Generally, Original Medicare (Part A and Part B) does not cover tooth extractions or routine dental procedures such as cleanings and fillings. However, Medicare may cover medically necessary tooth extractions related to other covered treatments or when the extractions are part of your in-patient hospital care.
Understanding how dental coverage works under Medicare, coverage alternatives, and estimated out-of-pocket costs for tooth extractions can help you proactively manage your dental care needs. The following guide explains the specifics and answers frequently asked questions regarding Medicare’s coverage for tooth extractions.
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Dental Health’s Impact on Older Americans
While dental care is important in each stage of life, it can be even more critical for older Americans. Of all adults aged 65 or older, 1 in 5 live with untreated tooth decay, which can lead to pain, severe infection, and the need for a tooth extraction in some cases.
Around 68% of older Americans suffer from gum disease, which can destabilize teeth and potentially lead to tooth loss. A surprising 20% of adults aged 65 and older have lost all their teeth. This can lead to other health issues, such as nutritional deficiencies.
In addition to tooth decay, other common dental problems that can lead to tooth extractions include:
- Significant gum disease
- Deep infection in the tooth
- Broken tooth
- Tooth overcrowding
- Trauma affecting the teeth
Limitations on How Original Medicare Covers Tooth Extractions
Under Original Medicare, dental benefits for routine tooth extractions, including wisdom teeth removal, are generally not covered. However, there are some specific scenarios when Medicare may cover tooth extractions:
- The tooth extraction is critical for the success of another covered medical treatment. For example, Medicare may cover a tooth extraction to treat an infection before receiving chemotherapy or a heart valve replacement.
- The tooth extraction is part of preparing for another covered procedure. For example, Medicare may also cover wisdom teeth removal for procedures like corrective jaw surgery or radiation therapy.
- The tooth extraction requires hospitalization. Medicare may cover tooth extractions if the procedure cannot be performed on an outpatient basis. This may happen because of an underlying medical condition or when the procedure is severe enough to require hospitalization.
Medicare Part A would provide coverage in these situations, as Part A helps cover hospital care. The other part of Original Medicare is Part B, which covers outpatient care. Part B does not provide coverage for tooth extractions, but may cover other dental care services.
General Dental Care Under Medicare
Medicare may cover the following scenarios for general dental work:
- Pre-surgical oral exams that are needed before procedures like heart valve replacement or organ transplant to ensure dental health will not affect the surgery
- Dental treatments related to medical complications, such as treatments needed after head or neck cancer procedures
- Dental ridge reconstruction after a procedure such as a tumor removal
- Procedures to stabilize teeth after a jaw fracture or dental splints as part of treatment for a dislocated jaw
However, beyond these scenarios, Medicare typically does not provide coverage for dental care like cleanings, cavity treatment, and dentures.
How Does Medicare Advantage Cover Tooth Extractions?
Medicare Advantage Plans, or Medicare Part C, are health plans offered by Medicare-approved private insurance companies. They are an alternative to Original Medicare but have features that beneficiaries may find helpful, like an annual out-of-pocket maximum.
These plans must at least have the same Part A and Part B benefits as Original Medicare, but they often include extra benefits like Part D prescription drug coverage and coverage for vision and hearing services. Many Medicare Advantage Plans also offer extended dental benefits, which may include relaxed eligibility criteria for tooth extractions and coverage for routine care like cleanings and fillings.
If you have significant dental needs, a Medicare Advantage Plan can help keep the costs of your oral care down. Reach out to a trusted licensed agent or broker to see which plans in your area may provide the dental coverage you need.
How Much Tooth Extractions Cost With Medicare
When the tooth extraction is covered under Medicare Part A, beneficiaries must first reach the Part A deductible, which is $1,632 per benefit period in 2024. Those with Medicare Advantage Plans have their deductible, copay, and coinsurance rates set by the insurance company.
Without Medicare or any kind of insurance coverage, a simple tooth extraction typically ranges from $75 to $200 per tooth. Extractions that require surgery generally range from $180 to $550 per tooth, while complex cases requiring more extensive surgery may cost anywhere from $800 to several thousand dollars per tooth.
Hospitalization Cost
Once the Part A deductible has been met, the cost of the tooth extraction would depend on how long you stay in the hospital. If you are hospitalized for 60 days or less, then you would not have to pay any additional fees for the extraction. If hospitalized for longer than 60 days, the fees would be:
- 61-90 days: $408 per day
- 91-150 days: $816 per day
After 150 days of hospitalization, you would be responsible for 100% of all costs for the remainder of the benefit period.
Skilled Nursing Facility Cost
If you go to a skilled nursing facility to recover after the extraction, your first 20 days there would be free. If you stay longer, you would pay $204 per day until the 100th day of your skilled nursing facility stay, after which you would be responsible for 100% of all costs for the remainder of the benefit period.
Other Options for Tooth Extraction Coverage
While Original Medicare does not provide coverage for routine dental care, beneficiaries can explore other dental coverage options, including:
- Medicare Advantage Plans: If you’re enrolled in Original Medicare and seeking coverage for a tooth extraction and other dental concerns, consider switching to a Medicare Advantage Plan that includes dental benefits.
- Stand-alone dental insurance: Private dental plans offer coverage for a range of dental services, including tooth extractions, routine cleanings, and more. Premiums and other out-of-pocket costs vary by plan.
- Medicaid: In some states, Medicaid provides dental benefits that may include tooth extractions. Eligibility and the extent of coverage varies widely among states, with some offering comprehensive dental care and others providing limited or emergency-only dental services.
- Community health programs: Many communities have health centers or dental clinics that offer dental services at reduced rates or on a sliding scale based on income. These programs may provide affordable tooth extractions and other dental care options, particularly for those with limited income or without dental insurance.
Putting It All Together
Original Medicare does not cover routine dental care, including tooth extractions, except in very specific circumstances. However, Medicare Advantage Plans may be suitable for beneficiaries who need more dental coverage because these plans often offer extended benefits.
With the cost of tooth extractions ranging from $75 to several thousand dollars per tooth, individuals without dental coverage through Medicare may want to consider other options. These include Medicare Advantage Plans, stand-alone dental policies, Medicaid, or community health programs.
If you’re not sure which coverage is right for you, consult with a trusted licensed insurance agent, broker, or financial planner who can help you understand your options and choose a plan that fits your budget and dental care needs.