Oral surgery is generally not covered by Original Medicare (Parts A and B)Original Medicare is a fee-for-service health insurance program available to Americans aged 65 and older and some individuals with disabilities. Original Medicare is provided by the federal government and is made up of two parts: Part A (hospital insurance) and Part B (medical insurance)., but there are a few medically necessaryHealthcare services that are necessary for the diagnosis or treatment of an illness, injury, condition, disease or symptoms. exceptions.
Exceptions can include tooth extraction for radiation therapy to treat certain conditions and oral surgery as part of a Medicare-covered treatment.
Without separate dental coverage, Medicare beneficiariesA beneficiary is a person who enrolls in a health insurance plan and receives benefits. must pay out-of-pocket for most oral surgery, including teeth extractions.
Medicare Advantage (Part C)Medicare Advantage (Medicare Part C) is health insurance for Americans aged 65 and older that blends Medicare benefits with private health insurance. This typically includes a bundle of Original Medicare (Parts A and B) and Medicare Prescription Drug Plan (Part D). offers the same coverage as Parts A and B but often includes additional benefits like dental plans. These plans usually cover oral surgery and other dental health needs.
If you need coverage for oral surgery or just about any other form of dental service, you’re probably going to need to look somewhere other than Original Medicare. Medicare Parts A and B don’t recognize most dental care as medically necessary; this includes most oral surgery. That doesn’t mean you should ignore your oral health; dental hygiene has been linked to many medical issues throughout the body, including cardiovascular disease. [i]
While it’s rare and limited, there are exceptions when Medicare will cover oral surgery. When, exactly, does Medicare cover oral surgery? And how?
To get to the root of the topic, let’s drill into the question: Does Medicare cover oral surgery?
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As we’ve mentioned, Medicare will not cover most dental care; however, there are circumstances when oral surgery is covered because it is deemed medically necessary. These exceptions, according to the Centers for Medicare and Medicaid Services (CMS) website, allow Medicare to cover dental services “that are an integral part either of a covered procedure (e.g., reconstruction of the jaw following accidental injury), or for extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw. Medicare will also make payment for oral examinations, but not treatment, preceding kidney transplantation or heart valve replacement, under certain circumstances.” [i]
In other words, Medicare may cover your dental services or oral surgery if:
- It is necessary as part of a covered procedure (in the example above, jaw reconstruction surgery).
- You’re living with the neoplastic disease of the jaw and need teeth extracted for radiation therapy.
- You require an oral exam before you receive a kidney transplant or heart valve replacement. Medicare may help cover the cost of the exam, but not treatment.
Medicare Advantage (Part C) must provide at least the same coverage and benefits as Parts A and B. But since private insurance companies offer it, it can also include additional coverages, including vision, hearing and dental. With Medicare Advantage, you may have benefit coverage for oral surgery.
In the majority of cases, Medicare does not cover oral surgery for tooth extractions. Medicare considers most tooth extractions to be routine dental care and do not include them as a covered benefit. Exceptions include tooth extraction as part of a more extensive procedure.
If you need to have a tooth surgically extracted and you don’t have Medicare, you have a few options:
- Pay full price: without coverage, you’ll be responsible for paying the total cost of your oral surgery out of pocket. Depending on the type of surgery you need and where you live, this can range from hundreds to thousands of dollars.
- Purchase stand-alone dental coverage: Medicare doesn’t offer dental insurance, so you’ll need to buy it from another source like a private insurance company. You’ll enroll in, and pay for, this policy separately from Medicare.
- Enroll in a Medicare Advantage (Part C) plan that offers dental coverage: Part C combines the benefits of Original Medicare (Part A & B). Medicare Part C often bundles additional services like dental, vision, hearing and prescription coverage.
To recap: Does Medicare cover tooth extraction? No, but you can purchase coverage in different ways. Without a dental policy to help, oral surgery for tooth extraction can range from hundreds to thousands of dollars that you’ll need to pay.
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Like other extractions, removing wisdom teeth is generally considered routine dental that Original Medicare does not cover. You’ll need a separate dental policy or a Medicare Advantage plan that includes dental coverage. Otherwise, you’ll probably pay the full cost of having your wisdom teeth extracted.
Despite their ironic name, wisdom teeth typically emerge during a person’s teenage years, and most extractions occur during that time. But some adults may still have them if there was no medical reason to have them removed when they were younger. Over time these teeth may become impacted, cracked or infected — all reasons older adults may need to have their wisdom teeth removed. But unless removing your wisdom teeth is necessary to perform another approved service, Medicare won’t help cover the cost to have them extracted. You’ll either need a separate dental policy or will have to pay for it yourself.
You’re not required to carry dental insurance when you’re a senior as it’s not part of Medicare and doesn’t include penalties for late enrollment. If you don’t, you’re not alone; roughly 37 million Medicare beneficiaries, or 65%, don’t have dental coverage. [i]
Not having some form of dental coverage can be a gamble, as oral health often worsens with age. Many older adults eventually need dental care, and even oral surgery, for a range of health issues, including:
- Gum disease
- Oral cancer
- Tooth decay and loss
These oral health issues aren’t exactly rare. According to the Centers for Disease Control (CDC), 68% of Medicare-aged adults live with Gum Disease while roughly 20% live with untreated tooth decay. [i] Sadly, almost 20% of all Medicare beneficiaries have reported difficulty chewing and eating solid feeds due to issues with their oral health. [i]
While determining whether you need dental coverage is personal, there is a chance you’ll experience oral health issues with age.
What extra benefits and savings do you qualify for?
Out-of-pocket medical costs for non-covered dental services can quickly break a person’s budget, especially if oral surgery is involved. To compound this issue, many older adults don’t realize they need to enroll in a separate dental plan, since they had been regularly receiving these benefits through a previous employer or group plans.
To guard against these issues, Medicare beneficiaries can enroll in stand-alone dental plans or other plans that include dental benefits (unless you still have a separate group plan). For individuals enrolled in Original Medicare, here are your options:
- Enroll in a stand-alone dental plan. A private insurance company offers these plans and often provides between $1,000 and $2,000 in benefit coverage for dental needs like oral surgery. Remember — you pay monthly and out-of-pocket costs for your dental coverage separately from your Original Medicare payments.
- Find a Medicare Advantage (Part C) plan in your area with dental benefits. Medicare Advantage plans typically offer additional benefits, including dental coverage. If you are enrolled in Medicare Parts A & B and want to know more about Medicare Advantage plans that cover dental services like oral surgery, give GoHealth a call. Our licensed insurance agents will review plans in your area and shop for options covering your specific needs — including dental.
What if I can’t afford dental insurance?
Don’t let financial stress keep you from receiving the dental care you need. If you have limited income, you may be able to seek care from other sources, including:
- Medicaid: Many Medicaid programs offer dental care as part of their coverage. Medicaid coverage is state-based, so where you live determines coverage.
- Dental schools: Many dental schools allow volunteers to receive no-cost dental care in return for being treated by a student.
- Dental and health clinics: Many areas offer reduced- or no-cost community health benefits, including dental care.
- Clinical trials: Some organizations like The National Institutes of Dental and Craniofacial Research (NIDCR) occasionally need volunteers to participate in studies that examine specific oral and dental conditions. If you qualify, you may receive no- or reduced-cost dental care. [i]
If you or a loved one are on Medicare and need coverage for oral surgery, give GoHealth a call. We’ll review your plan and make sure you have the benefits you’re looking for. If not, we’ll shop for other plans in your area that do. We want your health plan to handle all of your needs, from everyday health to those issues that pop up — including oral surgery.