Dental advantages aren’t typically lined by Medicare, besides below restricted circumstances, and many individuals on Medicare do not need any dental protection in any respect. Some Medicare beneficiaries have entry to dental protection via different sources, akin to Medicare Benefit plans, however the scope of dental advantages, when lined, varies extensively and is commonly fairly restricted, which may end up in excessive out-of-pocket prices amongst these with critical dental wants or unmet want.
Policymakers at the moment are discussing choices to make dental care extra reasonably priced by broadening dental protection for individuals on Medicare. President Biden’s FY 2022 budget request consists of as a part of the President’s healthcare agenda “enhancing entry to dental, listening to, and imaginative and prescient protection in Medicare.” Senate Democrats not too long ago introduced an settlement to incorporate Medicare expansions, together with dental, imaginative and prescient, and listening to, as a part of the finances reconciliation bundle, although particulars of the settlement haven’t but been launched. In 2019, the Home of Representatives handed the Elijah E. Cummings Lower Drug Costs Now Act (H.R.3) that might add a dental profit to Medicare Half B, together with a imaginative and prescient and listening to profit, along with provisions to scale back prescription drug prices. Earlier this 12 months, Consultant Doggett, joined by 76 members of the Home of Representatives, launched the Medicare Dental, Vision, and Hearing Benefit Act (H.R. 4311) which might cowl these advantages below Medicare Half B.
In mild of those ongoing coverage discussions, this temporary supplies new information on the share of Medicare beneficiaries with dental protection, the share with a dental go to up to now 12 months, and out-of-pocket spending on dental care. It additionally takes a more in-depth take a look at the scope of dental advantages provided to Medicare Benefit enrollees in particular person plans in 2021. We deal with Medicare Benefit plans as a result of they’ve turn into the main supply of dental protection amongst Medicare beneficiaries. Our evaluation attracts from a number of datasets, together with the Medicare Present Beneficiary Survey for info on dental visits and out-of-pocket dental prices and the Medicare Benefit Enrollment and Profit information for information on particular person Medicare Benefit plans. To current a extra detailed image of dental advantages past what’s obtainable in these information units, we study dental protection provided by 10 geographically dispersed Medicare Benefit plans provided by completely different insurers with comparatively excessive enrollment that supply dental advantages (see Methodology and Appendix for extra info).
Key Findings
- Almost half of Medicare beneficiaries (47%), or 24 million individuals, do not need dental protection, as of 2019.
- Virtually half of all Medicare beneficiaries didn’t have a dental go to inside the previous 12 months (47%), with greater charges amongst those that are Black (68%) or Hispanic (61%), have low incomes (73%), or who’re in honest or poor well being (63%), as of 2018.
- Common out-of-pocket spending on dental companies amongst Medicare beneficiaries who had any dental service was $874 in 2018. One in 5 Medicare beneficiaries (20%) who used dental companies spent greater than $1,000 out-of-pocket on dental care.
- In 2021, 94% of Medicare Advantage enrollees in individual plans (plans open for normal enrollment), or 16.6 million enrollees, are in a plan that gives entry to some dental protection. Amongst these Medicare Benefit enrollees:
- Most (86%) of those enrollees are provided each preventive and extra in depth dental advantages.
- Greater than three in 4 (78%) Medicare Benefit enrollees provided extra in depth protection are in plans with annual greenback limits on dental protection, with a mean restrict of $1,300 in 2021; greater than half (59%) of those enrollees are in a plan with a most dental advantage of $1,000 or much less.
- Almost two-thirds of enrollees (64%) with entry to preventive advantages, akin to oral exams, cleanings, and/or x-rays, pay no value sharing for these companies, although their protection is often topic to an annual greenback cap.
- The most typical coinsurance for extra in depth dental companies, akin to fillings, extractions, and root canals, is 50%.
- About 10% of Medicare Benefit beneficiaries are required to pay a separate premium to entry any dental advantages.
Dental Protection, Utilization and Out-of-Pocket Spending
Almost 24 million individuals, or about half of all Medicare beneficiaries (47%), didn’t have any type of dental protection in 2019 (Determine 1).
Determine 1: Almost half of all individuals on Medicare (47%) don’t have any dental protection
The remaining Medicare beneficiaries have entry to dental protection via Medicare Benefit plans, Medicaid, and personal plans, together with employer-sponsored retiree plans and individually bought plans.
In 2019, 29% of all Medicare beneficiaries had entry to some dental protection via Medicare Benefit plans (together with 3% of beneficiaries additionally eligible for Medicaid who had entry to dental protection via a Medicare Benefit plan). One other 16% had protection via non-public plans. About 11% of Medicare beneficiaries had entry to dental protection via Medicaid (together with the aforementioned who even have protection via Medicare Benefit plans). With the rise of Medicare Benefit enrollment, a rising share of Medicare beneficiaries have entry to some dental protection via their Medicare Benefit plan, so the share of all Medicare beneficiaries with some dental protection would probably be greater in 2021.
A previous KFF evaluation of the 2016 Medicare Present Beneficiary Survey (MCBS) and different information sources indicated that just about two-thirds of individuals on Medicare (65%) had no dental protection that 12 months. Nevertheless, due to an information assortment and processing difficulty subsequently recognized by CMS, the estimates for personal dental protection derived from the MCBS had been decrease than they need to have been by an unknown magnitude. CMS resolved this difficulty in 2017. Because of this and different methodological modifications in our evaluation, as defined within the methodology, estimates of the variety of individuals on Medicare with dental insurance coverage can’t be trended utilizing our 2016 estimate.
Lack of dental care can exacerbate power medical circumstances, akin to diabetes and heart problems, contribute to delayed prognosis of great medical circumstances, and result in preventable issues that generally lead to pricey emergency room visits. Restricted or no dental protection and price considerations contribute to Medicare beneficiaries foregoing routine and different dental procedures.
Utilization. In 2018, half of Medicare beneficiaries didn’t have a dental go to (47%) – with even greater charges reported amongst those that are Black or Hispanic (68% and 61%, respectively) (Determine 2).
Once we appeared by race and gender, we discovered a bigger share of Black and Hispanic ladies (64% and 59%, respectively) went with none dentist go to up to now 12 months than White ladies (40%). The identical sample exists amongst males: a bigger share of Black (74%) and Hispanic (64%) males than White males (44%) went and not using a dental go to.
Low-income beneficiaries are far much less probably than higher-income beneficiaries to report a dental go to within the prior 12 months. Almost three-quarters (73%) of Medicare beneficiaries with incomes of lower than $10,000 per 12 months didn’t go to a dentist, as in comparison with 25% of beneficiaries with incomes above $40,000.
Well being standing was additionally correlated with dental care. Almost two-thirds (63%) of all beneficiaries in honest or poor self-assessed well being had a dental go to up to now 12 months, as in comparison with 41% of beneficiaries in glorious, excellent, or good well being.
These comparatively low charges of dental use aren’t attributable to a drop in utilization attributable to the COVID-19 pandemic, as they’re based mostly on 2018 information, the latest 12 months obtainable, which was previous to the pandemic.
Out-of-Pocket Spending. Most beneficiaries who obtained dental companies in 2018 (88%) paid out of pocket for his or her care. Throughout all beneficiaries, common out-of-pocket spending on dental care was $454 in 2018, though this consists of a lot of beneficiaries who didn’t have any dental care that 12 months. Among the many roughly half of all Medicare beneficiaries who used any dental companies, common out-of-pocket spending on dental care was $874 in 2018. One in 5 beneficiaries who used dental companies spent greater than $1,000 out-of-pocket on dental care, together with one in ten that spent greater than $2,000 (Determine 3).
Medicare Benefit Dental Advantages
Medicare Benefit plans might present additional (“supplemental”) advantages that aren’t lined below conventional Medicare, akin to dental, imaginative and prescient, listening to, and health advantages. The price of these advantages could also be lined utilizing rebate {dollars}. Plans also can cost further premiums for such advantages. In 2021, 94% of Medicare Advantage enrollees in individual plans, have entry to some dental protection. The bulk (86%) of those Medicare Benefit enrollees have entry to a plan with extra in depth protection, whereas 14% had entry to preventive protection solely. Preventive dental protection below Medicare Benefit plans typically consists of oral exams, cleanings, dental x-rays, and generally fluoride remedies. Extra in depth advantages cowl a variety of companies, together with restorative companies (e.g., fillings), endodontics (e.g., root canals), periodontics (e.g., scaling and root planing), prosthodontics (e.g., dentures, dental implants), and oral surgical procedure.
The Scope of Coated Dental Advantages Varies Throughout Medicare Benefit Plans
Nearly all Medicare Benefit enrollees in plans that supply entry to dental advantages (together with in the event that they must pay a premium for these advantages), have entry to preventive companies, together with oral exams (100%), cleanings (100%), and x-rays (99%), though fewer enrollees have entry to fluoride therapy (59%).
Service Limits. Medicare Benefit plans sometimes restrict the frequency of acquiring sure lined companies throughout outlined time frames. For instance, almost all enrollees (88%) are in plans which have frequency limits on the variety of cleanings, with the commonest restrict being twice per 12 months. For different companies, akin to x-rays, the frequency limits differ extra throughout plans. For instance, 36% of enrollees are in plans that restrict the variety of x-rays to a specified timeframe, with the commonest restrict being as soon as per 12 months.
Coated Providers (Different Than Preventive). Amongst enrollees in plans that supply entry to extra in depth companies, the kind of lined companies varies throughout plans: 96% of enrollees are in plans that supply restorative companies, akin to fillings; 83% are in plans that cowl extractions; 76% are in plans that cowl periodontics and/or prosthodontics; 64% are in plans that cowl endodontics, akin to root canals; and 60% are in plans that cowl diagnostic companies and/or non-routine companies. Nevertheless, we didn’t study frequency limits for extra in depth companies as a result of these service classes embody a wide range of remedies, and it’s not all the time clear what a person plan covers in every of those service classes.
like different dental advantages, protection for dentures varies throughout plans
As a part of the prosthodontics service class, some beneficiaries might have entry to protection for dentures, a generally wanted service amongst older adults. As of 2018, nearly 14% of adults 65 and older are edentulous, which means they don’t have any pure enamel. We had been unable to find out specifics about denture protection based mostly on the evaluation of nationwide information, so we appeared on the ten illustrative plans in additional element. 5 of the ten plans specified that they lined dentures (partial and full) and every of those plans restrict dentures to 1 set each 5 years (Appendix Desk 1). Amongst these 5 plans, value sharing imposed on beneficiaries for dentures ranges from no copayment to a $500 copayment, and 50% to 70% coinsurance. All of those cost-sharing quantities are for in-network dental suppliers. 4 out of the 5 plans have annual caps towards lined companies, whereas one plan doesn’t specify if it has an annual cap. The opposite 5 plans that provided dental protection didn’t specify if dentures had been lined.
Medicare Benefit Plans That Provide Dental Advantages Sometimes Have an Annual Greenback Cap on Dental Protection
Most Medicare Benefit enrollees have entry to extra in depth advantages and the bulk (78%) of those enrollees are in plans that impose a most annual greenback cap on the quantity the plan pays for dental care. Some plans simply cap the quantity they’ll pay for the comparatively in depth dental advantages (with no cap on preventive companies), however the majority of enrollees are in plans that cap value sharing for each preventive and extra in depth companies.
The typical annual restrict on dental protection amongst plans that supply extra in depth advantages is about $1,300 in 2021, and greater than half (59%) of enrollees in these plans have dental advantages which can be capped at $1,000 or much less (Determine 4).
About 16% are in a plan that pays as much as $500, whereas 22% of enrollees are in plans with a $2000 annual restrict, and eight% of enrollees are in plans with a restrict better than $2,000 and as much as $5,000. Protection limits are much more widespread amongst plans that cowl extra in depth advantages than plans that cowl solely preventive companies.
Preventive Providers Are Usually Coated With out Price Sharing (Topic to Annual Greenback Limits); For Extra In depth Dental Providers, 50% Coinsurance and Caps Are the Norm
Medicare Benefit plans’ value sharing for dental advantages varies throughout plans and by service class – some plans don’t cost any value sharing (primarily for preventive companies), whereas others cost coinsurance and/or a flat copayment.
- Preventive Providers. Almost two-thirds of enrollees (64%) in plans with entry to oral exams, cleanings, and/or x-rays don’t pay value sharing for these companies, though the vast majority of these enrollees are in plans which have annual limits on lined preventive companies. A further 8% of enrollees might have preventive companies bundled as a part of an workplace go to, which suggests they might solely pay value sharing for the go to itself, or in different circumstances, might have further value sharing for every particular person service. About 3% of enrollees are in plans that require them to pay some kind of value sharing, which varies throughout plans. About 25% are in plans that don’t report their cost-sharing quantities for these preventive companies.
- Extra In depth Dental Providers. For plans that supply extra in depth advantages and require value sharing, coinsurance is extra widespread than copayments, and the commonest coinsurance quantity is 50% throughout the extra in depth service classes, together with restorative companies, extractions, endodontics, periodontics, prosthodontics, non-routine companies, and diagnostic companies.
- Price sharing for extra in depth dental companies varies throughout plans (and companies) and are sometimes topic to annual plan limits. For instance, 39% of enrollees which can be provided endodontic companies (e.g. root canals) are in plans that don’t require value sharing for these companies, however the majority of those enrollees are topic to an annual most on dental protection. One other 30% are required to pay coinsurance for endodontic companies – most frequently 50% – and in addition sometimes with an annual most. Among the many the rest, 15% are required to pay copayments for endodontic companies, and 15% of plans didn’t embrace information on cost-sharing quantities.
Among the many ten illustrative Medicare Benefit plans with dental protection, just one fees any value sharing for preventive companies ($10 copayment per service), although nearly all plans (7) embrace an annual restrict. Among the many 9 plans that supply extra in depth dental companies, 5 of the plans cost coinsurance, every of which is topic to an annual plan restrict, with coinsurance starting from 20% to 70% relying on the service, with 50% as the commonest coinsurance quantity throughout service classes. One of many plans requires copayments for extra in depth dental advantages that fluctuate relying on the service class (no annual most specified). Two plans that cowl extra in depth companies don’t require coinsurance or copayments; considered one of these plans has an annual restrict ($2,300), whereas the opposite doesn’t specify an annual restrict.
Some Medicare Benefit Enrollees Should Pay a Separate Premium for Any Dental Protection
General, 10% of Medicare Benefit enrollees in particular person plans are required to pay a month-to-month premium to entry any dental advantages, both preventive advantages solely or extra in depth advantages. For these enrollees, premiums common $270 per 12 months, starting from about $108 per 12 months to $692 per 12 months.
Some Medicare Benefit enrollees are in a plan the place they’re provided an choice to pay a premium for extra dental advantages past these included of their plan, and a few of these plans embrace imaginative and prescient and listening to advantages as a part of that protection. Dental premiums are along with premiums for different Medicare Benefit advantages, in addition to the Medicare Half B premium ($148.50 in 2021).
Medicare Benefit Plans Are inclined to Restrict Protection to In-Community Suppliers or Cost Extra for Out-of-Community Care
Medicare Benefit plans that supply dental protection might require enrollees to obtain all lined companies from in-network dental suppliers or impose further value sharing for companies delivered out-of-network. Because of information limitations, we had been unable to evaluate cost-sharing necessities for out-of-network dental care throughout all Medicare Benefit plans, so as a substitute reviewed the practices of the ten Medicare Benefit plans chosen for this evaluation.
Among the many 10 illustrative Medicare Benefit plans, three plans don’t cowl any out-of-network dental care (Appendix Desk 1). Two plans pay for out-of-network care “as much as a certain quantity” (quantity not specified), with the affected person billed for the rest of the costs. Two plans impose coinsurance starting from 50-55% for extra in depth companies obtained out-of-network, and one other plan imposes 30% coinsurance for preventive companies and 70% coinsurance for extra in depth companies delivered out-of-network. One plan covers out-of-network dental take care of emergencies solely, paying a most of $100 for every other out-of-network service. Lastly, one plan covers 100% of preventive companies obtained out-of-network.
How Medicare Benefit Dental Protection Compares to Reasonably priced Care Act (ACA) Market Protection
As context for assessing the scope of dental advantages provided to Medicare Benefit enrollees, we reviewed dental protection obtainable to those that buy dental protection via the ACA Marketplaces. Adults buying plans via the ACA Market might have dental protection as a part of their medical plan, or might select to buy separate stand-alone dental protection. Amongst stand-alone dental plans obtainable to adults on HealthCare.gov in 2021 (the federal market), 100% cowl routine preventive dental companies (e.g. exams, cleanings, x-rays), 97% cowl primary dental care (e.g. fillings, extractions, gum illness therapy, and root canals), and 81% cowl main dental care (e.g. crowns, bridges, and dentures). Not like the evaluation of Medicare Benefit plans, the information on the ACA Market isn’t enrollment-weighted.
Like Medicare Benefit plans, most plans have little to no value sharing for preventive companies. For grownup routine dental protection, most plans cost no coinsurance (57% of dental plans), adopted by no coinsurance after assembly the dental deductible (32%). The median dental deductible for a person is $50. For grownup primary dental care, the commonest value sharing quantity is 50% coinsurance after assembly the dental deductible (40% of plans that cowl this profit).
Equally, for grownup main dental care, the commonest value sharing quantity is 50% coinsurance after assembly the deductible (58% of plans that cowl this profit). These most typical coinsurance quantities for primary and routine dental protection are the identical as these in Medicare Benefit plans for extra in depth companies (50% coinsurance), although most Medicare Benefit plans don’t first cost a deductible. All of those coinsurance charges for the ACA Market dental plans are for in-network suppliers.
Most plans on the ACA Market have an annual restrict the plan pays towards lined companies, sometimes starting from $1,000 to $2,000. For stand-alone dental protection, premiums differ barely relying on the age of the enrollee. For an grownup age 40, the typical premium in 2021 is $290 per 12 months, and ranges from $97 per 12 months to $780 per 12 months.
How Present Proposals Would Add a Dental Profit to Medicare
Within the 116th Congress, the Home of Representatives handed the Elijah E. Cummings Lower Drug Costs Now Act (H.R.3), which amongst many provisions, supplied for dental protection below Half B of the Medicare program, beginning in 2025 if enacted into regulation. Medicare would cowl 80% of the price of preventive companies and primary remedies, and would section up protection for extra main remedies, protecting 10% of the associated fee in 2025, growing 10 share factors per 12 months to 50% in 2029 and thereafter. The Congressional Funds Workplace estimated this profit would value nearly $238 billion over 10 years (2020-209). The recently reintroduced version of H.R. 3 doesn’t embrace protection for a dental profit.
Consultant Doggett launched the Medicare Dental, Vision, and Hearing Benefit Act (H.R. 4311) in July 2021 that would offer dental protection below Medicare Half B. In distinction to H.R.3, the proposal, according to a press release, would require no coinsurance for preventive companies, and impose a 20% coinsurance for extra in depth advantages, which is analogous to how the Half B profit is structured for doctor and different outpatient companies, and is decrease than the 50% coinsurance sometimes charged by Medicare Benefit plans.
Dialogue
Since its enactment in 1965, Medicare has not lined routine dental care and half of Medicare beneficiaries (47%) do not need any dental protection, as of 2019. With out dental protection, many individuals on Medicare forego wanted and routine dental care – a difficulty that disproportionately impacts communities of colour – with considerably fewer visits to the dentist up to now 12 months amongst Black and Hispanic beneficiaries (68% and 61%, respectively) in comparison with White beneficiaries (42%). Untreated oral well being can exacerbate sure power illnesses, delay prognosis of great well being circumstances, and lead to pricey emergency visits. Additional, amongst beneficiaries who’ve the flexibility to pay for dental therapy, many expertise excessive out-of-pocket prices, with 20% of individuals spending greater than $1,000 out-of-pocket on dental care.
Medicare Benefit plans are the main supply of dental protection for individuals with Medicare. Whereas the scope of dental protection varies throughout Medicare Benefit plans, there are some widespread options: nearly all Medicare Benefit enrollees with entry to dental protection as a part of their plan have preventive advantages, and most have entry to extra in depth dental advantages, although value sharing for extra in depth companies is often 50% for in-network care, and topic to an annual cap on plan funds. Greater than three out of 4 (78%) enrollees with entry to extra in depth companies are topic to annual caps – averaging about $1,300 in 2021.
In conducting this evaluation, we discovered that plans don’t use commonplace language when defining their advantages and embrace various ranges of element, making it difficult for customers or researchers to check the scope of lined advantages throughout plans.
Given the continued curiosity in including a dental profit to Medicare, policymakers might want to weigh a range elements in designing this profit, together with the scope of lined advantages, value sharing for particular companies, and the way completely different ranges of dental protection might have an effect on Medicare prices and premiums.
Meredith Freed, Nancy Ochieng, Nolan Sroczynski, and Krutika Amin are with KFF.
Anthony Damico is an unbiased guide.
