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What dental services are covered by Medicare?

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Answer

When using the term “Medicare” we need to clarify that we are talking about the original Medicare program. The original Medicare program (Parts A and B) is different than Medicare Advantage (Part C), which is an alternative option to the original Medicare program for citizens in the United States who are over age 65. (Unlike Medicare, some Medicare Advantage plans do cover routine dental procedures.)

There is no single list that contains all the possible scenarios when dental services may be covered by Medicare. However, Medicare clearly excludes coverage for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth. This means that Medicare will not pay for most routine dental care, such as cleanings, radiographs, fillings, crowns, dentures, etc., even if those services are performed in a hospital.

Medicare will consider payment for certain dental services that are necessary to the provision of certain Medicare covered medical services. For example, Medicare may cover the following services:

  • Extraction of teeth prior to radiation of the jaw.
  • Extraction of a tooth when repairing a fractured jaw.
  • Reduction of a fractured jaw or facial boneBiopsy for oral cancer.
  • TMJ splint to treat pathology or injuries causing tempormandibular joint dysfunction TMD.
  • Sleep apnea oral appliance for those who have had polysomnography performed in a facility-based sleep study laboratory; have been diagnosed with obstructive sleep apnea; meet Medicare’s apnea and hypopnea criteria; and have tried but are not able to tolerate CPAP
  • An oral exam and radiographs to check for gum disease and caries prior to transplant surgery (e.g., heart valve replacement or a lung, kidney, or liver transplant)
  • The reconstruction of a ridge performed as a result of the surgical removal of a tumor; however, the reconstruction of a ridge performed primarily to prepare the mouth for dentures is not covered
  • Although implants are not normally covered, if implants are needed to retain a denture that is necessary due to oral cancer or trauma the implants may be covered. However, the dentures and the cost of preparing the mouth for dentures are excluded from coverage.

Question:

Where can we obtain Medicare’s fee schedule?

Answer:

Medicare fee information and relative value units (RVUs) can be obtained by using the search engine on the Medicare website at www.cms.gov. Medicare allowable fees are considerably lower than most commercial/private medical payers, which is another reason why many dentists choose not to enroll in Medicare. Fees are determined by multiplying Medicare’s conversion factor times the RVU assigned to each procedure code. RVUs are established by the American Medical Association and take into account the skill and effort required to perform a procedure, practice overhead (rent, supplies, staff, etc.), cost of liability insurance, and a geographic practice cost index. 

Question:

Do dentists need to enroll in Medicare in order for Medicare to process their claims?

Answer:

Medicare will not process claims for providers who have not enrolled in Medicare. Even though routine dental services are not covered by Medicare, if a dentist has not formally opted out of Medicare, he/she must enroll in Medicare if a patient asks him/her to submit a claim for a service that may be covered (e.g., oral biopsy, extraction of teeth prior to radiation therapy, oral exam prior to organ transplant or heart valve replacement, etc.). When enrolling in Medicare, dentists must decide whether to become a “participating” or “non-participating” provider. Both terms refer to providers who have enrolled in Medicare.

Medicare Participating Providers

A participating provider agrees to accept Medicare allowable fees and accept assignment on all Medicare claims. The Medicare allowable fee is 5% higher for participating providers than for non-participating providers. Participating providers may collect the applicable deductible and coinsurance (typically 20%) that applies to Medicare covered services. Dentists can charge Medicare patients their full fee for “routine dental services” since they are statutorily excluded from Medicare.

Medicare Non-participating Providers

Medicare non-participating providers can choose to accept or decline assignment of benefits on an individual claim basis. When accepting assignment Medicare will pay the provider directly. If a non-participating dentist does not accept assignment, Medicare will send the payment to the patient.

If a non-participating provider accepts assignment on a claim for a potentially covered service, he/she is limited to collecting 95% of Medicare’s participating provider allowable fee schedule. (Medicare will typically pay 80%, and the patient will be responsible for 20%.)

Non-participating providers who choose not to accept assignment of benefits on a claim are allowed to charge/collect 115% of the fee that Medicare allows for non-participating providers who do accept assignment. (See Medicare reimbursement overview below.) However, Medicare will send the payment to the patient, which means that the dentist must collect the allowed fee/limiting charge in full from the patient.

Question:

If Medicare will not process a claim because we are not enrolled, can we still charge the patient for the service?

Answer:

Dentists who have not enrolled in Medicare are allowed to charge their full fee to Medicare patients for routine dental services that are statutorily excluded from Medicare benefits. If a dentist is not enrolled and has not formally opted out of Medicare, he/she cannot charge Medicare patients for non-routine services that may be covered (i.e., biopsies, sleep apnea appliances, TMJ orthotics, extractions prior to radiation therapy, reconstruction services due to oral cancer, etc.).

Question:

What does it mean to “opt out” of Medicare?

Answer:

When a dentist opts out of Medicare, he/she must submit a formal affidavit (letter) to Medicare stipulating that Medicare will not be billed for services for a two-year period. The dentist must also enter into written private contracts with Medicare patients (prior to service) informing them that no services performed by the dentist will be paid (or submitted) to Medicare during the two-year opt-out period.