Medicare does not pay for dental implants unless a treatment step is medically necessary or integral to a covered medical service. Therefore, most seniors will need to find an alternative way to make all of the procedures more affordable.
Unfortunately, buying a dental insurance plan as an individual is unlikely to offer much help. Three barriers make discount plans and other options a better avenue.
However, patients recovering from medical conditions often find that Medicare could pay for the early stage oral surgery steps needed to restore function. Also, those dually eligible for Medicaid or enrolled in an Advantage plan could enjoy additional benefits.
Dental Implant Insurance for Seniors
Seniors on Medicare looking for dental insurance that covers implants will frequently encounter three impediments. Some patients will be able to navigate around these obstacles, while others will need to find an alternative.
- Missing tooth exclusions apply to the lifetime of the policy
- Waiting periods delay benefits for teeth you plan to extract
- Age-based premiums increase monthly costs
Dental implant financial assistance programs sometimes target low-income seniors. While donors and charitable organizations have a soft heart for the elderly, resources are often inadequate to support this expensive procedure.
However, you could find help in surprising ways.
- Take advantage of tax-saving opportunities
- Apply for grants if you have dental insurance
- Dental schools offer low-cost care
- Enroll in Medicaid (see below)
Monthly payment plans can help older adults with Medicaid make dental implants more affordable. The treatments take place in phases with ample time in between for healing. The entire process takes at least eight months and can continue up to twenty months if you need bone grafting.
Patients can take advantage of these lengthy time frames by deploying several strategies that could lower out-of-pocket costs.
- Borrow money via a personal loan or finance company
- Look for programs offering financial help (see next section)
- Buy insurance to address late-stage treatments (see further below)
Retired senior citizens often no longer have the option of participating in work-based group dental insurance, which can have better benefits for implants and other procedures the industry deems cosmetic. Therefore, they must find a lesser plan in the non-group market.
Individual plans bought privately rarely provide the types of coverage older people seek. Discount programs are often the better alternative because they overcome the three main caveats you will find.
- Missing tooth exclusions deny benefits throughout the lifetime of the policy. Many people delay purchasing a plan until after it is too late.
- Waiting periods and or graded benefits apply to patients who plan to extract their teeth shortly. You could have to pay premiums for six to twenty-four months before the plan begins making a meaningful contribution.
- Aged-based premiums increase the monthly amount you must pay before the waiting period expires. Elderly patients require more dental work, and the insurance companies price the policies to reflect the higher claims exposure.
When Medicare Covers Dental Implants
Your Medicare plan (Parts A, B, and Supplement Part E) may cover selected steps in the dental implant process – but not all. Your practitioners do not treat you in a single day, and some phases could be eligible for reimbursement.
The federal government publishes three statements that guide the payment parameters.
- Statutory Exclusion: “services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth.”
- Dental Benefits: “services that are an integral part of a covered procedure.”
- Medically Necessary: “Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.”
Reading between the lines of these three statements allows us to make educated guesses about claims support during each treatment phase. Follow along as we break down the probabilities for oral surgery for everyone, patients dually eligible for Medicaid, and individuals recovering from specific diseases.
Medicare may honor claims for selected dental implant treatments performed by an oral surgeon when medically necessary and or when the service is an integral part of a covered procedure. Surgery is the starting point for all patients.
The federal government provides two concrete examples of when Medicare will pay for oral and maxillofacial surgery. Therefore, elderly patients can feel confident about benefits for these possible procedure steps.
- The extraction of teeth to prepare the jaw for radiation treatment of neoplastic disease
- Reconstruction of the jaw following an accidental injury
However, we quickly enter a gray area when it comes to other oral surgery patients. Have the practice write a narrative explaining why the services are an integral part of a covered procedure before submitting the precertification (Advantage) or claim.
Both Medicare and Medicaid will sometimes pay for early-stage dental implant procedures but rarely cover later steps. Both government-run programs are health insurance at their core. However, dual-eligible seniors could find more ways to cut costs on preliminary steps and alternative treatments.
Medicaid sometimes pays for dental work for adults, but benefits vary on a state-by-state basis.
- Oral surgery: 24 states
- Removable: 25 states
- Fixed: not likely in the 25
- Implants: 0 states
People living in states with oral surgery benefits could have better coverage for the beginning steps. In a few cases, Medicaid (secondary) will honor claims after Medicare (primary) declines.
Seniors enrolled in Medicaid Advantage (Part C) could likewise have coverage for early implant procedure steps (CAT Scan, extractions, grafting). Private companies offer Advantage plans unique to each state, which provide all of your Part A, Part B, and Part D benefits – and could include dental care.
With so many possible designs, consult your Advantage plan document to determine the level of extra dental benefits it provides.
- Diagnostic and preventive: exams, cleanings, x-rays
- Basic: fillings, root canal, periodontics, extractions
- Major: crowns, oral surgery, dentures
Your Advantage plan could pay only for medically necessary treatment, or a few other steps, depending on the level of dental benefits it includes.
Medicare is more likely to approve claims for early-stage dental implant procedures when an elderly patient needs medical care after a covered accident or illness. Once again, CAT Scans, extractions, and bone grafting could be integral to a medically necessary procedure.
Medicare pays for reconstructive surgery if needed after an accident or to improve the function of a malformed body part. For example, it will cover a breast prosthesis for women after mastectomy due to cancer. Therefore, logic suggests similar benefits could be available to patients recovering from other maladies.
- After radiation therapy of the head and neck for cancer has the closest correlation to the breast reconstruction example
- CMS.gov clearly declares that reconstruction of the jaw following accidental injury is a covered procedure
- Replacement of lost teeth after decay (caries) is never a viable benefit
In conclusion, seniors on Medicare have six strategies they can pursue to lower their out-of-pocket costs for dental implants. However, there is no silver bullet that works for everyone. Do your best to save money where you can, and consider dentures as a fallback.