What to Expect of MA Plan Dental Benefits

Medicare Advantage (MA) plans are very often marketed on the strength of extra benefits not provided by Original Medicare (OM). Principal among these extra benefits are dental benefits. So, what exactly can you expect of dental benefits included in an MA plan? That's what this article is about.

Why Are You Enrolled in an MA Plan?

You're enrolled in an MA plan PRIMARILY for medical access and services. DO NOT make an MA plan decision solely on the strength of its dental benefits. For the plan to work for you, it must provide access to your preferred medical providers and reasonable costs for your prescription drugs. Beyond that, if you can use the extra benefits like dental and others, great.

If you have a great MA plan that is meeting your medical needs but you're not happy with the dental benefits or the dental providers available to you, you might be better off looking at ways to cover your dental needs outside of your MA plan. Remember, you're enrolled in your MA plan just for the cost of paying your monthly Part B premium to Medicare. Perhaps you can afford to spend on dental coverage that meets your needs, does not rely on your MA plan enrollment and does not change if you switch MA plans. Once you decouple your dental coverage from your MA plan, that gives you the freedom to shop your MA plan every year just concentrating on medical access and drug costs. There's a very low chance of keeping your dentist from one MA plan when switching to another MA plan. Decoupling your dental coverage eliminates that obstacle to switching MA plans if you find one better suited to your medical and prescription drug needs.

Which Dentists Will be In Network for Your MA Plan?

In most cases, you will need to use a dental provider that is in-network for your MA plan. For a dental provider to participate in an MA plan dental network, they have to agree to a fee schedule that may have the office performing dental procedures for significantly less than is reasonable and customary in their geographical area, sometimes for less than what some procedures actually cost them. Why would they do that? To get people in the door. And once you're in the door, it's not unusual for offices to upsell you on procedures that you may not need and that may not be covered by your plan.

A skilled dental provider who has built a reputation on quality dental work does not need to contract with an MA plan to get people in the door. Draw your own conclusions as to what kind of dental providers that leaves to contract with MA plans. Usually it's the chain dental centers that you'll find in network for MA plans; far less often an independent dental office.

How MA Plans Provide Dental Benefits

There are three primary ways that MA plans provide dental benefits.

1. The dental benefits are structured such that the plan caps the dental benefit at an annual total benefit dollar amount. Typically you'll see plans that offer dental benefits in the range of $1,000 to $5,000 in dental costs in the plan calendar year. This number is the total cost of all dental procedures received in a calendar year at the negotiated fee schedule rates.

2. The dental benefits are structured such that the plan caps the dental benefit at some number of CDT codes per year. CDT codes, current dental terminology codes, are the codes assigned to all dental procedures and are what drive dental billing. So instead of having, for example, a dental benefit of $5,000 in a calendar year, this type of plan will allow some number of filling codes, crown codes, extraction codes, etc., in a calendar year.

3. The dental benefits are structured as a direct member reimbursement (DMR) with a total calendar year benefit amount. In this type of dental benefit, the plan allows you a specific dollar amount for the year, say $1,000. You use the dentist of your choosing, make your best deal at the dental office, pay the dentist up front, then submit the dental bill and proof of payment to the plan. The plan reimburses you up to the calendar year amount.

Don't think that because you have a plan with a high annual benefit amount and you're using an in-network dental provider that you won't pay something when you have major dental work done. This is because, in addition to the calendar year benefit limit, the plans do not cover every possible CDT that a dental provider may use to get a specific job done. For example, the preparation and installation of a dental crown can involve multiple CDT codes, depending on the specific procedures required. There are over 400 CDTs associated with a dental crown (D2390-D2799) and your MA plan typically will cover only some of them. Whatever codes are not covered by your plan you will pay for out-of-pocket at the negotiated fee schedule rate.

Other things to watch for:

• All plans have service limitations and exclusions. For example, the plan may say it covers crowns, but in the fine print it's specified that only crowns that are part of a bridge are covered. The plan may exclude specific dental procedures altogether. For example, many plans now are excluding implants entirely.

• All dental work outside of routine cleanings, x-rays and such require prior authorization approval by the plan. So, while your dentist may propose what they think is needed in the way of major dental work, the plan might not agree and can deny prior authorization approval. Any work that does not have prior authorization approval won't be paid for by the plan. If the work is done anyway, you will be paying for that work out-of-pocket.

Which MA Plans Have the Most Generous Dental Benefits?

Medicare HMOs have the richest dental benefits, followed by Medicare PPOs which typically have lower benefit allowances. It's a basic truth in Medicare Advantage managed care plans: the more control the plan has over your medical access, the more money the plan can afford to use for extra benefits like dental. Medicare HMOs typically have smaller medical provider networks and often require referrals to see specialists. That saves the plan money which can be used toward dental and other extra benefits. Medicare PPOs have larger medical provider networks and no referrals, so that reduces the money available for dental and other extra benefits.

JAMA Published Study of MA Plan Dental Benefits vs Traditional Medicare

The Journal of the American Medical Association (JAMA) published a study on January 24, 2025, looking at Medicare beneficiaries with MA plan included dental benefits compared to those on Traditional Medicare (TM, aka, Original Medicare, which has no coverage for routine or restorative dental care). The 5-year study was well designed, looking at 76,557 people over the years 2017-2021. The study subjects were split between those on TM and those on MA plans with dental benefits (Medicaid recipients were excluded). I have included an excerpt of the study below along with a link to the study online. But let me summarize the findings this way: This study found that while more Medicare Advantage enrollees have included dental coverage, Medicare Advantage enrollment does not appear to be associated with more use of these services. On average, Medicare Advantage enrollees spend just as much money out of pocket on dental, vision, and hearing services as people on original Medicare with no dental, vision, or hearing benefits.

The study offered no conclusion as to why many on MA plans with dental benefits do not use those benefits. I have my own observations about this, but if you read this article carefully, I think you'll come to a few conclusions of your own. Here's the study excerpt:

Benefit Design and Access to Dental Care Among Seniors With Medicare Advantage Dental Benefits However, evidence suggests that having dental coverage via MA has little impact on dental outcomes. MA enrollees still have difficulty accessing dental care compared with other populations. Among US residents ages 65 years and older, 12.6% of enrollees with an MA dental benefit reported a cost barrier to dental care compared with 7.4% with non-MA private dental insurance. This suggests that MA dental coverage may not provide the same financial protection as private dental insurance. Another study also shows that enrollment in MA does not result in higher dental care use compared with TM once people become eligible for Medicare after age 65 years. Similarly, compared with TM enrollees, MA enrollees experience a larger decrease in dental spending after transitioning into Medicare from private dental insurance after retirement. Enrollees with MA dental benefits also experience substantial out-of-pocket costs for dental care, nearly equivalent to TM enrollees. These results may suggest that MA dental benefit design may be insufficient when it comes to reducing financial barriers to dental care among Medicare enrollees.

Conclusions

So, to review:

• Don't pick an MA plan just for its dental benefits

• You may want to consider buying dental coverage outside of your MA plan so that you can see the dentist you want to see and have benefits you can count on and that stay the same from year to year

• You may have to try a few different dental offices that are in network for your MA plan to find a dental experience you're comfortable with and a dentist who has your best interests in mind

• No matter what your annual dental benefit may be, you will probably have to pay some costs out of pocket when receiving any major dental work

• Watch out for service limitations and exclusions and prior authorization requirements

One way to improve your chances of getting decent dental care from your MA plan: use a knowledgable local agent like me! I make it my business to know which dental offices in which plans will provide decent service to my clients. And I can help you decipher the ins and outs of MA plan dental benefits. If you're looking to add dental coverage outside of your MA plan, I can help you with that too. Click here to check out my dental page. Remember, I'm just phone call away! Contact me here.