Dental, Hearing, and Vision Costs and Coverage Among Medicare Beneficiaries in Traditional Medicare and Medicare Advantage – Kaiser Family Foundation
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Filling the need for trusted information on national health issues
Meredith Freed , Juliette Cubanski Follow @jcubanski on Twitter , Nolan Sroczynski , Nancy Ochieng , and Tricia Neuman Follow @tricia_neuman on Twitter
Published: Sep 21, 2021
Notably missing among covered benefits for older adults and people with long-term disabilities who have Medicare coverage are dental, hearing, and vision services, except under limited circumstances. Results from a recent KFF poll indicate that 90% of the public says expanding Medicare to include dental, hearing, vision is a “top” or “important” priority for Congress. Policymakers are proposing to add coverage for these services as part of budget reconciliation legislation, and a provision to add these benefits to traditional Medicare was included in the version of H.R. 3 that passed the House of Representatives in the 116th Congress.
The Biden Administration endorsed improving access to these benefits for Medicare beneficiaries in the FY2022 budget. Addressing these gaps in Medicare benefits is grounded in a substantial body of research showing that untreated dental, vision, and hearing problems can have negative physical and mental health consequences. Adding these benefits to Medicare would increase federal spending, and they will be competing against other priorities in the budget reconciliation debate.
Dental, hearing, and vision services are typically offered by Medicare Advantage plans, but the extent of that coverage and the value of these benefits varies. Some beneficiaries in traditional Medicare may have private coverage or coverage through Medicaid for these services, but many do not. As a result, beneficiaries who need dental, vision, or hearing care may forego getting the care or treatment they need or face out-of-pocket costs that can run into the hundreds and even thousands of dollars for expensive dental treatment, hearing aids, or corrective eyewear.
In a separate KFF analysis, we analyzed dental coverage, use, and out-of-pocket spending among Medicare beneficiaries and provided an in-depth look at coverage of dental services in Medicare Advantage plans. In this brief, we build on our prior work by analyzing hearing and vision use, out-of-pocket spending and cost-related barriers to care among beneficiaries in traditional Medicare and Medicare Advantage, incorporating top-level findings from our analysis of dental services to provide a comprehensive profile of dental, hearing, and vision benefits in Medicare Advantage plans. The analysis of spending, use, and cost-related barriers to care is based on self-reported data by beneficiaries in both traditional Medicare and Medicare Advantage from the 2018 and 2019 Medicare Current Beneficiary Survey, and analysis of Medicare Advantage plan benefits is based on the 2021 Medicare Advantage Enrollment and Benefit files for data on individual Medicare Advantage plans (see Methods for details).
Most Medicare Advantage plans provide some coverage of routine dental, vision, and hearing benefits, unlike traditional Medicare. Plans can use rebate dollars – a portion of the difference between their bid to cover Medicare Parts A and B services and the benchmark – to provide supplemental benefits, such as dental, hearing, and vision benefits. Plans also use rebate dollars to lower enrollee cost sharing and reduce premiums, and for administrative expenses and profit. According to MedPAC, about 21% of rebate dollars in 2021, or $29 per enrollee per month, were used to cover supplemental benefits not covered by traditional Medicare.
In 2021, 94% of Medicare Advantage enrollees or 16.6 million people, are in a plan that offers access to some dental coverage. Virtually all Medicare Advantage enrollees have access to preventive dental benefits and most have access to more extensive dental benefits, according to a prior KFF analysis. Most enrollees with access to more extensive benefits are typically subject to annual dollar limits on coverage, which averages $1,300.
Among Medicare Advantage enrollees with access to dental coverage:
In 2021, 97% of Medicare Advantage enrollees or 17.1 million people, have access to a hearing benefit. Among these enrollees, virtually all (95%) are in plans that provide access to both hearing exams and hearing aids (either outer ear, inner ear, or over the ear). Hearing aid coverage is typically subject to annual dollar limits on coverage or frequency limits, with an average dollar limit of $960 and the most common frequency limit of one set of aids per year.
Among Medicare Advantage enrollees who have access to hearing coverage:
In 2021, 99% of Medicare Advantage enrollees or 17.5 million people, have access to some vision coverage. Among these enrollees, virtually all (93%) are in plans that provide access to both eye exams and eyewear (contacts and/or eyeglasses). Most enrollees do not pay cost sharing for eyewear, but nearly all vision coverage is subject to annual dollar limits on coverage, averaging $160.
Among Medicare Advantage enrollees who have access to vision coverage:
In conducting this analysis of Medicare Advantage benefits, we found that plans do not use standard language when defining their benefits and include varying levels of detail, making it challenging for consumers or researchers to compare the scope of covered benefits across plans. Our analyses take into account benefits, as described in the Medicare Advantage Plan Benefit files, which includes annual limits on plan benefits, frequency limits on obtaining covered services, and cost-sharing requirements, but does not take into account plan restrictions that may affect access, such as type or model of hearing aids covered, type of eyeglasses or lenses covered (e.g. bifocals, graduated lenses), the extent to which prior authorization rules are imposed, or network restrictions on suppliers.
While some Medicare beneficiaries have insurance that helps cover some dental, hearing, and vision expenses (such as Medicare Advantage plans), the scope of that coverage is often limited, leading many on Medicare to pay out-of-pocket or forego the help they need due to costs. Traditional Medicare generally does not cover routine dental, hearing, or vision services, and coverage for these services under Medicare Advantage varies.
Based on self-reported data, use of dental, hearing, and vision services ranges widely among Medicare beneficiaries overall, with just over half of all beneficiaries reporting that they used dental services in 2018, roughly one-third using vision services, and fewer than one in 10 using hearing services. While it is not the case that use of these services is indicated or required annually for everyone on Medicare, our analysis shows that vision and hearing difficulty is not uncommon among Medicare beneficiaries and cost prevented many beneficiaries in both traditional Medicare and Medicare Advantage plans who sought dental, hearing, or vision care from getting it in 2019.
Medicare Advantage plans are the leading source of dental coverage for people with Medicare, and a main source of coverage for hearing and vision. According to our analysis of plan benefit data, most Medicare Advantage plans provide access to these benefits; only 6% of enrollees are in plans that do not cover dental benefits, 3% are in plans that do not cover hearing exams and/or aids, and 1% are in plans that do not cover eye exams/glasses. While the scope of coverage varies across Medicare Advantage plans, there are some common features within each category. Nearly all Medicare Advantage enrollees with access to dental coverage have preventive benefits, and most have access to more extensive dental benefits, though cost sharing for more extensive services is typically 50% for in-network care, and subject to an annual cap on plan payments. Almost all Medicare Advantage enrollees have access to both hearing exams and hearing aid coverage; hearing aid coverage is subject to either a maximum annual dollar cap and/or frequency limits on how often plans cover the service. Virtually all Medicare Advantage enrollees have access to both vision exams and eyewear coverage, and this coverage is typically subject to maximum annual limits, averaging about $160 per year.
Policymakers are considering adding dental, hearing, and vision benefits to Medicare as part of the budget reconciliation bill – a change that would be the largest expansion of Medicare benefits since the Part D drug benefit was launched in 2006. These program improvements would lead to higher federal spending of $358 billion over 10 years (2020-2029), including $238 billion for dental and oral health care, $89 billion for hearing care, and $30.1 billion for vision care, according to a Congressional Budget Office estimate of the version of H.R.3 passed by the House in 2019. Additionally, in a July 2021 executive order, President Biden called for the Secretary of Health and Human Services to issue a proposed rule that would allow hearing aids to be sold over-the-counter, as allowed under the FDA Reauthorization Act of 2017 – a move that could help make hearing aids more affordable for people with hearing difficulties who may be foregoing purchasing them due to cost. Expanding Medicare coverage for dental, hearing, and vision services and making lower-cost hearing aids available would address significant gaps in coverage and could alleviate cost concerns related to these services for people on Medicare.
This work was supported in part by the AARP Public Policy Institute. We value our funders. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities.
Respondents were coded as having hearing difficulty if they reported having “a little trouble hearing”, “a lot of trouble hearing”, or deafness/serious difficulty hearing.
Respondents were coded as having vision difficulty if they reported having “a little trouble seeing”, “a lot of trouble seeing”, blindness, or blindness/difficulty seeing even with glasses. This analysis was weighted to represent the ever-enrolled population, using the weight ‘EEYRSWGT’.
For the analysis of out-of-pocket spending on dental, hearing, and vision services, we relied on the 2018 MCBS Cost Supplement data, which includes survey-reported events for these services since they are generally not Medicare-covered services and therefore there are no Medicare claims. We identified dental events based on the Dental segment, and vision and hearing events using the Medical Provider Events (MPE) segment. We subset the file to beneficiaries with hearing events, which were identified as medical provider specialty events for an audiologist or hearing therapist or where the type of event was for a hearing or speech device or a hearing aid, and beneficiaries with vision events, which were identified as medical provider specialty events for an optometrist or where the type of event was for eyeglasses. We analyzed out-of-pocket spending on dental, hearing, and vision services (separately) among community-dwelling beneficiaries overall, and among the subset of community-dwelling beneficiaries who were coded as having a dental, vision, or hearing event. This analysis was weighted to represent the ever-enrolled population, using the Cost Supplement weight ‘CSEVRWGT’. We also analyzed out-of-pocket spending among community-dwelling beneficiaries who reported having difficulty hearing or difficulty seeing.
The Medicare Advantage Enrollment and Benefit files for 2021 were used to look at dental, hearing, and vision coverage for beneficiaries enrolled in individual Medicare Advantage plans (e.g., excludes Special Needs Plans, employer-group health plans, and Medicare-Medicaid Plans (MMPs)). This analysis includes enrollees in the 50 states, Washington D.C., and Puerto Rico. Plans with enrollment of 10 or fewer people were also excluded because we are unable to obtain accurate enrollment numbers. For cost-sharing amounts for dental, vision, and hearing coverage, many plans do not report these figures, and in cases where enrollee cost sharing does not add up to 100%, it is due to plans not reporting this data. Due to data limitations, we examine benefits offered, but are unable to analyze the extent to which enrollees in Medicare Advantage plans use supplemental benefits specifically offered by their plan, such as dental, hearing and vision, because encounter data for these benefits are not available. It is also unclear from the plan Benefit files the extent to which plans limit the type of eyeglasses or hearing aids, impose network restrictions or prior authorization.
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