In America, more than 65.9 million1 people are enrolled in Medicare, a critical healthcare program that provides coverage to individuals aged 65 and older, certain younger individuals with disabilities, and people with end-stage renal disease (ESRD). Traditional Medicare includes Parts A and B, and prescription drug coverage is available via Medicare Part D.
Part C, also called Medicare Advantage (MA), is a managed care alternative to traditional Medicare including all Part A/B benefits as well as additional supplemental coverages. For more information on the different parts of Medicare, please see medicare.gov.
Despite having been considered as a potential program addition over the years,2 most dental care is not covered as part of traditional Medicare. A proposed amendment to the Inflation Reduction Act of 2022 would have expanded coverage for dental care under the Medicare program, but the amendment was not included in the final bill.3 Some dental procedures considered medically necessary as an integral part of covered medical procedures must now be covered through traditional Medicare under the 2023 Medicare Physician Fee Schedule Final Rule.4 Most dental services, however, are not covered by Medicare Parts A or B. MA plans help to fill this gap, as many MA plans do provide coverage for at least some dental services. As of May 2023, more than 32 million Americans were enrolled in MA plans, and MA enrollment is expected to reach 50% of all Medicare enrollment in a few years.
MA beneficiaries interested in dental benefits have two primary options for getting coverage. Medicare Advantage plans can embed dental coverage as a mandatory supplemental benefit, which is provided at no additional cost to the beneficiary, or they can offer dental coverage as an optional supplemental benefit, which comes with an additional separate beneficiary premium. Some plans include both mandatory and optional supplemental benefits, which can be combined to enable even greater coverage. For example, if a plan includes some mandatory preventive dental coverage and additional coverage is desired, the beneficiary may also purchase optional supplemental dental coverage, if offered by their chosen MA plan. Dental services are among the most common mandatory supplemental benefit offerings5, and are also very common among optional supplemental benefit offerings – 97% of 2021 plans with OSBs include comprehensive dental in their OSB package6. Some MA plans are offered at a zero beneficiary premium while others require a premium. In 2023, of MA general enrollment plans (i.e., non-Special Needs Plans) that include a mandatory dental benefit, 75% of plans have a zero premium and 25% have non-zero premium.
Regardless of whether the dental coverage is offered as a mandatory or optional supplemental benefit, the coverage may include preventive services only or preventive and comprehensive services. Preventive dental services generally help maintain good oral health like routine oral exams, cleanings, and x-rays. Comprehensive dental benefits include specialty dental services, such as prosthodontics, restorative services, extractions, endodontics, and other procedures. Plans that cover only preventive services usually have lower premiums compared to plans that cover comprehensive services. Preventive dental services generally help maintain good oral health and usually have lower costs, like routine oral exams, cleanings, and x-rays. Plans can cover some or all of these procedure types.
This white paper reviews the dental benefits provided within MA general enrollment plans using 2023 Centers for Medicare and Medicaid Services (CMS) data and explores how the overall MA dental landscape is changing. We examine trends in MA dental plan enrollment, dental benefits offered, and the purchasing habits of beneficiaries. This paper does not include analysis of Special Needs Plans (SNPs.)
Medicare Advantage 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 2023 enrollment at over 18.9 million out of 19.7 million total enrollees in general enrollment plans. 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.
Figure 1: Enrollment in general enrollment MA plans with mandatory dental benefits
Trends in mandatory supplemental dental benefit limits and shared limits
Benefit limits define the maximum aggregate amount of claims, sometimes of a particular type, that a plan will cover within a given time period. For MA plans with mandatory dental coverage, benefit limits can 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. Shared limits can also apply to a broader set of supplemental benefits including not only dental but also other coverages such as vision, hearing, or other benefits that might be offered under a plan. 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.
A shared limit falls under the definition of a “combo benefit package,” which is discussed more in the Milliman article 2023 Combined Benefits in Medicare Advantage – Tracking benefit strategy and options.
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 fairly common for mandatory supplemental dental benefits that cover only preventive services. 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 into four categories:
- (1) Limits less than $1,000
- (2) Limits of $1,000 to $1,999
- (3) Limits of $2,000 or greater
- (4) No annual limit
Approximately 65% of enrollees in plans with mandatory dental benefits have a shared preventive/comprehensive dental limit. Shared limits are commonly $1,000 or greater. For non-shared limit plans, enrollees most commonly have an unlimited preventive dental benefit. This is often combined with a comprehensive dental benefit with a separate limit.
We see variation among mandatory supplemental dental benefit limits at the state level. For instance, Wyoming has 100% of its mandatory dental enrollees in a plan with a shared limit, while almost 80% of California enrollees have unlimited preventive coverage (regardless of existence of, or limits on, comprehensive dental). Some of these state-level differences in benefit limits may be indicative of broader differences in dental benefit richness by state, or on MA plans’ particular benefit strategies in a state.
Figure 2: Most common limit for MA plans with mandatory dental benefits by state enrollment†, ‡
† “No Preventive Limit” refers to the most common limit design being a no limit on preventive dental coverage specifically; it can be accompanied by no comprehensive coverage or can be paired with comprehensive coverage that is either limited or unlimited.
‡ Alaska is excluded as there is no MA dental plan data available in this state.
MA dental coverage is categorized into 11 service types:
- Preventive dental is comprised of oral exams, cleanings, x-rays, and fluoride.
- Comprehensive dental includes diagnostic services, endodontics, periodontics, extractions, oral surgery, prosthodontics, and restorations.
For each general enrollment MA plan offering mandatory supplemental dental, we counted the number of service categories covered as a general way to assess benefit richness, and we compared that against the benefit limits being offered. The following service category trends were observed in 2023 data as it relates to limits:
- Generally, plans with shared limits cover more dental service categories than non-shared limit plans.
- For plans specifying a limit on preventive services, the total number of dental service categories covered largely depends on the comprehensive limit.
- Plans with no limit on comprehensive coverage tend to cover fewer service categories than those with a comprehensive dental limit, helping to mitigate the risk of offering an unlimited benefit maximum.
- For plans with a limit on comprehensive coverage, the total number of service categories covered is similar to shared limit plans, but there remains a slight tendency to be lower.
- More than 17% of enrollees in mandatory dental plans with a specified preventive limit have no mandatory comprehensive dental coverage at all.
Figure 3: Number of dental service categories covered, by shared/non-shared benefit limit†, ‡
† Percentages may not add up to 100% due to rounding.
‡ The number of dental service categories is based on both preventive and comprehensive benefits as listed in the Methodology section
Preventive and comprehensive dental benefit trends
We also reviewed MA general enrollment plans offering various covered dental services more generally, without regard for associated benefit maximums. Consistent with 2022, nearly 100% of preventive dental plan enrollees have coverage for oral exams, cleanings, and x-rays. There continues to be substantial growth in enrollment in plans with a fluoride benefit, at 80% this year compared with 70% in 2022.
Coverage for plans with mandatory dental coverage including both preventive and comprehensive dental benefits continues to evolve as well. As shown in Figure 4, the covered dental services associated with preventive and comprehensive enrollment increased significantly from 2022 to 2023. There are a few possible drivers for this trend:
- This could be due to consumer decisions to enroll in plans with richer dental coverage, and/or richer dental offerings by MA carriers overall.
- As shared benefit limits become more popular, the trend to cover more comprehensive service categories may go hand in hand.
- Different MA carriers tend to have targeted strategies for broader MA plan design. As company market shares change due to an MA plan’s overall popularity, enrollment in the associated mandatory dental benefit will change accordingly.
Figure 4: Percentage of MA-with-preventive and comprehensive dental enrollment in plans with various covered services: 2021-2023
| Comprehensive Dental Service Category | Zero-Premium Plans | Nonzero-Premium Plans | ||||
|---|---|---|---|---|---|---|
| 2021 | 2022 | 2023 | 2021 | 2022 | 2023 | |
| Prosthodontics | 77% | 78% | 88% | 67% | 67% | 79% |
| Nonroutine Services | 54% | 62% | 80% | 56% | 56% | 67% |
| Diagnostic Services | 59% | 70% | 92% | 56% | 66% | 84% |
| Restorative Services | 95% | 93% | 93% | 89% | 84% | 87% |
| Endodontics | 58% | 63% | 86% | 59% | 61% | 80% |
| Periodontics | 71% | 78% | 94% | 72% | 80% | 90% |
| Extractions | 79% | 82% | 95% | 75% | 81% | 89% |
What’s next
The MA dental landscape continues to evolve rapidly. Enrollment in MA plans with mandatory dental benefits continues to increase, and the scope of covered services of mandatory dental plans is increasing as well. This evolution of benefits over time can be viewed through the lens of not only MA plans competing with one another but also MA plans competing for enrollees that could alternatively choose coverage under the traditional Medicare program. The more services a plan covers, the more attractive the plan 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 and induced utilization.
Finally, the ever-changing political environment affects the MA dental landscape. The recent legislative proposals7 to include dental coverage in Medicare Part B illustrate the dynamic environment of the health insurance setting. Legislation that would expand dental coverage beyond the 2023 Medicare Physician Fee Schedule Final Rule could alter MA enrollment and MA benefit offerings. Additionally, other changes that would alter MA financing could similarly modify the MA dental landscape.
Methodology
The Milliman Medicare Advantage Competitive Value Added Tool (Milliman MACVAT®) was used to compare 2023 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 plans with mandatory dental benefits include all plans with dental cost sharing and plans offering preventive benefits, as well as plans that offer both mandatory 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. The following benefits are considered to be preventive: x-ray, oral exam, prophylaxis, and fluoride. All of these benefits in aggregate are considered to be the possible dental service categories for the purposes of this study.
Comparisons to the 2019-2023 period were made based on values from our articles and analyses from prior years.8
Thank you to Danny Ramones, Sarah Holt, and Jack Olson for their contributions to this article.
1 CMS (May 2023). Medicare Monthly Enrollment. Retrieved September 18, 2023, 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 See https://www.congress.gov/amendment/117th-congress/senate-amendment/5211.
4 See https://www.federalregister.gov/documents/2022/11/18/2022-23873/medicare-and-medicaid-programs-cy-2023-payment-policies-under-the-physician-fee-schedule-and-other.
5 Prevalence of supplemental benefits in the general enrollment Medicare Advantage marketplace: 2019 to 2023 https://www.milliman.com/en/insight/prevalence-supplemental-benefits-general-enrollment-ma-marketplace-2023.
6 Trends in Medicare Advantage optional supplemental benefits https://www.milliman.com/en/insight/trends-in-medicare-advantage-optional-supplemental-benefits.
7 Op. cit. See https://www.congress.gov/amendment/117th-congress/senate-amendment/5211.
8
For the 2018 article, see Fontana, J.E. (November 2018). Dental coverage in Medicare Advantage plans: Nationwide market landscape. Available at: https://www.milliman.com/en/insight/dental-coverage-in-medicare-advantage-plans-nationwide-market-landscape.
For the 2019 article, see Fontana, J.E., and Bryniarski, J. (November 2019). Dental coverage in Medicare Advantage plans: Nationwide market landscape, 2019 update. Available at: https://www.milliman.com/en/insight/dental-coverage-in-medicare-advantage-plans-nationwide-market-landscape-2019-update.
For the 2020 article, see Fontana, J,E., Bryniarski, J. & Tang, C. (January 2021). Dental coverage in Medicare Advantage plans: Nationwide market landscape, 2020 update. Available at: https://www.milliman.com/en/insight/Dental-coverage-in-Medicare-Advantage-plans-Nationwide-market-landscape-2020-update.
For the 2021 article, see Fontana, J.E. and Tang, C. (September 2021). Dental coverage in Medicare Advantage plans: Nationwide market landscape, 2021 update. Available at: https://www.milliman.com/en/insight/Dental-Coverage-in-Medicare-Advantage-Plans-Nationwide-Market-Landscape-2021-Update.
For the 2022 article, see Fontana, J.E., Tang, C.. & Youngblood, G. (August 2022). Dental coverage in Medicare Advantage plans: Nationwide market landscape, 2022 update. Available at: https://www.milliman.com/en/insight/dental-coverage-in-medicare-advantage-plans-nationwide-market-landscape-2022-update.