Why Doesn’t Medicare Cover Routine Dental Services?

A question we are often asked is why original Medicare doesn’t cover routine dental and vision services. Honestly, when a vision benefit is offered through employment, it is typically a very limited benefit so not worth addressing here. Coverage for routine dental is more important to people but often they are not aware of how limited dental coverage tends to be. Dental coverage has a maximum benefit per person and that typically ranges from a low of $1000 to about $2500. There are richer plans, of course, but not many. Many Advantage Plans offer some limited dental coverage, but the coverage varies by plan, generally only covers in-network dentists, and there is no requirement that dental services be covered. As a result, that benefit could change or be eliminated.

To be thorough, I should add that Medicare does cover dental procedures under very limited circumstances, such as when a procedure requires hospitalization, but that is also very rare.

Typically, the people who’ve had rich group coverage are those most taken aback by Medicare not covering routine dental because their employer or union has offered dental coverage. But there is a different dynamic at play with an employer who wants to offer a competitive benefit package versus coverage subsidized by the government and taxpayers. Also, a good argument could be made that dental coverage isn’t insurance in the classic sense of spreading the risk of a catastrophic event across a population that might be a ruinous expense to an individual.

We are not suggesting dental care isn’t important. Dental health is important to overall health. We are simply trying to inform our readers that good, cost-effective dental coverage for adults is almost always a benefit of employment.

It is possible that one day Medicare might cover dental services but coverage of routine dental is expressly prohibited by current law.

Under current law, Section 1862(a)(12) of the Social Security Act, Medicare is prohibited from making payments for “…services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth.”

Nevertheless, Medicare has evolved and added benefits over the years. Legislation has been proposed to cover dental services but hasn’t passed. It doesn’t help that most dentists likely don’t want Medicare involved since Medicare pays physicians less than commercial payors. For the first forty years of its existence, Medicare didn’t cover outpatient prescription drugs. Eighteen years later that is almost unfathomable.

Whether to buy individual dental is a personal financial decision. Many opt to take dental if COBRA is offered to them for the eighteen months they can elect it and then make the decision about whether to buy as an individual. Some people want the coverage but many choose not to buy it and just pay for services out of pocket. After all, if you only have two cleanings in a given year and pay for dental coverage, you would most likely have been better off paying out of pocket. And, in the years more extensive services are needed, coverage can disappoint. Coverage for individual dental often includes a waiting period which many are unhappy about. But, again, dental companies don’t want to provide coverage immediately to someone who’s let issues fester and then seeks to buy a plan when considerable work is needed.

As people approach retirement and the transition to Medicare, factoring in the cost of possible future dental expenses is important. Medicare coverage of routine dental might change in the future but we suggest no one count on that.