Why You May Receive a Bill for Dental, Vision, Hearing, and Chiropractic Services with a Medicare Advantage Plan
One of the most attractive features of many Medicare Advantage Prescription Drug (MAPD) plans is the additional benefits they may provide beyond Original Medicare. Depending on the plan, these benefits can include routine dental care, eye exams and eyewear, hearing aids, and additional health and wellness services.
These benefits can be extremely valuable. However, they can also create confusion when a Medicare beneficiary receives a bill after being told that a service was “covered.”
How can something be covered by your Medicare Advantage plan and still leave you with a bill?
The answer often comes down to an important distinction: having a benefit does not necessarily mean that every provider, every service, or the provider's entire charge is covered.
These Benefits Are Often Supplemental Benefits
Original Medicare generally does not cover routine dental care, routine eye exams for eyeglasses, hearing aids, or exams for fitting hearing aids. Medicare Advantage plans can add benefits that Original Medicare does not normally provide.
That means your dental, vision, or hearing benefit may operate differently from the medical portion of your Medicare Advantage plan.
For example, your plan might provide a certain dollar allowance for dental services or eyewear. It might use a separate dental or vision provider network. It might limit how frequently a service is covered. It may also establish a maximum amount that it will pay toward a particular service.
Understanding those rules is important because the word “covered” does not necessarily mean “covered at 100%.”
The Provider's Charge and the Plan's Allowance May Be Different
Consider a simple example.
Suppose a dental office charges $1,200 for a procedure.
Your Medicare Advantage dental benefit may recognize only $800 of that amount under its contracted fee schedule or benefit rules. Depending on the plan, network status, and type of benefit, you could potentially be responsible for some or all of the difference in addition to your normal copayment or coinsurance.
This is one reason we encourage Medicare beneficiaries to ask more than:
“Do you take my insurance?”
A better question is:
“Are you currently contracted as an in-network provider with my specific Medicare Advantage plan, and will you accept the plan's contracted amount for this service?”
Those are very different questions.
Dental Services
Dental is probably one of the most common areas where confusion occurs.
Original Medicare does not cover most routine dental services, including cleanings, fillings, dentures, and many extractions. Medicare Advantage plans may provide these services through supplemental dental benefits.
However, the dental benefit may have:
A specific provider network
Annual benefit limits
Frequency limitations
Copayments or coinsurance
Different coverage for preventive and comprehensive dental services
Prior authorization requirements
Different rules for in-network and out-of-network providers
A dentist may also accept certain insurance products from a company without participating in the specific Medicare Advantage dental network associated with your plan.
This can result in the patient owing considerably more than expected.
Vision Services
Routine vision benefits can work similarly.
Original Medicare generally doesn't cover routine eye exams for eyeglasses or contact lenses. A Medicare Advantage plan may provide an annual eye examination and an allowance toward frames, lenses, or contacts.
The important word is often allowance.
If your plan provides an eyewear allowance and you select glasses that cost more than that allowance, you may be responsible for the difference. There may also be restrictions involving participating optical providers, specific frame selections, lens upgrades, coatings, progressive lenses, or other options.
For example, having a $300 eyewear benefit doesn't necessarily mean every pair of $300 glasses will cost you nothing. The actual amount you owe depends upon the plan's benefit structure and the provider's participation.
Hearing Benefits
Hearing benefits can be even more complicated.
Original Medicare doesn't cover hearing aids or examinations specifically for fitting hearing aids, although Medicare Part B does cover certain diagnostic hearing and balance examinations when Medicare's requirements are met.
Many Medicare Advantage plans therefore offer hearing benefits as an additional benefit.
The plan may require members to use a particular hearing network or approved hearing-aid supplier. It may cover certain models or provide an allowance toward hearing aids.
If a beneficiary goes to a provider outside that arrangement or chooses equipment beyond what the benefit covers, the member may have additional out-of-pocket expenses.
This is why it's particularly important to verify hearing benefits before ordering the hearing aids, not after.
Chiropractic Care Is a Little Different
Chiropractic services require an additional distinction because some chiropractic care is covered under Medicare Part B.
Medicare coverage for chiropractic treatment is limited. A chiropractor may provide other examinations, therapies, treatments, or services that aren't covered under the Medicare benefit.
A Medicare Advantage member might therefore receive both Medicare-covered and non-Medicare-covered services during treatment.
For example, the plan may cover the qualifying chiropractic manipulation while another service performed during the same appointment isn't covered under the Medicare benefit or the member's plan.
That can result in an additional bill.
The important question isn't simply whether the chiropractor “accepts Medicare.” Members should determine whether the specific services being performed are covered by their Medicare Advantage plan and what their responsibility will be.
In-Network vs. Out-of-Network Matters
Provider networks are another major source of unexpected bills.
Medicare advises Medicare Advantage members to determine whether their plan has a network and whether their provider participates in it. Some Medicare Advantage plans allow members to receive services outside the network, but the member will generally pay a larger share of the cost.
For supplemental dental, vision, and hearing benefits, the network may also be different from the network used for the medical portion of the Medicare Advantage plan.
A doctor being in your medical network does not automatically mean every service performed by that provider is covered under every supplemental benefit.
“They Said They Take My Insurance”
This is one of the most common misunderstandings we see.
A provider saying, “Yes, we take that insurance,” doesn't necessarily mean:
“We are contracted with your exact plan, this exact service is covered, we have verified your remaining benefit, and you will have no additional financial responsibility.”
It may simply mean the office is willing to submit a claim to that insurance company.
Before receiving expensive dental, vision, hearing, or chiropractic services, ask the provider to verify your specific plan and specific benefit.
For more expensive procedures, consider requesting a written treatment plan or cost estimate showing the expected insurance payment and your estimated responsibility.
Your Medicare Advantage Plan Is Still Providing Valuable Coverage
None of this means that Medicare Advantage supplemental benefits aren't worthwhile.
Dental, vision, hearing, and other supplemental benefits can potentially save beneficiaries hundreds or even thousands of dollars.
The key is understanding how the benefit works before receiving the service.
Remember these four questions:
Is this specific service covered by my plan?
Is this specific provider in my plan's network for this benefit?
How much will the plan pay or allow for the service?
What will I be responsible for paying?
Getting answers to those questions beforehand can prevent an unpleasant surprise after the appointment.
HealthWise Insurance Group: Helping You Understand Your Benefits
Medicare Advantage plans can provide benefits that Original Medicare doesn't offer, but every plan has its own rules, networks, limitations, and cost-sharing requirements.
At HealthWise Insurance Group, we believe Medicare beneficiaries should understand not only what benefits they have, but also how to use those benefits correctly.
Before scheduling significant dental work, purchasing hearing aids or eyewear, or receiving services you're unsure about, review your Evidence of Coverage and contact your Medicare Advantage plan or the benefit administrator listed on your insurance card.
A few questions before receiving the service can make a big difference in what you owe afterward.
HealthWise Insurance Group
Your Path to Better Coverage
This article is for general educational purposes and is not a guarantee of coverage or payment. Medicare Advantage benefits, provider networks, allowances, copayments, coinsurance, prior authorization requirements, and coverage limitations vary by plan and service area. Members should verify coverage directly with their Medicare Advantage plan before receiving services.