Medicare and You

Included in the Medicare & You Handbook (page 49) and the Medicare.gov website (https://www.medicare.gov/coverage/dental-services and https://www.medicare.gov/coverage/eyeglasses-contact-lenses).

Original Medicare doesn’t cover most dental care, dentures, and eye exams related to prescribing glasses. This provides a big burden on the beneficiary to self-insure their overall dental and vision health upon retirement, unless they have access to alternative coverage.

This post digs into exactly what Medicare covers, and where to find assistance with the things that Medicare leaves out.

Medicare & Dental

Medicare’s coverage of dental service is very limited and doesn’t include any of the most common dental procedures that are performed across the nation, including oral exams, x-rays, cleanings, fillings, crowns, root canals, treatment for gum disease and extractions.

Original Medicare Part A will pay for certain dental services that beneficiaries may receive when they’re hospitalized, whether that is for emergency or complicated dental procedures, or due to an accident or illness. It’s important to note that while Part A may pay for the facility charges, the doctor/specialist charges may not be covered.

Medicare Part B covers medical reconstruction of the jaw due to disease or accident, diagnostic testing and imaging of the jaw to diagnose a condition, and tooth extraction caused by an underlying health condition/disease.

Part B will also pay for a preliminary dental exam if the beneficiary is having an organ transplant or another complicated procedure that requires one and it’s done during an office visit.

Under durable medical equipment, Medicare will cover dental appliances that can help reduce the symptoms of sleep apnea with a 20% charge paid by the beneficiary.

Medicare & Vision:

Medicare’s coverage of vision services are based on treating specific conditions, including cataracts, glaucoma, macular degeneration, and eye prosthesis. For cataracts, Medicare will cover the cost of a surgery to implant an intraocular lens and either one pair of eyeglasses with standard frames or one set of contact lenses after the surgery.

It’s important to understand that the supplier of the eyeglasses or contact lenses must be enrolled in Medicare, and it’s good practice for the beneficiary to check with the supplier prior to obtaining those items.

Glaucoma screenings are covered, but only for individuals with a high risk of developing the disease. Those with high risk are defined as beneficiaries with a family history of glaucoma, African American age 50 and older, Hispanic Americans age 65 and older, and individuals with diabetes.

Medicare provides coverage for macular degeneration including screenings, ocular photodynamic therapy with verteporfin and other outpatient prescription drugs.

Medicare Part B will also cover eye prosthesis due to a birth defect, trauma to the eye, or surgical removal of the eye. It also covers polishing and resurfacing of the prosthetic twice per year, one enlargement or reduction in size (without documentation) per device, and replacement of the prosthesis if it’s lost, stolen, or irreparably damaged within the first 5 years.

Alternative Coverage

Due to Medicare’s limitations of dental and vision services, many beneficiaries are in need of alternative forms of coverage. Older adults are at higher risk for oral health problems like untreated tooth decay, gum disease, tooth loss, oral cancer and chronic disease.

Prescription medications and those that are disabled, homebound or institutionalized increases the risk of poor oral health so it’s important that they have access to regular exams, cleanings, and checkups to help avoid issues that can become catastrophic (https://www.cdc.gov/oralhealth/basics/adult-oral-health/adult_older.htm).

Furthermore, poor vision can lead to loss of independence and mobility as one ages. One of the most popular forms of alternative coverage are Medicare Advantage plans, or Part C of Medicare.

These plans can include valuable extra benefits over and above Original Medicare including routine dental, preventive dental, comprehensive dental, routine vision exams and eyewear allowances. In fact, according to the Kaiser Family Foundation’s “A Dozen Face About Medicare Advantage in 2020”, April 22, 2020, 74% of Medicare Advantage beneficiaries have additional dental coverage and 79% have additional vision coverage.

Dental and vision benefits will vary by plan, including covered services and participating providers.
Medicare beneficiaries with funds in a Health Savings Account (HSA) or a Medicare Medical Savings Account (MSA) can use them to pay for cleanings, x-rays, fillings, extractions, dentures, other dental ailments, and vision services and eyewear (according to IRS publication 502).

Growing in popularity amongst Medicare beneficiaries are individual dental and vision plans. These plans are offered by private insurance companies, will have varied benefits and coverage deductibles, copays/coinsurance, and policy maximums and may use specific provider networks.