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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

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.
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.
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.
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).
Data and Methods