Whether you’re dealing with a dental emergency or require surgery as part of a larger treatment plan, it’s essential to know what Medicare will and won’t cover. You might be surprised to learn that Medicare’s coverage for dental services is limited, and it’s not always clear what falls under the umbrella of covered oral surgery. In this article, we’ll break down the basics of Medicare and its parts, so you can better understand your coverage options and potential out-of-pocket costs for oral surgery.
What is Oral Surgery?
Oral surgery is a broad term that encompasses a variety of surgical procedures performed on your mouth, teeth, gums, and jaw. These procedures are typically carried out by oral and maxillofacial surgeons, who are dentists with additional training in surgery.
Some common types of oral surgery include tooth extractions, especially for impacted or damaged teeth, and dental implants, which involve placing artificial tooth roots into your jawbone to support replacement teeth. You might also need jaw surgery to correct misalignments or treat temporomandibular joint (TMJ) disorders.
In some cases, oral surgery is necessary to repair birth defects like cleft lip and palate or to treat oral infections and diseases, such as cysts or tumors in your jaw. Your dentist or doctor may recommend oral surgery if you have a condition that can’t be treated with less invasive methods or if you require more complex dental work.
Maintaining good oral health is crucial for preventing tooth decay, gum disease, and other oral health issues that can lead to pain, infection, and even tooth loss, as well as for promoting your overall well-being. Poor oral health has been linked to various systemic health problems like heart disease, diabetes, and respiratory infections.
Specific Scenarios for Medicare Coverage
Medicare usually doesn’t cover dental services, but there are some exceptions where oral surgery may be covered. If you’re admitted to the hospital as an inpatient for a dental procedure due to an underlying medical condition or based on the severity of the procedure, Medicare may provide coverage. Additionally, Medicare may cover specific inpatient or outpatient dental services that are related to a covered medical treatment, as the dental service is considered necessary for the success of the treatment.
For example, if you’re preparing for a major medical procedure, such as a heart valve replacement or an organ transplant, Medicare may cover a pre-procedure oral exam and necessary dental treatments to ensure your mouth is healthy before surgery. This is because infections in your mouth could potentially lead to complications during or after your medical procedure.
Another situation where Medicare may step in is if you require dental procedures to treat a mouth infection before undergoing cancer treatments like chemotherapy. For example, if you need a tooth extracted due to an infection, Medicare may cover this procedure to help prevent the infection from spreading or compromising your cancer treatment.
Additionally, if you experience complications during head and neck cancer treatment, Medicare may cover dental services needed to address these issues. This could include procedures to manage pain, infection, or other side effects caused by your cancer treatment.
In these situations, Medicare will only cover the dental services if they’re considered essential for the success of your covered medical treatment. Your healthcare provider must submit documentation that supports the medical necessity of the oral surgery to ensure Medicare coverage.
Costs in Original Medicare for Oral Surgery
If your oral surgery isn’t covered by Medicare, you’ll have to pay 100% of the costs yourself. This means you’ll be responsible for the entire bill, which can be quite expensive depending on the procedure.
If your oral surgery is covered under Medicare Part A as part of an inpatient hospital stay, you’ll need to pay the Part A deductible, which is $1,632 for each benefit period in 2024. You’ll also be responsible for paying coinsurance for each day you stay in the hospital beyond the 60th day. From days 61-90, you’ll pay $408 per day in coinsurance. If your hospital stay extends beyond 90 days, you’ll need to pay $816 per day for each “lifetime reserve day” you use.
For oral surgeries covered under Medicare Part B, you’ll typically be responsible for paying 20% of the Medicare-approved amount for the procedure after you’ve met your Part B deductible, which is $240 in 2024. If you receive the covered oral surgery in an outpatient hospital setting or ambulatory surgical center, you may also need to pay a copayment or coinsurance for the facility fee.
It’s worth noting that if you have a Medicare Advantage plan or a Medigap policy, your out-of-pocket costs for covered oral surgeries may differ from Original Medicare. These plans may have different deductibles, copayments, and coinsurance amounts, so it’s important to check with a licensed agent to understand your specific coverage and costs. For immediate assistance, please call 866-633-4427.
Other Medicare Plans for Oral Surgery
Medicare Advantage (Part C) plans often include extra benefits like routine dental coverage, which can help cover the costs of oral surgery. These plans are offered by private insurance companies and combine your Part A and Part B benefits into a single plan. Just keep in mind, the specific coverage and costs can vary widely between plans.
If you’re enrolled in a Medicare Prescription Drug Plan (Part D), these plans can help cover the costs of medications related to your oral surgery, such as painkillers or antibiotics. If you require intravenous medications as part of your oral surgery, these will usually be covered under Part B rather than Part D.
Finally, a Medicare Supplement (Medigap) policy can help cover some of the out-of-pocket costs associated with oral surgery, such as deductibles and coinsurance amounts. However, Medigap policies don’t provide coverage for routine dental services or oral surgeries that aren’t covered by Original Medicare.
Conclusion
While Medicare’s coverage for dental services is limited, there are certain situations in which it may cover oral surgery, such as when it’s necessary for the success of another covered medical procedure or when it’s part of a covered inpatient hospital stay. Always be aware of the potential out-of-pocket costs you may face when undergoing oral surgery with Medicare coverage. These can include deductibles, coinsurance, and copayments, depending on whether your surgery is covered under Part A or Part B.
Lastly, you might consider enrolling in a Medicare Advantage, Medicare Part D or Medigap plan. These plans offer additional benefits and may help you manage your out-of-pocket costs for oral surgery more effectively. It’s advised to consult with a licensed agent to compare different plans and benefits. For more information, call 866-633-4427 to speak with a Senior Healthcare Solutions Medicare expert.
