Understanding Dental Benefits with Medicare Advantage
Why more dentists are opting out, and how to use your coverage in and out of network.
Many Medicare Advantage plans include dental coverage, but using it is not always as simple as showing your card. Your costs can depend on which dentist you see, whether that dentist works with your plan, and how the bill is handled.
This blog explains what to expect, so there are fewer surprises at the front desk or in the mail.
Why some dentists don't work with your plan
Original Medicare (Part A and Part B) generally does not cover routine dental care, such as cleanings, fillings, or dentures. When a Medicare Advantage plan offers dental coverage, it is an extra benefit provided by the insurance company, not by Original Medicare.
Each insurance company, or the dental company it partners with, sets its own payment rates for dentists. A dentist can choose whether to join that network and accept those rates. Increasingly, more and more dentists have decided the carrier rates do not work for their office and choose not to participate.
This is a business decision by the dental office. It does not mean your coverage has changed, but it can change how your visit is billed and what you pay.
In-network and out-of-network dentists
An in-network dentist has an agreement with your plan. An out-of-network dentist does not.
In-network: The dentist agrees to the plan's rates. You pay only your share, such as a copay or coinsurance, as listed in your plan documents.
Out-of-network: Many plans still pay something toward care from a dentist outside the network. But your share of the cost is often higher, and extra charges may apply (see "Balance billing" below).
Not every plan covers out-of-network dental care. Some plans only pay for dentists in their network. Check your plan's Evidence of Coverage, or call Member Services, to confirm how your plan works.
When the dentist won't bill your plan
Even when out out-of-network, often dentists will send the claim to your plan for you. But if your dentist does not bill your plan, you may be asked to pay the full amount at your visit.
If your plan covers out-of-network dental care and your dentist will not bill the carrier, you can usually ask to be paid back. The steps vary by plan, but often look like this:
Ask the dental office for an itemized bill or receipt. It should list each service and its procedure code.
Call the Member Services number on your plan ID card. Ask how to submit a claim for repayment, and whether there is a form.
Send the form and your itemized bill to the address or website Member Services gives you.
Keep copies of everything you send, and note the date you sent it.
Plans usually set a time limit for sending in claims. Ask Member Services about the deadline when you call.
Balance billing: Exta costs
Your plan sets an allowed amount for each dental service. That is the most the plan will count toward the service. An out-of-network dentist is not bound by that amount and may charge more.
When that happens, you may owe the difference between what the dentist charges and what the plan allows. This is called balance billing. It can apply whether the dentist bills your plan or you send in the claim yourself.
Here is a simple example. The numbers are for illustration only and are not based on any specific plan.
Amount | |
Dentist's charge for a filling | $250 |
Plan's allowed amount | $150 |
Plan pays (example: 50% of allowed amount) | $75 |
Your share of the allowed amount | $75 |
Balance bill (charge minus allowed amount) | $100 |
Total you pay | $175 |
As another example, many plans cover preventive services at 100% of the allowed amount when you see an in-network dentist. Here is the same cleaning at two different offices, again for illustration only:
In-network dentist | Out-of-network dentist | |
Dentist's usual charge for a cleaning | $150 | $150 |
Plan's allowed amount | $125 | $125 |
Plan pays (example: 100% of allowed amount) | $125 | $125 |
Balance bill (charge minus allowed amount) | $0 (dentist accepts plan's rate) | $25 |
Total you pay | $0 | $25 |
Keep in mind that most plans have a yearly maximum. Once you reach it, you pay the full cost of further dental care that year.
Questions to ask before your appointment
A few short calls can save you from an unexpected bill.
Ask the dental office:
Are you in network with my plan?
If not, will you send the claim to my plan, or will I need to pay up front?
Can you give me a written cost estimate before treatment?
Ask your plan's Member Services:
Does my plan cover this service out of network?
What is the allowed amount for this service?
How much of my yearly maximum have I used?
How do I submit a claim, and what is the deadline?
We're here to help
If you have questions about your dental benefits, or want to review whether your current plan still fits the dentist you use, contact us at info@milestonemedicare.com.
We can walk through your plan's dental benefits with you.
This article is for general education only. Dental benefits, networks, allowed amounts, and claim rules vary by plan and can change each year. Always check your plan's Evidence of Coverage or call Member Services for details about your coverage.
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