Is Oral Surgery Covered By Medicare?
The bad news is, Original Medicare does not cover routine dental services or oral surgery for your general dental health, but sometimes Medicare will approve oral surgery for some medical conditions.
Certain oral surgery types can be covered with limited coverage with Original Medicare, such as an approved procedure or surgery related to a covered health condition like a tooth extraction before jaw cancer treatment.
In this Senior Affairs article we’re going to walk you through everything Medicare does cover that’s related to oral surgery.
Unless you have a stand-alone dental plan for seniors like this one, You’ll pay 100% for non-covered services which include most dental care, dental procedures, supplies, cleanings, fillings, tooth extractions, dentures, or dental plates.
Since Medicare Advantage provides the same benefits as original Medicare, it generally covers the same types of oral surgeries.
This article will explain the oral surgery and dental services that are covered by Medicare plans, possible out-of-pocket costs that could apply to an approved oral surgery, and look at some alternative options that may help you.
Here are a few terms that we use in the article and what they mean. They are helpful to understand when selecting the best insurance plan.
Deductible -This is your out-of-pocket costs annually that must be paid before the insurer starts to kicks in funding for your treatments.
Coinsurance – This is a percentage of a treatment that must pay out-of-pocket. For Medicare Part B, this is equal to 20%
Copayment – A fixed dollar amount that you must pay if you have Medicare when you receive certain treatments. Prescription drugs usually fall in this category.
What Does Medicare Cover For Dental Treatment?
Original Medicare Part A and Part B will not cover preventive dental procedures or oral health that a dentist can perform care or maintenance for.
Medicare Part A covers inpatient care, skilled nursing services, some home health and rehabilitation costs. Part A will pay for certain dental services if you get them in the hospital.
However, if the oral treatment that you need affects your overall health, some coverage exists. Keep in mind that surgery and dental care must be medically necessary. Some examples are:
- If you need an oral exam before a heart valve replacement or kidney transplant.
- Getting a tooth extracted before radiation treatment for jaw cancer.
- Jaw reconstruction after you get a tumor removed from your face.
- If you need to get your jaw surgically repaired due to a fracture or injury.
Dental health can include routine care, like cleanings and x-rays, it also includes annual checkups that can reveal issues that require oral surgery, your dentist can write you a referral to a specialist. The oral surgeon can perform tooth extractions, corrective jaw surgery, dental implants, and biopsies if needed.
Secondary Service Examples
Suppose you needed to get dentures fitted because you had to get all of your teeth removed due to oral cancer. Medicare does cover the removal of your teeth because it’s medically necessary to treat cancer. Normally would not cover dentures, but it was connected to an approved service, so this is the secondary service.
Oral Surgery And Out-of-Pocket Costs
Original Medicare consists of Part A, hospitalization insurance, and Part B, the outpatient medical insurance.
Most of the costs related to an approved oral surgery are going to fall under Medicare Part A.
The out-of-pocket expenses could change every year, but Part A costs for 2021 were:
- $1452 deductible for each benefit period.
- $0 coinsurance for the first 60 days of the benefit period.
- $362 per day coinsurance for days 61-90 of the benefit period.
A benefit period starts when you first enter the hospital, and it ends after not receiving any inpatient hospital care for 60 days consecutively.
Medicare Part B would cover the outpatient tests that you may need before surgery. Costs include the $198 annual deductible and 20% coinsurance. Part B may pay for a dental exam before a kidney transplant or heart valve replacement.
Medicare Part D covers prescription drugs and is administered by private companies instead of federal or state offices. If you have the traditional Medicare plan and not Medicare Advantage you can sign up for Part D. If you are interested in enrollment, go to medicare.gov or by phone at 800-MEDICARE (800-633-4227) or in-person at a local insurance office.
Medicare Advantage and Dental
Medicare Part C, also known as Medicare Advantage, is the alternative to original Medicare.
The deductibles, copayments, and coinsurance offered by private insurance companies can be different, but they provide the same benefits of Part A and Part B Plans.
Some Medicare Advantage plans include coverage for routine dental care, and check-ups however the extent of the coverage may vary.
Since Medicare only covers oral surgery in some instances, if you need a procedure done, you should check with Medicare Advantage will cover the costs. If you contact the plan’s provider, you can estimate your Medicare costs and be prepared for the expenses.
Prescription Drug Coverage
If you needed medication while in the hospital after having oral surgery, you would cover those costs covered under Part A.
When a doctor discharges you from the hospital, your Part D plan will cover the approved drugs your doctor prescribes.
Part D is your prescription drug plan available to you with Original Medicare. These private insurance companies can administer Part D plans.
Most Medicare Advantage plans include Part D prescription medication coverage, but not all do.
If you have a Medicare Advantage plan and are discharged by the hospital and need medication after being discharged, your policy may cover those costs.
Does Medigap Cover Oral Surgery?
Medigap plans are Medicare supplement insurance policies available to you if you have Original Medicare, but not if you have Medicare Advantage.
Medigap policies are similar to Medicare Advantage plans in that private health insurance companies administer them. Millions of Medicare beneficiaries are enrolled in Medicare Supplement Insurance (Medigap) plans.
If you have original Medicare and need oral surgery treatment approved, you could use Medigap to help pay for parts A and B deductibles, copayments, and insurance.
These plans won’t help to pay for routine dental care costs. You can call a licensed insurance agent to check your eligibility and learn more about how a Medigap plan could help by paying some of the costs of a Medicare-covered oral surgery and other Medicare costs.
Non-Medicare Dental Coverage
Some programs may help if you need extra help and support to pay expenses related to dental costs. These are –
- Medicaid – Run by the state that sometimes offers dental benefits if you qualify.
- The Bureau of Primary Health Care – Supporting community health centers in the U.S. that receive federal funds that provide free or reduced-cost dental care. You can call them toll-free at 888-275-4772.
What Are Possible Alternatives to Dental Insurance?
It could be beneficial if you purchased a stand-alone dental plan, (click here for more info) these are designed to subsidize the costs of receiving regular dental services that are essential to prevent the major issues that come from not seeing the dentist regularly.
Dental plans allow you to save 10-60% on dental procedures like cleanings and dentures. Unlike dental insurance, there are no waiting periods and no paperwork and you can use it as often as you want.
- Original Medicare will not cover oral surgery unless it’s medically necessary.
- Sometimes Medicare does cover oral surgery to benefit your general health.
- Medicare Advantage can cover some kinds of medically necessary oral surgery.
- Your specific deductible, copay, and coinsurance costs for an approved surgery will depend on the policy that you choose.
Because Medicare only offers limited oral surgery coverage, you may consider checking your plan to determine if you have coverage for the treatments you need.
Disclaimer: Senior Affairs website is not a licensed health insurance agency. Our website and related properties are not associated with or endorsed by the U.S. government or the federal Medicare program. The purpose of this site is not to solicit insurance business, but rather to educate and inform, we recommend doing further research and due diligence on these matters before choosing insurance and plans.