
The Center for Medicare Advocacy has long lobbied for Medicare to expand the definition of “medically necessary” dental care, arguing that it has the legal authority to do so. A wider definition might be helpful to patients like Ms. Phillips.
More comprehensive solutions would require legislation. A standard set of benefits for dental, vision and hearing could be added under Medicare Part B — with services covered under the same terms applied to other outpatient services. If this was done, Medicare Advantage plans would be required to mirror the benefits in traditional Medicare.
The Congressional Budget Office estimated that an earlier proposal to add these benefits would have increased Medicare spending by $358 billion from 2020-29. Some proposals call for offsetting those higher costs by permitting Medicare to negotiate prescription prices with pharmaceutical companies.
Another option is a voluntary stand-alone program similar to Part D, which covers prescription drugs.
“There’s a great deal of interest in helping people who are struggling with the cost of their dental care,” Dr. Neuman said. “But there is a real issue about what it would mean for Medicare spending and potentially for Medicare premiums.”
Still, it’s not clear how a stand-alone plan could address all three needs — dental, vision and hearing. And adding a standard benefit would be the most straightforward solution, Dr. Willink said.
“A standard set of benefits in Part B for all beneficiaries would be really important,” she said. “As we’re seeing in Medicare Advantage, people may be getting plans that include these types of care, but they don’t quite understand what’s really included. A standard benefit would remove some of the confusion from a program that is already challenging to navigate.”
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