Medicare and Dental Plans

Currently, Medicare coverage of dental services is very limited. Medicare does not cover routine dental care or most dental procedures such as cleanings, fillings, tooth extractions or dentures. Medicare does not pay for dental plates or other dental devices. In general, you pay for 100% of dental services.

This has given rise to the popularity of discount dental plans.

Section 1862 (a)(12) of the Social Security Act states in partial that Medicare will not cover dental care, "where such expenses are for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth.” Structures directly supporting the teeth means the periodontium, which includes the gingivae, periodontal membrane, dentogingival junction, cementum of the teeth, and the alveolar bone (i.e. alveolar process and tooth sockets).

The dental exclusion was included as part of the initial Medicare program. The principle being that Coverage is not determined by the value or the necessity of the dental care but by the type of service provided and the anatomical structure on which the procedure is performed.

Dental services that are an integral part of a covered procedure (e.g., reconstruction of the jaw following accidental injury).

Extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw.

Oral examinations, but not treatment, preceding kidney transplantation or heart valve replacement, under certain circumstances. Such examination would be covered under Part A if performed by a dentist on the hospital's staff or under Part B if performed by a physician. This is because the purpose of the examination is not for the care of the teeth or structures directly supporting the teeth. Rather, the examination is for the identification, prior to a complex surgical procedure, of existing medical problems where the increased possibility of infection would not only reduce the chances for successful surgery but would also expose the patient to additional risks in undergoing such surgery.

Hospital stays if needed for emergency or complicated dental procedures, even when the dental care itself is not covered. In these cases you should call your Part A contractor for more information.

Inpatient hospital services in connection with the provision of such dental services if the individual, because of his underlying medical condition and clinical status or because of the severity of the dental procedure, requires hospitalization in connection with the provision of such services.

Surgical procedures for the reconstruction of a ridge as the result of and at the same time as a tumor removal (for other than dental purposes).

Payment for the wiring of teeth when it is done in connection with the reduction of a jaw fracture.

Dental splints are covered if used in conjunction with the treatment of a covered medical condition (i.e., dislocated upper and/or lower joints).

Medicare makes payment for a covered dental procedure no matter where the service is performed. The hospitalization or non-hospitalization of a patient has no direct bearing on the coverage or exclusion of a given dental procedure.

Payment may also be made for services and supplies furnished incident to covered dental services. For example, the services and supplies of a dental technician or nurse who is under the direct supervision of the dentist or physician are covered if the services are included in the dentist's or physician's bill.

Medicare Advantage Plans And Part D Plans

Medicare Advantage Plans, also known as Part C, are offered by approved private companies and are similar to an HMO or PPO. A Medicare Advantage Plan provides full Part A and Part B coverage which is your Hospital Insurance and Medical Insurance. All Medicare Advantage Plans also cover emergency and urgent care. Medicare Advantage Insurance must cover all services that Original Medicare covers excluding hospice care.

Some Medicare Advantage Plans have extra coverage like vision, hearing, dental or wellness programs, and most have Medicare Part D Prescription Drug Coverage. You must pay your Part B premium and another monthly premium for other services. Medicare pays a flat rate to the companies offering Medicare Advantage Plans and these companies are required to follow rules set by Medicare. They can charge you differently for out-of pocket expenses and can have different rules for how you receive services.

There are several different types of Medicare Advantage Plans. The most common include: Health Maintenance Organization Plans (HMO), Preferred Provider Organizations (PPO), Private Fee-for-Service Plans (PFFS) and Special Needs Plans (SNP). There are also less common plans including HMO Point of Service Plans and Medical Savings Account Plans.

In a regular HMO, your care usually comes from the plan’s network (excluding emergency care). HMO plans usually cover prescription drugs but not always. You will most likely have to choose a primary care doctor in an HMO and will probably need a referral from that doctor to see a specialist. If your primary doctor leaves the plan you will need to choose a new doctor. You should also make sure you know the rules of the plan. In some cases, you will need to prior approval from your provider to get care outside of the network.

In a PPO, you can get your care from any doctor or hospital. PPOs can have a network but you can go outside that network if you are willing to pay a higher cost. Most PPOs cover prescription drugs. You will not need to choose a primary care physician or get a referral to see a specialist. You should note that there are Regional PPOs and Local PPOs. Regional PPOs work in one of the 26 Medicare regions while Local PPOs serve the counties the PPO Plan chooses.

A PFFS plan allows you to go to any Medicare-approved physician. Hospitals that accept the plans payment terms are also allowed, however, not all hospitals or providers will accept the terms. Some PFFS plans have networks; if you join such a network you can use any of their providers. These plans sometimes offer prescription drug coverage. If your plan doesn’t cover prescriptions you can join a Medicare Prescription Drug Plan (a Part D plan). You will not need to choose a primary doctor or get a referral for a specialist. You should be aware that a PFFS plan decides how much you pay for a given service and doctors/hospitals may decide to not treat you, even if you have been a patient before. You may also pay more if you choose an out of network doctor if your PFFS plan has a network. In an emergency, hospitals and doctors must treat you.

SNP plans require you to get care from doctors and hospitals in your plan’s network, except for emergency care. In an SNP all prescription drugs are provided for under a Part D plan. You will need to choose a primary doctor and you will most likely need a referral for most specialists. These plans are limited to people who live in institutions like nursing homes, are eligible for Medicare and Medicaid, or have specific chronic conditions (including HIV/AIDS, ESRD or diabetes).

How do you Qualify? 
To qualify for a Medicare Advantage Plan you need to qualify for Medicare and have Medicare Part A and Part B. You will have to pay the monthly Part B Premium to Medicare. You will probably have to pay a monthly premium to your Medicare plan as well.

If you get a Medicare Advantage Plan, and have a Medigap/Medicare Supplemental Plan, the Medigap/Medicare Supplemental Plan will not work; it won’t pay deductibles, copayments, or other costs. You may want to drop any Medigap/Medicare Supplemental Plan—although legally you do not have to.

You must also reside in the service area of the plan you select. If you have End-Stage Renal Disease you cannot join a Medicare Advantage Plan except under certain circumstances.

If you have other coverage through an employer or union, you should check with them before getting a Medicare Advantage Plan. A Medicare Advantage Plan might cause you to lose such coverage. Sometimes, however, you can use Union or Employer coverage with a Medicare Advantage Plan. You need to talk to your employer or union before getting a Medicare Advantage Plan.

How much does it cost?
What you pay for a Medicare Advantage Plan will vary. There are some questions you need to ask to determine what you pay.

Does the plan charge a monthly premium?Does the plan pay any of your Part B premium?Does the plan have a yearly deductible or other deductibles?What copayment or coinsurance payments are required of you?What sort of services do you medically need, with what frequency and does the plan cover them?Can you follow the plan’s rules regarding care?Do you medically need extra benefits not covered by the plan and what are the charges for those extra benefits?What is the plan’s yearly limit on out-of-pocket expenses for all your medical services?

Where/how do you get it? 
You can join a Medicare Advantage Plan by completing a paper application, calling the plan, or enrolling on a plan’s website. You will need to provide your Medicare number when you enroll and know when your Part A and B Medicare Coverage began.

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Will Premiums for Medicare Advantage Plans Go Up in 2011?

For most Medicare beneficiaries who are enrolled in a Medicare Advantage Plan, the answer is “no.” In fact, the Centers for Medicare & Medicaid Services announced in Sept. of 2010 that the 2011 Medicare premiums for beneficiaries with Medicare Advantage Plans should decrease by approximately 1 percent.

In addition to reduced Medicare premiums, beneficiaries with Part C Medicare coverage will see positive changes in their Medicare benefits thanks to the 2010 Patient Protection and Affordable Care Act. These include expanded services and reduced out-of-pocket expenses. Medicare copays are expected to vary depending on Medicare coverage.

Switching Plans
Beginning in 2011, Medicare will no longer offer the Jan. 1 through March 31 open enrollment period. Under most circumstances, this means beneficiaries will be required to keep whichever Medicare Advantage Plan they are enrolled in on Jan. 1 for the rest of the calendar year. Certain exceptions apply, and from Jan. 1 through Feb. 14, beneficiaries may elect to de-enroll in their Medicare Advantage Plans and enroll in Original Medicare instead. If a beneficiary is enrolled in a plan that increased Medicare premiums in 2011, the beneficiary may decide that a switch to Original Medicare is the best move. Additional information about switching to Original Medicare from a Medicare Advantage Plan can be obtained by calling 1-800-MEDICARE (TTY 1-877-486-2048).

Medicare beneficiaries will be able to join a new plan or switch from one Medicare Advantage Plan to another during the 2011 Annual Enrollment Period. Unlike in previous years when the Annual Enrollment Period ran from Nov. 15 to Dec. 31, the 2011 Period will begin in Oct. and end Dec. 7. There are numerous Medicare Advantage Plans offered by private insurance companies to Medicare beneficiaries nationwide. Beneficiaries may choose between Health Maintenance Organization (HMO) Plans, Preferred Provider Organization (PPO) Plans, Private-Fee-For-Service (PFFS) Plans, and Special Needs Plans.

With the variety of plans available, beneficiaries should spend time comparing their options. The plans’ Medicare premiums and Medicare copays are important aspects to consider during comparison. It is also important to remember that the number of people enrolled in a plan, the services most requested by the plan’s beneficiaries, the cost to provide medical services in the beneficiaries’ counties, and a number of other factors can all cause Medicare premiums to vary from year to year.

Plan Access
Nearly 25 percent of all Medicare beneficiaries, 11.8 million people, were enrolled in a Medicare Advantage Plan in 2010. Industry experts expect at least a 5 percent increase in enrollment in 2011. Depending on where they live, beneficiaries who wish to enroll in a Medicare Advantage Plan in 2011 will have, on average, approximately 24 plans from which to choose. Some areas may have significantly more. The vast majority of counties will have at least 10 different Medicare Advantage Plans.

As in previous years, HMO Plans are expected to remain the most common type of Medicare Advantage Plan, with at least 50 percent of Medicare Part C beneficiaries enrolled in one. The number of PFFS Plans available is expected to drop by almost 50 percent nationwide in 2011. The number of SNP Plans available is also expected to decline between 2010 and 2011.

The specific Medicare benefits available to a Medicare Advantage Plan beneficiary, including Medicare premiums and Medicare copays, will depend on the beneficiary’s plan and residence.

Medicare Premiums for Drug Coverage
Medicare premiums for prescription drug coverage, included as part of a Medicare Advantage Plan, are expected to be an average of $50.61 per month. This is almost a $5 decrease from 2010 premiums, which averaged $55.86. As in prior years, the 2011 Medicare premiums for drug benefits for beneficiaries with Part C Medicare coverage will be least expensive under an HMO Plan (average Medicare premium is expected to be $36.24 for 2011) and most expensive under a Cost Plan (average Medicare premium is expected to be $131.18 for 2011). Medicare premiums for prescription drug benefits under PPO plans will likely range between $50 and $70 per month. The vast majority of Medicare beneficiaries will have access to at least one Medicare Advantage Plan that offers prescription drug coverage at no additional premium.

Out-of-Pocket Costs and Medicare Copays
In 2011, in order to meet new requirements included in the 2010 healthcare reform bill, all Medicare Advantage Plans will feature annual out-of-pocket maximums. In the past, many plans provided no such limits. By law, the maximums cannot be greater than $6,700, and the Centers for Medicaid & Medicare Services has encouraged providers to offer Medicare coverage with out-of-pocket limits set at $3,400 or less.

Plans that offer Medicare coverage with reduced Medicare copays often charge higher monthly premiums. Which option will result in the most cost savings will depend on how often a beneficiary receives medical treatment. Those who have a frequent need for medical services may choose to go with a higher monthly premium in order to receive lower Medicare copays.

Extra Help
Low-income subsidies may be available for Medicare beneficiaries who have a difficult time paying for their prescription drug coverage. Extra Help is a Medicare program for beneficiaries with low income and limited resources. Any beneficiary who receives full Medicaid benefits and/or receives Supplemental Security Income automatically qualifies. Medicare copays for beneficiaries who receive Extra Help are expected to be approximately $2.50 for each generic drug purchased and $6.30 for each brand-name drug purchased. Additional help paying monthly Medicare premiums for Part B Medicare coverage may be available through state Medicaid offices.

For more information, call 1-800-MEDICARE (TTY 1-877-486-2048).

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The Different Types of Medicare Advantage Plans

Often referred to as Medicare “Part C,” a Medicare Advantage Plan is an additional health plan choice offered to most people eligible for Original Medicare. The plans do not offer supplemental coverage but are instead a private company option to Original Medicare. Different Medicare Advantage Plans offer plan-specific Medicare benefits, so it is important to compare Medicare plans to find out which one is best suited for you.

All Medicare Advantage Plans provide Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) benefits, and provide coverage for emergency medical care and urgent care services. They are also required to cover all services covered by Original Medicare except hospice care, which Original Medicare covers for everyone on Medicare, regardless of plan choice. Most Medicare Advantage Plans offer Part D prescription coverage either as an included benefit or at an additional cost.

There are four main types of Medicare Advantage Plans: HMO health plans, PPO health plans, Private Fee-for-Service plans, and Special Needs plans. HMO Point-of-Service plans and Medical Savings Accounts plans are two additional but less common Medicare Advantage Plans that may be available to some people. To compare Medicare plans, you should focus on the benefits and coverage you most medically need. Since Medicare Advantage Plans are offered by private companies approved by Medicare, there are a number of differences between the plans, including: how much the different Medicare benefits cost; whether the plans offer extra vision, hearing, dental and/or wellness coverage; and the rules for obtaining services.

Health Maintenance Organization (HMO)
A Health Maintenance Organization (HMO) plan is a health care plan in which your primary care doctor provides referrals to any specialists you may medically need to see for particular services. If you do not follow the proper rules for services, you may have to pay the full costs of the specialist’s care yourself. Except under certain circumstances, you are typically not covered for services obtained outside of the plan’s network of Medicare providers. While the rules of an HMO health plan may be relatively restrictive compared to other plans, in many cases, the extra rules are offset by the plan’s lower costs. A slightly different and less common version of the HMO health plan is the HMO Point-of-Service plan. Unlike a traditional HMO health plan, a HMO Point-of-Service plan allows you to obtain services from an out-of-network provider at a higher out-of-pocket cost. This benefit can make the plan function more like a PPO.

Preferred Provider Organization (PPO)
With a Preferred Provider Organization (PPO) plan you can generally obtain health care from any doctor or hospital you want. If you use an out-of-network provider you will often be required to pay a higher portion of the provider’s fees. PPO health plans typically do not require a referral for care by a specialist. Compared to an HMO health plan, a PPO plan is much less restrictive. However, the monthly premium for a PPO plan is often higher than that of a more restrictive plan.

Private Fee-for-Service
A Private Fee-for-Services plan allows you to go to any Medicare-approved doctor or hospital that agrees to treat you and will accept the plan’s payment terms. You do not need to choose a primary care doctor and referrals are not required for treatment by specialists. However, not all Medicare providers accept the plan. With a Private Fee-for-Services plan, the plan decides how much you pay the provider for each service. Some plans may have a network of providers that have agreed to accept the plan’s payment terms.

Special Needs
A Special Needs plan is a health care plan much like an HMO health plan, but it has limited membership. Some plans may include only those people who live at a particular nursing home or may limit coverage to individuals with a particular medical condition. If you are eligible for a Special Needs plan, you typically must obtain health care services from in-network providers, and you must choose a primary care doctor. Except for certain services (such as yearly mammograms), your primary care doctor must give you a referral to see a specialist if you want the services to be covered under the plan.

Medical Savings Account (MSA)
A Medical Savings Account (MSA) plan is much less common than the other types of Medicare plans. In an MSA, a high deductible health plan is combined with a bank account. Medicare deposits a particular amount of money per year into the bank account and you are allowed to use the money to pay for any health-care-related expenses throughout the year. It should be noted, however, that the deposit made by Medicare is often less than the yearly deductible, which means that if you get sick or medically need care you will likely have to spend more than the amount originally deposited into the account.

How Do the Plans Differ?
A major disparity between Medicare Advantage Plans is how much you are required to pay for different medical services. Out of pocket costs will vary depending on the plan you choose. Some Medicare Advantage Plans charge a monthly premium on top of your monthly premium for Part B coverage. Yearly deductibles can vary significantly between plans, with some ranging from a few hundred to a few thousand dollars. When you compare Medicare plans, keep in mind the type of health services you medically need, how often you get them, and what the copayment or coinsurance amount for those services would be under the different plans.

As mentioned, different plans also have different rules for obtaining services. Some plans may require you to get a referral from your primary doctor if you want to see a specialist. In such cases, the absence of a referral may mean the services provided by the specialist will either not be covered by your plan or will require you to pay higher costs out-of-pocket. Also, with some plans, if you obtain services from an out-of-network provider your out-of-pocket costs may be higher and/or the plan may decline to cover the services. To find out more about the particular benefits and coverage options offered by a Medicare Advantage Plan, contact the plan and request a Summary of Benefits document.

The new health care law includes changes that will give new incentives to private companies who offer Medicare Advantage Plans to improve your quality of care. Different health plans may change their benefits to ensure better coordination of your care and provide more options for services. When you compare Medicare plans, you should keep these changes in mind. Additionally, the new law requires every plan to include an annual cap on how much you are required to pay out of pocket for Part A and Part B services. This is called your annual maximum out-of-pocket cost and it may vary between Medicare Advantage Plans.

For help comparing Medicare plans, you can contact your State Health Insurance Assistance Program or visit www.medicare.gov.

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