Case File #004: Medicare, Medicare Advantage & Dual-Eligible Patients
Why Dental Providers Must Understand These Plans Now More Than Ever
As dental providers, consultants, and advocates, we are entering a new era of care.
The senior population is rapidly increasing. Patients are living longer. They are medically complex. And more of them are enrolled in Medicare, Medicare Advantage, and dual Medicaid + Medicare plans than ever before.
Yet many dental offices still:
Refer medically complex seniors out immediately
Request medical clearance and feel overwhelmed
Assume “Medicare doesn’t cover dental”
Opt out entirely without understanding the consequences
This is no longer sustainable.
If we want to serve seniors properly — clinically and financially — we must understand how these plans work and how to integrate them into dental workflows.
Understanding Original Medicare (Parts A & B)
Original Medicare includes:
Part A – Hospital coverage
Part B – Outpatient/medical services
What Medicare DOES NOT Cover (Typically)
Routine dental:
Cleanings
Fillings
Crowns
Dentures
What Medicare CAN Cover
Dental services that are:
Medically necessary
Integral to the treatment of a covered medical condition
Examples:
Extractions prior to radiation therapy
Dental clearance before organ transplant
Oral surgery tied to trauma
Treatment related to systemic infection
Certain sleep apnea diagnostics and services
The key phrase is:
“Inextricably linked to a covered medical service.”
When dental conditions affect systemic health — and they often do — coverage becomes possible.
Participating vs Non-Participating vs Opted-Out Providers
This is where many dental providers unknowingly limit patient access.
1️⃣ Participating (PAR) Provider
Accepts Medicare assignment
Agrees to Medicare’s fee schedule
Medicare pays provider directly
2️⃣ Non-Participating (Non-PAR) Provider
Does NOT accept assignment routinely
May collect from patient upfront
Patient can submit claim and receive reimbursement
Limited up-to 115% of Medicare allowable
3️⃣ Opted-Out Provider
Signs private contract
Medicare will not reimburse patient
Patient pays fully out-of-pocket
No claim submission allowed
Why At Minimum You Should Consider Non-PAR
When a provider opts out:
The patient cannot bill Medicare
There is no reimbursement pathway
Seniors are less likely to move forward with treatment
Access to care is reduced
When you remain at least Non-Participating, you preserve:
The patient’s right to reimbursement
Financial flexibility
Trust
Access
For medically complex seniors, this can be the difference between treatment acceptance and delay.
Medicare Advantage (Part C): The Game Changer
Medicare Advantage plans are private plans that replace Original Medicare.
They:
Must cover everything Original Medicare covers
Often include additional benefits
Frequently include limited dental benefits
Operate through networks (HMO, PPO)
Important Differences:
Coverage varies by carrier and region
Some include preventive dental
Some include comprehensive dental
Some require prior authorization
Network status matters significantly
Providers must:
Verify plan type
Confirm network participation
Understand authorization requirements
Determine if medical necessity applies
Dual-Eligible Patients (Medicare + Medicaid)
These patients often:
Have the highest medical complexity
Have limited financial resources
Qualify for additional support
Depending on the state:
Medicaid may provide dental benefits
Medicare may cover medical-linked dental
Coordination of benefits becomes critical
Dual patients are where advocacy coordination becomes invaluable.
When a Patient Has Both Medicare and Medicaid (Dual Eligible)
If a patient is enrolled in:
Medicare
Medicaid
Then:
🥇 Medicare Pays First
🥈 Medicaid Pays Second (if applicable)
Medicaid acts as the “payer of last resort.”
That means Medicaid may:
Cover Medicare deductibles
Cover Medicare coinsurance
Cover copays
Cover services Medicare doesn’t (depending on state)
Example (Medical Scenario)
Patient needs medically necessary oral surgery tied to systemic infection.
Bill Medicare Part B first.
Medicare processes claim.
Remaining balance automatically or manually crosses to Medicaid.
Medicaid may pay remaining allowable balance (state dependent).
Important Exception: Medicare Advantage (Part C)
If the patient has a Medicare Advantage plan:
That plan replaces Original Medicare.
So in that case:
The Medicare Advantage plan is primary.
Medicaid is still secondary.
Dental-Specific Nuance (Where It Gets Interesting)
For dental services:
Scenario 1 – Service is medically necessary
Medicare (or Medicare Advantage) may pay first.
Medicaid may pick up remainder.
Scenario 2 – Routine dental (Original Medicare)
Medicare pays nothing.
Medicaid may be primary for dental (state dependent).
Scenario 3 – Medicare Advantage plan with dental rider
Medicare Advantage dental benefit is primary.
Medicaid may coordinate secondary if allowed.
This is why verification is critical every time.
When Medicaid Can Be Primary
Medicaid may be primary in cases where:
Service is NOT covered by Medicare at all
Patient has QMB, SLMB, or full dual status
Dental benefit is strictly under state Medicaid
But even then: Medicare must usually deny first before Medicaid processes — unless it is clearly a non-Medicare-covered benefit category.
Key Rule to Remember
If a patient has both:
👉 Medicare always processes first for Medicare-covered services.
👉 Medicaid is payer of last resort.
The Mouth-Body Connection
We cannot discuss Medicare without discussing systemic health.
Seniors frequently present with:
Diabetes
Cardiovascular disease
Kidney disease
Osteoporosis
Autoimmune disorders
Sleep apnea
Cancer history
Oral infections can:
Elevate A1C
Increase cardiac inflammation
Complicate joint replacements
Delay cancer treatments
Worsen pneumonia risk
When dental conditions are tied to systemic health, documentation becomes everything.
And this is where integration matters.
Why Advocacy Is Critical for Senior Patients
How many times have you:
Requested medical clearance
Referred to PCP
Sent forms back and forth
Waited weeks
Felt stuck between providers
Had a patient overwhelmed and confused
That moment — that overwhelm — is the first clue.
It may be time to involve an advocacy organization.
Organizations like the National Dental Advocacy Program (NDAP) help:
Coordinate care between medical and dental providers
Review Explanation of Benefits (EOBs)
Identify Medicare-linked coverage opportunities
Assist dual-eligible coordination
Help patients utilize advocacy benefits through qualifying Medicare plans
In certain cases, advocacy services themselves may be eligible for coverage under specific plan structures when qualifying criteria are met.
This reduces:
Administrative burden on dental offices
Patient confusion
Treatment abandonment
Why Using the Medicare Medical Plan First Can Be Powerful
Unlike traditional dental insurance:
Medical plans do NOT have a low annual maximum (like $1,000–$2,000 typical dental caps)
Medical coverage is diagnosis-driven
There is no annual dental-style cap when medically necessary
This means:
Medical plan can cover:
Medically necessary procedures
Surgical services
Diagnostics tied to systemic condition
Dental insurance can then remain available for:
Preventive services
Basic restorative
Services not tied to medical necessity
This is full-circle financial coordination.
Why This Matters More Than Ever
The senior population is growing faster than any other age demographic.
Dental providers who:
Learn Medicare integration
Understand Advantage plan variation
Avoid unnecessary opt-out status
Coordinate with advocacy services
Document systemic linkage properly
…will be positioned to serve this population effectively.
Those who don’t may unintentionally reduce access to care.
Key Takeaways for Dental Providers
✔ Review your Medicare enrollment status
✔ Consider remaining at least Non-Participating
✔ Understand local Medicare Advantage plan networks
✔ Verify benefits thoroughly
✔ Document systemic connections
✔ Build relationships with advocacy organizations like NDAP
✔ Train your team on coordination workflows
Helpful Resources
Official Medicare Information: https://www.medicare.gov
Medicare Provider Enrollment (PECOS): https://pecos.cms.hhs.gov
Medicaid State Information: https://www.medicaid.gov
National Dental Advocacy Program: nationaldentaladvocacy.org
Need help with credentialing & medical billing? elitedentalsystems.com
Final Thoughts
Seniors are not “difficult patients.” They are medically complex patients navigating layered systems.
When dental providers understand Medicare structures and coordinate appropriately:
Treatment acceptance increases
Financial barriers decrease
Systemic health outcomes improve
Administrative overwhelm reduces
There are options.
And as the population ages, integration between medical and dental care is no longer optional — it is essential.
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