What does your plan's dental really cover?
October 31, 2026
Listen Now
Subscribe
Ready to talk with an advisor?
The advisors at American Retirement Advisors have been having these conversations for over 25 years. A no-cost discovery session is the fastest way to find out where you actually stand.
Schedule a Discovery Session
Show Notes
Eddie and Betty's Conversation
Welcome to The American Retirement Advisor. I'm here with Eddie, as always, and today we are talking about something that affects a lot of people on Medicare Advantage, and plenty of them aren't sure what they actually have. We're talking about dental coverage, specifically how to figure out what your plan already includes, because it might be more than you think.
And the article we're working from today is by Ian Schaeffer, our COO, and it is part four of a five-part series called Dental Care in Retirement. So this is not a general overview. This is the practical, roll-up-your-sleeves piece. How do you actually read what your plan says?
Which, by the way, he opens with Halloween candy and a joke about teeth, so points for that.
As openings go, it earns its place.
Okay so here is the thing that got me right away. Ian Schaeffer writes that dental can be a valuable benefit that goes unused, because each plan's dental works a little differently. And I thought, wait, people have coverage and just... don't use it?
Yes, and the reason is they don't know exactly what they have. The benefit is there, but the plan documents are sitting in a drawer somewhere, or in an email they meant to read, and they never quite figured out what it covers.
So the first question is just, which papers do I even need to look at?
There are three. The Summary of Benefits, which is the short version, the overview. The Evidence of Coverage, which is the full rulebook. And the Annual Notice of Change, which is what shows up by September 30th and tells you what's different next year.
That's a real deadline.
And the Evidence of Coverage, plans have to send that by October 15th. So there's a rhythm to it every fall.
I bet so many also just can't find those documents. Like they got them, they put them somewhere safe...
So safe nobody can locate them.
Ha! Right. Ian Schaeffer actually addresses that directly. If you can't find them, you can call the client care team at 602-281-3898 and they'll help you track them down. Which I love that he just says, just call us.
Because that is genuinely the fastest path. Don't spend forty minutes hunting through old emails.
So let's say I found my Summary of Benefits. I've got it in front of me. Where do I even look?
You're looking for a section called Dental, or Dental Services, or Dental Coverage. Ian Schaeffer notes it's often right next to vision and hearing. Sometimes there's literally a little tooth icon next to it.
I am delighted by that.
Navigate by tooth.
Okay, and what am I looking at once I find it? Because this is where I think people's eyes glaze over.
So the article walks through a made-up example, and Ian Schaeffer is clear it's not a real plan, but it illustrates what the section can look like. There's typically a preventive category and a comprehensive category.
And here's where I had a question, because he specifically says not to get too attached to those labels.
That is a big point. Preventive and comprehensive mean different things in different plans. What you want to do is look past the label and find the actual list of services. Does it say oral exams? Cleanings? X-rays? Fillings? Crowns? Root canals? If the service isn't named, don't assume it's in.
So if I'm looking for, say, implants, I shouldn't just take it for granted that they're under comprehensive. I should find the word implants in the document.
Exactly. And this is the part of the article that genuinely surprised me. Ian Schaeffer points out that dentures and implants are the services most often limited or left out entirely. They are the big-ticket items and plans treat them very differently.
So someone could have what sounds like full dental coverage and still have zero coverage for implants?
Completely possible. Which is why you look for those words specifically. In the made-up example he gives, the comprehensive line does list dentures and implants, so in that fictional plan they're covered, but only up to the annual maximum.
What is that exactly?
The most the plan will pay for dental in a calendar year. Once you hit that ceiling, you're paying the rest yourself. In the made-up example in the article it's $2,500, combined for preventive and comprehensive.
So one implant could eat the whole year.
Right, and that's exactly why knowing the number matters. It's not just 'do I have dental.' It's 'how much dental do I have.'
That's such a different question. Okay, and there's also something in there about how some of it is built in and some is optional, right?
Yes. Some plans include dental for every member automatically. Others have a richer dental option that you can add for an extra monthly premium. So you may have basic coverage without realizing you could have upgraded.
Or maybe you're already paying extra for something you've never used.
That too. Either direction, worth knowing.
Let's talk about the types of dental coverage, because Ian Schaeffer lays out three different structures and I think most people don't know these are different things.
So the first one is a Dental PPO. That's probably what most of us picture. You can usually see any dentist, but in-network dentists cost less and they bill the plan directly. Out of network, you might pay upfront and submit for reimbursement.
That phrase always sounds so simple until you're actually doing the paperwork.
It's a process, yes. The second structure is a Dental HMO, which is more locked in. You have to use the plan's network. In exchange you get set copays, often zero dollars for cleanings and X-rays, but higher for bigger work like root canals or crowns.
And the third one is the one that caught my attention. The allowance.
Right. The plan just sets aside a dollar amount for you each year, and you draw from it for covered services until it's gone. Some allowances are network-only, some pay more in network. It's almost like a dental gift card with rules.
Oh that's a good way to put it. And you really do have to know how it works or you leave money on the table.
Whether unused dollars carry over is something the article doesn't cover, so if you have an allowance-style plan and you're wondering exactly how yours works, that's a great question for one of our advisors.
Good call. Don't guess on that one. Now there was a cost term I want to make sure people have down, because I hear these words and I still mix them up sometimes. Copay versus coinsurance.
The flat one's simple. You owe twenty dollars, or zero dollars, regardless of what the procedure costs. Coinsurance is a percentage. Ian Schaeffer uses twenty percent out of network as his example, which means if the dentist charges five hundred dollars, you're on the hook for a hundred.
So coinsurance can surprise you if the bill is bigger than you expected.
Which is exactly why you want to know which one your plan uses for each type of service, not just one number.
There's also something in Ian Schaeffer's piece that I thought was a little surprising, the way the dental benefit is actually structured inside the plan.
It's one of the more practically useful details. It's part of the Medicare Advantage plan, so your plan is responsible for it. But many plans hire a separate company to actually run it. So your care might come with its own network, its own phone number, its own website.
Wait, so it's like a plan within a plan?
Sort of, yes. The umbrella is your Medicare Advantage plan. But the dental piece has its own plumbing underneath it.
So if I call the main number for my health plan asking about it, they might just route me somewhere else entirely.
Possibly. And knowing that in advance saves you a frustrating phone call. Or three.
Okay let's talk about limits for a second, because Ian Schaeffer has a list of things to specifically look for in your documents, and a couple of them really jumped out.
The frequency limits are the ones people miss most. Your plan might cover two cleanings a year. Fine. But it might cover one set of X-rays every few years, not every year. If you go in assuming they're covered and they're not due yet, you're getting a bill.
That's such a simple thing to check ahead of time.
Five minutes of reading versus an unexpected dental bill. Not a hard trade.
And cosmetic stuff, he's pretty direct about that.
Whitening and similar procedures are generally not covered. Don't go looking for that one.
Ha! Good to know. Okay so let me try to put this together, because there's actually a pretty clear sequence here for someone listening who wants to go do this today.
Find your Summary of Benefits. If you can't find it, call 602-281-3898. Open it up, go to the dental section, navigate by tooth if necessary...
That's my new life motto.
And then look past the category labels. Find the actual services listed. Find your annual maximum. Figure out if it's a PPO, an HMO, or an allowance. Check the frequency limits. And if you see something that doesn't make sense, especially around dentures or implants, go to the Evidence of Coverage for the full detail.
And if it raises more questions than it answers?
That is what advisors are for. Ian Schaeffer even mentions that if you'd like someone to read your plan's dental section with you, you can call the team. That is genuinely an option.
Which is not a small thing. Having a human being help you read a document that was not written for human beings.
Plan documents aren't exactly written for easy reading. Someone helping you decode it is not a luxury.
Also, Ian Schaeffer mentions there is a full guide called Dental Care in Retirement, and the walk-through with the made-up plan explained line by line is in there. So if reading through it yourself sounds useful, that resource exists.
And this episode is part four of five in that series, so there is more coming.
The last part, part five, is apparently about where you can actually get care and whether you can see a dentist who doesn't take Medicare. Which, that is a question I hear a lot.
Spoiler: the answer is not a simple yes or no, which means it deserves its own piece.
One more thing I want to flag before we close, because I think it's the real takeaway from this whole piece. Ian Schaeffer's core point is that dental coverage in Medicare Advantage can be genuinely valuable, but it goes unused because people don't know what they have.
You're not going to use a benefit you didn't know existed. And the documents that explain it are sitting there, mailed to you by the deadlines the law requires, waiting for you to open them.
Coffee, kitchen table, Summary of Benefits. Ian Schaeffer actually puts it that way in the article.
He does. It really is that approachable.
Okay. So here's what I want you to do if you're listening. Go find that Summary of Benefits today. Even if you've had your plan for years and think you know what's in it, go look at the dental section with fresh eyes. Check the services listed, the annual maximum, the frequency limits, and whether dentures or implants are specifically named.
And if you want help, you do not have to do it alone. That's 602-281-3898. Real people, ready to sit down with you on this.
Because your coverage is only as good as what you actually use. Thanks so much for spending time with us today. We mean it when we say this stuff matters, and we're glad you're here.