Drilling Down on Dental Coverage and Costs for Medicare Beneficiaries
| Table 1: Medicare Beneficiaries Who Did Not Visit a Dentist in the Past Year and Beneficiaries’ Out-of-Pocket Spending on Dental Care, Among Dental Users | |||||||||
| Number of Medicare Beneficiaries (in millions of people) | No Dental Visit in Past Year |
Beneficiaries’ Out-of-Pocket Spending on Dental Care, Among Dental Users |
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| Any Dental Spending (in millions of people) |
Total | $0 | $1 – $500 | $501 -$1000 | $1001 -$2000 | $2001 or More | |||
| Overall | 56.4 | 49% | 28.7 | $922 | 11% | 59% | 12% | 8% | 11% |
| Age | |||||||||
| Under 65 years | 8.7 | 62% | 3.3 | $713 | 22% | 60% | 7% | 5% | 7% |
| 65-74 years | 28.0 | 44% | 15.7 | $950 | 10% | 59% | 11% | 9% | 11% |
| 75-84 years | 14.0 | 47% | 7.3 | $966 | 9% | 57% | 14% | 8% | 13% |
| 85+ years | 5.7 | 56% | 2.5 | $894 | 6% | 62% | 14% | 9% | 9% |
| Gender | |||||||||
| Men | 25.7 | 51% | 12.6 | $977 | 10% | 57% | 12% | 9% | 12% |
| Women | 30.7 | 47% | 16.1 | $879 | 11% | 60% | 11% | 8% | 10% |
| Race/Ethnicity | |||||||||
| White | 42.1 | 43% | 23.8 | $964 | 8% | 60% | 12% | 9% | 11% |
| Black | 5.4 | 71% | 1.5 | $706 | 23% | 55% | 7% | 6% | 9% |
| Hispanic | 5.0 | 65% | 1.7 | $661 | 36% | 44% | 7% | 3% | 10% |
| Other | 3.6 | 58% | 1.5 | $733 | 17% | 59% | 11% | 3% | 11% |
| Income | |||||||||
| Less Than $10,000 | 7.3 | 70% | 2.1 | $732 | 23% | 51% | 9% | 8% | 8% |
| $10,000 – $19,999 | 14.2 | 66% | 4.8 | $931 | 16% | 56% | 11% | 8% | 9% |
| $20,000 – $39,999 | 17.7 | 47% | 9.4 | $975 | 9% | 61% | 12% | 7% | 11% |
| $40,0000 or above | 17.2 | 27% | 12.4 | $911 | 7% | 59% | 12% | 9% | 13% |
| Geographic Area | |||||||||
| Metropolitan | 44.9 | 46% | 23.8 | $973 | 11% | 57% | 12% | 8% | 12% |
| Rural Micropolitan | 7.5 | 59% | 3.2 | $745 | 6% | 66% | 9% | 9% | 9% |
|
Rural Adjacent or Nonadjacent |
4.1 | 69% | 1.7 | $538 | 9% | 69% | 8% | 8% | 6% |
| Health status | |||||||||
| Excellent | 8.8 | 33% | 5.8 | $759 | 10% | 58% | 13% | 11% | 8% |
| Very Good | 15.7 | 40% | 9.4 | $976 | 7% | 59% | 12% | 9% | 13% |
| Good | 15.9 | 52% | 7.6 | $914 | 12% | 60% | 10% | 8% | 10% |
| Fair | 8.5 | 62% | 3.1 | $879 | 17% | 56% | 10% | 5% | 11% |
| Poor | 2.9 | 64% | 1.0 | $718 | 17% | 55% | 9% | 7% | 12% |
| NOTE: Excludes beneficiaries in long-term care facilities as they do not collect data on dental utilization. Numbers may not sum due to rounding. Income numbers have been adjusted to align with the Urban Institute Dynasim model. SOURCE: Kaiser Family Foundation analysis of Medicare Current Beneficiary Survey (MCBS) Cost Supplement, 2016. |
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| Table 2: Medicare Beneficiaries Who Needed Dental Care, But Could Not Afford It, by Selected Characteristics | ||
| Number of Medicare Beneficiaries (in millions) |
Share Who Could Not Afford Dental Care in the Last 12 Months |
|
| Overall | 54.7 | 10% |
| Age | ||
| Under 65 years | 7.8 | 26% |
| 65-74 years | 27.3 | 9% |
| 75-84 years | 14.4 | 6% |
| 85+ years | 5.2 | 4% |
| Gender | ||
| Men | 24.5 | 10% |
| Women | 30.2 | 11% |
| Race/Ethnicity | ||
| White | 41.7 | 9% |
| Black | 5.6 | 12% |
| Hispanic | 4.8 | 15% |
| Other | 2.7 | 10% |
| Income | ||
| <100% FPL | 6.3 | 19% |
| 100-200% FPL | 12.0 | 18% |
| 200-400% FPL | 17.5 | 9% |
| 400%+ FPL | 18.9 | 4% |
| Health status | ||
| Excellent/Very Good | 22.7 | 5% |
| Good/Fair | 28.2 | 12% |
| Poor | 3.8 | 24% |
| NOTE: Numbers may not sum due to rounding. In 2017, 100% of the federal poverty level was $11,756 for an individual and $14,828 for a couple older than 65. SOURCE: Kaiser Family Foundation analysis of the National Health Interview Survey (NHIS), 2017, which excludes institutional residents. |
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| Table 3: Dental Benefits for Dual Eligibles Under Medicaid and for Medicare Advantage Enrollees (in thousands of beneficiaries) | ||||||
| Dental Benefits for Dual Eligibles Under Medicaid | Dental Benefits for Medicare Advantage Enrollees | |||||
| State | Dental Benefit Covered | Total Dual Eligibles* | Full Dual Eligibles with Some Dental Benefits | Limits on Services | Total Medicare Advantage Enrollment | % With Access to Dental Coverage |
| National | 9,995 | 6,218 | 16,925 | 60% | ||
| Alabama | No | 203 | 0 | No dental benefit | 255 | 60% |
| Alaska | Yes | 15 | 15 | Must have PA | N/A | N/A |
| Arizona | Yes | 185 | 138 | $1000 limit for emergency dental services, $1000 comprehensive benefit for ALTCS members | 433 | 61% |
| Arkansas | Yes | 129 | 32 | Limited mix of services -fewer than 100 diagnostic, preventive, and minor restorative procedures; annual expenditure for care is $1,000 or less | 120 | 74% |
| California | Yes | 1,278 | 1,238 | $1,800 cap on services/year; does not apply to emergency services or to residents of nursing facilities, cap can be exceeded with PA | 2,229 | 57% |
| Colorado | Yes | 108 | 67 | $1,000 benefit maximum. Limitations apply depending on the dental procedure. | 288 | 45% |
| Connecticut | Yes | 167 | 73 | $1000 annual benefit maximum unless medically necessary. Also excludes dental surgery, dentures and some dental treatment. | 167 | 78% |
| Delaware | No | 28 | 0 | No dental benefit | 17 | 66% |
| DC | Yes | 30 | 20 | Some procedures require PA | 12 | 71% |
| Florida | Yes | 764 | 371 | Problem focused visits, extractions, pain management, and dentures based on medical necessity | 1,644 | 72% |
| Georgia | Yes | 294 | 125 | Emergency dental visits only | 508 | 71% |
| Hawaii | Yes | 31 | 37 | Emergency treatment | 115 | 44% |
| Idaho | Yes | 45 | 27 | No limits | 90 | 58% |
| Illinois | Yes | 329 | 283 | Extensive mix of services – more than 100 diagnostic, preventive, and minor and major restorative procedures; annual expenditure cap for care is at least $1,000 | 408 | 52% |
| Indiana | Yes | 191 | 110 | PA for specified services Exam and cleaning 1/year (2/year for nursing facility residents), x-rays vary by type, periodontia limited | 277 | 65% |
| Iowa | Yes | 84 | 65 | Extensive mix of services – more than 100 diagnostic, preventive, and minor and major restorative procedures; annual expenditure cap for care is at least $1,000 | 99 | 34% |
| Kansas | Yes | 61 | 38 | 1 exam/cleaning per 6 months; x-rays vary by type;1 crown per 5 years | 66 | 83% |
| Kentucky | Yes | 164 | 87 | Comprehensive exam – 1 per year, x rays vary by type, prophylaxis limited by age, all other limited by age | 227 | 58% |
| Louisiana | Yes | 206 | 108 | Limited to following services: Examination; Radiographs; Complete Dentures Denture relines Denture repairs; Acrylic Partial Dentures | 250 | 92% |
| Maine | Yes | 84 | 49 | 2 exams with cleaning/year but only 1 in 150 days; 1 orthodontia treatment | 75 | 61% |
| Maryland | No | 137 | 0 | No dental benefit | 90 | 68% |
| Massachusetts | Yes | 297 | 275 | No limits | 247 | 26% |
| Michigan | Yes | 295 | 248 | Frequency limits on most services. Some services require PA. | 624 | 43% |
| Minnesota | Yes | 133 | 116 | Non-pregnant adults receive limited benefits. Exams and cleanings limited to 4 times per year; x-rays vary by type | 505 | 40% |
| Mississippi | Yes | 161 | 78 | $2500 annual maximum | 83 | 98% |
| Missouri | Yes | 171 | 132 | Traditional Medicaid Adults have dental coverage under a limited dental package | 334 | 85% |
| Montana | Yes | 26 | 16 | $1,125 annual maximum benefit; Aged, Blind, Disabled not subject to annual cap; Diagnostic, Preventive, and Anesthesia don’t count toward cap | 40 | 57% |
| Nebraska | Yes | 39 | 34 | Dental coverage limited to $750 per fiscal year, excludes emergencies | 38 | 31% |
| Nevada | Yes | 53 | 26 | Emergency-Only | 153 | 85% |
| New Hampshire | Yes | 30 | 19 | Emergency-Only | 22 | 29% |
| New Jersey | Yes | 199 | 172 | No limits | 245 | 35% |
| New Mexico | Yes | 85 | 51 | Most restorative services such as crowns are not covered for adults | 120 | 36% |
| New York | Yes | 805 | 663 | Extensive mix of services – more than 100 diagnostic, preventive, and minor and major restorative procedures; annual expenditure cap for care is at least $1,000 | 1,240 | 59% |
| North Carolina | Yes | 313 | 238 | Yes – Not Specified | 541 | 48% |
| North Dakota | Yes | 14 | 11 | 1 exam/evaluation per year 1 panoramic radiographic image every 5 years; 1 prophylaxis per year; 2 fluoride per year | 22 | 17% |
| Ohio | Yes | 333 | 211 | Comprehensive adult dental coverage. Certain services require PA. | 734 | 68% |
| Oklahoma | Yes | 111 | 90 | Emergency Extractions only | 116 | 59% |
| Oregon | Yes | 124 | 78 | Prevention of dental disease states, limits on denture, crown, and periodontal coverage. | 337 | 53% |
| Pennsylvania | Yes | 441 | 354 | Dental services limited to: Dentures – 1 per lifetime; Exams/prophylaxis – 1 per 180 days; Crowns, Periodontics, Endodontics only approved via exception | 1,017 | 69% |
| Rhode Island | Yes | 38 | 31 | Not all codes covered | 72 | 81% |
| South Carolina | Yes | 149 | 122 | Limited mix of services -fewer than 100 diagnostic, preventive, and minor restorative procedures; annual expenditure for care is $1,000 or less | 221 | 91% |
| South Dakota | Yes | 20 | 12 | $1,000 annual limit (emergency, preventive services, dentures exempt from $1,000 limit). | 31 | 25% |
| Tennessee | No | 274 | 0 | No dental benefit | 442 | 68% |
| Texas | No | 670 | 0 | No dental benefit | 1,161 | 52% |
| Utah | Yes | 35 | 28 | Pregnant, Blind or Disabled adult Medicaid members are allowed dental services. All others receive Emergency Dental Services only. | 119 | 77% |
| Vermont | Yes | 28 | 20 | $510 per year for non-pregnant adults; limits on treatment for TMJ disorders and prophylaxis; Certain services required PA | 10 | N/A |
| Virginia | No | 183 | 0 | No dental benefit | 218 | 68% |
| Washington | Yes | 184 | 127 | Some may require PA | 359 | 75% |
| West Virginia | Yes | 80 | 46 | Emergency services only | 102 | 41% |
| Wisconsin | Yes | 160 | 138 | 1 Exam/cleaning per year, certain services require PA | 402 | 44% |
| Wyoming | Yes | 10 | 7 | Preventive and emergency services only. No restorative | 2 | N/A |
| NOTES: Numbers may not sum due to rounding; numbers rounded to nearest thousands. N/A denotes sample size is too small to be reliable with fewer than 2,000 beneficiaries in the cell. *Includes Partial Dual Eligibles with No Coverage; PA – Prior Authorization 2016 is the most recent year of data available for the 5% Sample of Medicare claims and was used to estimate Medicaid dental coverage, based on 2018 dental benefits in each state. 6 States in the Kaiser Family Foundation analysis of state Medicaid benefits were listed as NR (No Response): IL, IA, NV, NH, NY, SC; in the Limits on Services section, AR was also listed as NR. State Medicaid benefits in these states came from the CHCS data. SOURCE: Kaiser Family Foundation analysis of the 5% Sample of Medicare claims, 2016; Kaiser Family Foundation. State Health Facts – Medicaid: Dental Benefits. 2018; The Center for Health Care Strategies. Medicaid Adult Dental Benefits: An Overview. Updated November 2018. |
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| Table 4: Three Scenarios: Costs of Dental Procedures | ||
| Dental Treatment Scenarios | Services Received | National Median Fees |
| Scenario 1 | ||
| Linda, age 67, is in excellent health and visits her dentist regularly. In a typical year, such as last year, Linda has one dental visit with an oral exam, cleaning, and x-rays, and a follow-up exam and cleaning six months later. | First Preventive Dental Visit | |
| Periodic Oral Exam (D0120) | $53 | |
| Prophylaxis (D1110) | $95 | |
| 4 Bitewing Radiographs Every 24-36 months (D0274) | $67 | |
| Second Preventive Dental Visit | ||
| Periodic Oral Exam (D0120) | $53 | |
| Prophylaxis (D1110) | $95 | |
| Total Cost | $363 | |
| Scenario 2 | ||
| James, age 72, went to the dentist after realizing he hadn’t had an oral exam in close to two years. After what he hoped would be a routine check-up and cleaning, his dentist said he would need periodontal treatment, three fillings, and two crowns due to degradation of restorations. After receiving these restorative services, he returned six months later for a regular check-up where he received periodontal maintenance. | First Dental Visit | |
| Periodic Oral Exam (D0120) | $53 | |
| Periodontal Scaling and Root Planing – Four or More Teeth per Quadrant (D4341) ($259×4) |
$1,036 | |
| 4 Bitewing Radiographs Every 6-18 months (D0274) | $67 | |
| Follow-Up Restorative Dental Visits | ||
| #13 DO-Resin Based Composite-2 Surfaces Posterior (D2392) | $239 | |
| #14 MO-Resin Based Composite-2 Surfaces Posterior (D2392) | $239 | |
| #29 MOD-Resin Based Composite-3 Surface Posterior (D2393) | $290 | |
| #3 Crown-Porcelain Fused to Noble Metal (D2752) | $1,108 | |
| #30 Crown-Porcelain Fused to Noble Metal (D2752) | $1,108 | |
| Second Preventive Dental Visit | ||
| Periodic Oral Exam (D0120) | $53 | |
| Periodontal Maintenance (D4910) | $145 | |
| Total Cost | $4,338 | |
| Scenario 3 | ||
| Dorothy, age 80, has diabetes, heart disease, and arthritis, and takes multiple medications to manage her medical conditions, some of which cause dry mouth. Because she was more focused on her other health problems, she had not been to a dentist in three years. Last year, she went to see a dentist at the suggestion of her physician after she complained of a dull throbbing pain in her lower left jaw. After a comprehensive exam and x-rays, her dentist told her that she needed a root canal and crown, and would need to have four upper teeth extracted. Her dentist recommended two implants to replace the extracted teeth, but when she heard what that would cost, she opted instead for a partial upper denture. | First Dental Visit | |
| Comprehensive Oral Examination (D0150) | $85 | |
| Panoramic X-Ray (D0330) | $118 | |
| FMX (D0120) | $138 | |
| Treatment Planning (D9450) | $135 | |
| Prophylaxis (D1110) | $95 | |
| Follow-Up Restorative Dental Visits | ||
| Endodontic Therapy, Molar #19 (D3330) | $1,075 | |
| Crown #19 – Porcelain Fused to Noble Metal (D2752) | $1,108 | |
| 4 Extractions (D7140) ($180 x 4) | $720 | |
| Maxillary Partial Denture with Resin Denture Bases (including any conventional clasps, rests, and teeth) (D5211) | $1,300 | |
| Total Cost | $4,774 | |
| NOTE: Fees do not assume negotiated discounts between dental providers and insurers. SOURCE: Kaiser Family Foundation analysis of the American Dental Association, 2018 Survey of Dental Fees, (Chicago, IL: American Dental Association, Health Policy Institute, 2018). |
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