Overview of Medicare and Dentistry

Comprehensive resources for dentists who want to treat Medicare patients.

Medicare is a health insurance program administered by the Centers for Medicare & Medicaid Services (CMS) under the Health and Human Services Department of the U.S. Government. Medicare covers people age 65 or older, people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).

Medicare is organized into many “Parts”. The following are the “Parts” of Medicare most relevant to dentists.

Part A — Covers inpatient hospital stays, skilled nursing facility stays, some home health visits, and hospice care. [Also called “Traditional Medicare” and administered by CMS through contractors]

Part B — Covers physician visits, outpatient services, preventative services, and some home health visits. [Also called “Traditional Medicare” and administered by CMS through contractors]

Part C — Refers to the Medicare Advantage program through which beneficiaries can enroll in a private health plan, such as a health maintenance organization (HMO) or preferred provider organization (PPO) and receive all Medicare-covered Part A and Part B benefits and possibly part D benefits. [Called Medicare Advantage and administered by insurance companies]

Part D — Covers outpatient prescription drugs through private plans that contract with Medicare, including both stand-alone prescription drug plans (PDPs) and Medicare Advantage drug plans (MA-PD plans); enrollment in Part D plans is voluntary.

Medicare does not cover most routine dental services, but this has recently changed. Read the Basics of Medicare (PDF) to review these changes.

Medicare information for providers

If Medicare does not cover most routine dental services, why am I seeing patients in my office with “Medicare Advantage plans” or “Medicare Part C” or “supplemental dental benefits with Medicare Advantage plans”? What is this program?

Some Medicare Advantage Plans may include “supplemental” dental benefits above and beyond what is covered by Part A & Part B of Medicare. These additional dental benefits are not offered by traditional Medicare. Many dental patients seen in outpatient dental offices today may have these supplemental dental benefits through Medicare Advantage plans or other private coverage. These plans would typically cover “cleanings and X rays” although we are seeing more plans covering more dental procedures. Most importantly you DO NOT need to be enrolled or formally opted-out of Medicare to file claims for dental benefits that are supplemental dental benefits covered by Medicare Advantage.

Understanding Supplemental vs. Covered Benefits with Medicare Advantage (PDF)

How can I treat Medicare patients for covered services?

Medicare does not provide coverage for routine dental services such as cleanings or x-rays. However, CMS recently began reimbursement for dental procedures that are inextricably linked to, and substantially related and integral to, the clinical success of otherwise covered medical procedures. Below is a list of procedures Medicare may cover:

Dental or oral exams as part of a comprehensive workup prior to the Medicare-covered services listed below, and medically necessary diagnostic and treatment services to eliminate an oral or dental infection prior to or contemporaneously with these Medicare-covered services:

Organ transplant, including hematopoietic stem cell and bone marrow transplant
Cardiac valve replacement
Valvuloplasty procedures; and
Chemotherapy, chimeric antigen receptor (CAR) T-cell therapy, and the administration of high-dose bone-modifying agents (antiresorptive therapy) when used in the treatment of cancer

Dental or oral exams as part of a comprehensive workup prior to medically necessary diagnostic and treatment services to eliminate an oral or dental infection prior to or contemporaneously with, and medically necessary diagnostic and treatment services to address dental or oral complications after, Medicare-covered treatment of head and neck cancer using radiation, chemotherapy, surgery, or any combination of these.
Dental or oral examination in the inpatient/outpatient setting or medically necessary diagnostic and treatment services to eliminate an oral or dental infection prior to, or contemporaneously with, Medicare-covered dialysis services for the treatment of end-stage renal disease.
Dental ridge reconstruction done as a result of and at the same time as surgery to remove a tumor.
Services to stabilize or immobilize teeth related to reducing a jaw fracture.
Dental splints, only when used as part of covered treatment of a covered medical condition such as dislocated jaw joints.

Dentists who provide Part B covered items or services to patients who are Medicare beneficiaries have obligations under the Medicare program, even if the dentist is not enrolled as a Medicare provider. NOTE: This guidance DOES NOT apply to supplemental benefits provided by Medicare Advantage. Dentists DO NOT need to be enrolled or formally opted-out of Medicare to file claims for dental benefits that are supplemental benefits provided by Medicare Advantage.

In order to treat Medicare beneficiaries for covered services, dentists have the following options:

Enroll as a participating provider
Enroll as a non-participating provider
Formally opt-out.

Learn more by reading Options for Treating Medicare Beneficiaries for Covered Procedures (PDF).

How do I become a participating provider?

Being a participating provider means that you are enrolling in Medicare and will accept the Medicare fee for covered services. You will be included in the Medicare Provider Directory, and your payments are processed faster than payments for non-participating providers.

To learn more about enrolling as a participating provider, and the responsibilities it entails, read Participating Provider Guide to Enrollment and Responsibilities in Medicare (PDF).

How do I become a non-participating provider?

Being a non-participating provider means that you are enrolling in Medicare, and you will see patients with Medicare. However, you will not be included in the provider directories Medicare provides for its recipients. With this option, you will either accept assignment case-by-case or directly balance bill your patient.

To learn more about enrolling as a non-participating provider, and the responsibilities it entails, read Non-Participating Provider Guide to Enrollment and Responsibilities in Medicare (PDF).

How do I opt out of Medicare?

If you wish to provide covered services to beneficiaries but do not want to bill Medicare and instead have your Medicare patients pay you out of pocket, you need to opt out of Medicare.

Opting-out of Medicare allows you to enter into private contracts with patients who are on Medicare. This requires that you submit an affidavit to the Medicare Administrative Contractors (MACs)

To learn more about registering as an opt-out provider for Medicare, and the responsibilities it entails, read Registration and Responsibilities with Medicare as an Opt-Out Provider (PDF).

Will I be audited as a provider who treats Medicare beneficiaries?

As a dentist, being audited is stressful and can cause anxiety related to the reimbursement of your hard work. However, routine or program-specific audits from CMS for Medicare are rare.

To learn more about the auditing process and audit frequency with Medicare, you can read Audits or Program Integrity with Medicare (PDF).

What does reimbursement look like if I treat Medicare beneficiaries for covered services?

There are different amounts or mechanisms for reimbursement if you are a participating, non-participating, or opted-out provider. While the Medicare fee-schedule may change on an annual basis, it is important to know your possible reimbursement based on the specific provider enrollment or registration selection you have made.

To help understand your possible Medicare reimbursement, you can read Possible Reimbursement for Participating, Non-Participating, and Opt-Out Providers (PDF).

Understanding how to file claims for Medicare

What is required for a claim submission?

Dental claims for Medicare can be filed using ADA’s 837D Electronic Dental Claim Form (PDF).

Beginning July 1, 2025, all dental claims submitted to Medicare must include applicable ICD-10 codes on in Box 34A of the ADA Dental Claim Form and the appropriate administrative modifier next to each procedure code. Here are instructions for to utilize the Medicare administrative modifiers (PDF).

Before submitting a claim, an exchange of information or care coordination must occur with a physician in order for Medicare to pay for dental services that are inextricably-linked to the clinical success of a Medicare procedure. Documentation of this requirement can be done through ADA’s Medicare Referral Form (PDF) and should be saved in the patient’s record.

Do not attach radiographs, periodontal charting, or proof of exchange of information to your claim. Medicare Administrative Contractors or local Medicare claims administrators will reach out to you in writing if they require this information.

Where do I submit dental claims for Medicare?

Beginning July 1, 2024, CMS can now accept, process and pay dental claims under traditional Medicare electronically. Your CMS Medicare Administrative Contractor should be able to receive 837D electronic dental claims.

837P or the ADA Paper Claim Form can also be mailed to your local Medicare Administrative Contractor. Your Medicare Administrative Contractor (PDF) is listed by state on CMS’s website.

For supplemental dental benefits with Medicare Advantage, claims should only be submitted to through the Medicare Advantage plan sponsor’s claims submission process.

What is the ADA Medicare Referral Form? Is it required for claims submission?

The ADA Medicare Referral Form (PDF) is a template provided by the ADA to gather necessary information to prove that an exchange of information or care coordination has occurred with a physician. This helps provide the basis for payment of dental services that are inextricably-linked to the clinical success of a Medicare procedure. An exchange or care coordination must occur before services are rendered and a claim is submitted.

The ADA Medicare Referral Form (PDF) or any proof of information exchange/care coordination is not required as an attachment for claims submission. However, the referral form or any documentation related to information exchange/care coordination between healthcare providers should be saved in the patient’s file or record in the case that a claims administrator seeks further information in the future.

Disclaimer

This resource was current at the time it was published or uploaded onto ADA.org. Medicare laws and policy can and do occasionally change, so it is recommended to remain aware of changes. This resource was prepared as an informational tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of this information, the ultimate responsibility for remaining in compliance lies with the provider of items and services. The American Dental Association makes no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this resource, which is a general summary that explains certain aspects of the Medicare program, but it is not a legal document. The official Medicare program provisions are contained in the relevant laws, regulations, and rulings.