In America, 64.3 million¹ people are enrolled in Medicare, a critical healthcare program that provides healthcare coverage to individuals aged 65 and older, certain younger individuals with disabilities, and people with end-stage renal disease (ESRD). Medicare coverage is divided into four different parts:

• Medicare Part A covers inpatient hospital, skilled nursing facility, hospice, and home health care
• Part B covers medically necessary and preventive care
• Part C is also known as Medicare Advantage (MA) and is an alternative way to achieve coverage for both Parts A and B via managed care rather than the standard fee-for-service (FFS) program
• Part D provides prescription drug coverage

Coverage for dental care, despite having been considered as a program addition over the years, is not a standard Medicare benefit.² Many MA plans do provide coverage for at least some dental services, helping to fill this gap. As of June 2021, more than 28.9 million³ Americans were enrolled in MA plans.

For MA beneficiaries interested in dental benefits, there are many options. The dental benefits can be mandatory—that is, embedded in the MA plan as a supplemental benefit—or optional, where the benefit is available for an additional, separate premium along with the chosen MA plan. For example, if the MA plan contains some mandatory dental coverage (e.g., preventive dental services) and additional coverage is desired (e.g., comprehensive dental services), the beneficiary can also purchase optional supplemental dental coverage, if offered by their chosen MA plan. This would enhance the benefits they already have with their MA plan. Dental services are by far the most common optional supplemental benefit offering.⁴

MA plans can either be offered for a zero-dollar premium or have a non-zero-dollar premium. In general enrollment plans offering mandatory dental benefits, 70% have zero-dollar premium and 30% have non-zero-dollar premium.

Within mandatory or optional supplemental dental benefits, the dental coverage may include preventive services only, or both preventive and comprehensive services. Preventive dental benefits are those that help maintain good oral health and usually have lower costs, like routine oral exams, cleanings, and x-rays. Comprehensive dental benefits tend to include specialty dental services and have a higher cost. These include prosthodontics, restorative services, extractions, endodontics, and other procedures.

This article reviews the dental benefits provided within MA general enrollment plans using 2022 Centers for Medicare and Medicaid Services (CMS) data and explores how the overall MA dental landscape is changing. We look at trends in MA dental plan enrollment, the benefits offered, and the purchasing habits of beneficiaries. This article does not include an analysis of Special Needs Plans (SNPs).

MA mandatory dental enrollment trends

MA general enrollment plans with mandatory dental benefits continue to grow steadily in popularity. Enrollment in plans with either preventive only or both preventive and comprehensive mandatory supplemental dental benefits has been increasing for the past few years, with 2022 enrollment at nearly 17.5 million. MA plans offering mandatory supplemental dental benefits offer convenience to beneficiaries who only need to look for a single plan that provides both dental as well as medical coverages, rather than separately seeking dental insurance.

Preventive and comprehensive dental benefit trends

We reviewed MA general enrollment plans offering various covered dental services. All plans offering dental benefits covered both oral exams and prophylaxis; x-ray coverage followed closely, covered for over 99% of enrollees. There was a substantial increase in enrollment in plans with a fluoride benefit, at 70% this year compared with 63% in 2021. In general, enrollees are receiving a higher level of dental benefits than in the past.

Plans with mandatory dental coverage including both preventive and comprehensive dental benefits also saw growth. There were relatively large increases in enrollment in zero-dollar premium plans offering nonroutine services and diagnostic services, as well as in non-zero-dollar premium plans offering diagnostic services and periodontics. As seen in Figure 2, enrollment in zero-dollar premium plans with nonroutine services increased 8% since last year, and enrollment in zero-dollar premium plans covering diagnostic services increased 11%. Enrollment in non-zero-dollar premium plans covering diagnostic services increased 10% and periodontics, which focuses on what is commonly called “gum disease,” increased approximately 8% in non-zero-dollar premium plans. Nonroutine services, diagnostic services, and periodontics are either becoming more important to enrollees, being offered by more plans, or some combination of the two.

Diving deeper into benefit limits and shared limits

Benefit limits are an important consideration for MA enrollees as they define the maximum aggregate number of claims, sometimes of a particular type, that a plan will cover within a given time period. For MA plans including mandatory dental coverage, benefit limits may be set separately for preventive and comprehensive dental coverage. Alternatively, a shared limit may be used—a single limit applying to both preventive and comprehensive dental—or coverage could apply even more broadly to include not only dental, but also other coverages such as vision, hearing, or other benefits. In our analysis, we focused on plans identified as having shared limits applying just to dental (preventive and comprehensive combined) or to dental and other benefits. In 2022, a large portion of shared limits appear to be for the dental product only and reflect a combined preventive/comprehensive limit for that benefit.

A shared limit falls under a combo benefit package which is discussed more in the Milliman article Combo benefits: Understanding the landscape of this innovative Medicare Advantage benefit in 2022.

Limits can apply over a variety of periods: every three months, every six months, every year, every two years, or another reasonable duration. For shared limits, non-annual periods are rare, but do occur. It is also possible for a plan to have no limit, which is commonly seen with preventive and comprehensive dental coverage. In our analysis, limits for each plan were annualized to allow us to compare all limits on a similar basis.

For this analysis, we split our annual limit data in two ways. First, we identified enrollment in plans with a preventive limit, comprehensive limit, or shared limit. Second, we divided the data by limit amount into four categories:

1. Limit between $1 and $1,000
2. Limit between $1,000 and $2,000
3. Limit of $2,000+
4. No annual limit

No annual limit in preventive, no annual limit in comprehensive, and a $1,000+ shared limit appear to be popular among mandatory dental enrollees. For plans without a shared limit, it is most common for the preventive dental plan to have no benefit limit. For plans with a shared limit, limits tend to be $1,000 or more. Approximately 60% of mandatory dental enrollees have a shared limit, representing a large portion of total mandatory dental enrollment.

We see variation at the state level in the common benefit limits associated with mandatory supplemental dental coverage. For instance, 59% of California's enrollment is in plans with no limit on preventive dental coverage, while some states have no unlimited preventive plans. Massachusetts is the only state that has $1,000-$2,000 preventive limits as its most popular enrollment option, but had the $1,000-$2,000 shared limit as a close second. Some of these state-level differences in benefit limits may be indicative of broader trends in dental benefit richness for the general enrollment MA market by state.

We also observed that, on average, plans with shared limits tend to have a richer set of underlying dental covered services than plans without shared limits. This difference in benefits covered could be evidence that non-shared limit plans are attempting to mitigate their risk through covering fewer benefits.

Alaska is excluded as there is no MA dental plan data available in this state.

Methodology

The Milliman Medicare Advantage Competitive Value Added Tool (Milliman MACVAT®) was used to compare 2022 MA dental enrollment and trends to those of the past few years. Special Needs Plans (SNPs), Medicare-Medicaid plans (MMPs), employer group waiver plans (EGWPs), Program of All-Inclusive Care for the Elderly (PACE) plans, Part B-only plans, Cost plans, and Medicare Medical Savings Account (MSA) plans were excluded. For this paper, the dental plans with mandatory benefits include all plans with dental cost sharing and plans that offer preventive benefits, as well as plans that offer both preventive and comprehensive benefits. Plans classified as having preventive and comprehensive benefits offer at least one of the following benefits: prosthodontic, nonroutine, diagnostic, restorative, endodontic, periodontic, and extraction services.

Comparisons to the 2019-2022 period were made based on values from our articles and analyses from prior years.⁵

What’s next

The MA dental landscape saw a variety of changes over the past year in terms of enrollment, covered benefits, and benefit limits. The enrollment in MA general enrollment plans with mandatory dental benefits continues to increase, and plans with preventive and both preventive and comprehensive benefits saw increases in enrollment in line with what we have seen over the past few years.

Based on the data we reviewed, it appears it has become essentially universal for general enrollment MA plans with mandatory dental benefits to cover oral exams, cleanings, and x-rays. The types of dental services included with mandatory supplemental dental are growing to include more and more preventive benefits, to the advantage of beneficiaries. Enrollment in plans offering nonroutine services, diagnostic services, and periodontics has been growing, demonstrating that carriers are competing to offer richer benefits and individuals may be actively seeking out these comprehensive benefits, especially in the zero-dollar premium space. The more services a plan covers, the more attractive they may be to members, especially if there is no premium change associated with the additional coverage.

In a similar fashion, competitive decisions regarding benefit limits also hold trade-offs. Plans with high or no coverage limits may be more enticing to members, but come at the cost of more expenses for the plan as well as potential adverse selection.

Lastly, the ever-changing political environment impacts the MA dental landscape. Varying legislative proposals continue to push for dental coverage in Medicare Part B, illustrating the dynamic environment of the health insurance realm. Additional legislative action, as well as the competitive marketplace, will continue to create innovative benefit offerings in the MA space.

¹ CMS (March 2022). Medicare Monthly Enrollment. Retrieved July 19, 2022, from https://data.cms.gov/summary-statistics-on-beneficiary-enrollment/medicare-and-medicaid-reports/medicare-monthly-enrollment/data.

² See https://www.congress.gov/bill/116th-congress/house-bill/3 and https://www.congress.gov/bill/117th-congress/house-bill/502/text?q=%7B%22search%22%3A%5B%22hr+8%22%5D%7D&r=98&s=1.

³ CMS. Monthly Contract Summary Report – May 2022. Retrieved July 19, 2022, from https://www.cms.gov/research-statistics-data-and-systemsstatistics-trends-and-reportsmcradvpartdenroldatamonthly/contract-summary-2022-05.

⁴ Friedman, J.M. & Yeh, M. (September 30, 2021). Trends in Medicare Advantage Optional Supplemental Benefits. Milliman Insight. Retrieved July 19, 2022, from https://www.milliman.com/en/insight/trends-in-medicare-advantage-optional-supplemental-benefits.

⁵ For the 2018 article, see: https://www.milliman.com/en/insight/dental-coverage-in-medicare-advantage-plans-nationwide-market-landscape.
For the 2019 article, see: https://www.milliman.com/en/insight/dental-coverage-in-medicare-advantage-plans-nationwide-market-landscape-2019-update.
For the 2020 article, see: https://www.milliman.com/en/insight/Dental-coverage-in-Medicare-Advantage-plans-Nationwide-market-landscape-2020-update.
For the 2021 article, see: https://www.milliman.com/en/insight/Dental-Coverage-in-Medicare-Advantage-Plans-Nationwide-Market-Landscape-2021-Update.