Medicare provides medical and prescription drug coverage to people aged 65 and older, younger people who are disabled, and people with end-stage renal disease (ESRD). Fee-for-service (FFS) Medicare includes inpatient hospital, skilled nursing facility, hospice, and home healthcare under Part A, and preventive and other medically necessary care under Part B. Prescription drug coverage is included under Part D. FFS Medicare does not cover dental services. However, Medicare beneficiaries may opt for a Medicare Advantage (MA) plan from an insurance company that covers Part A and Part B and sometimes Part D services; many MA plans offer dental coverage as an embedded mandatory supplemental benefit. Enrollment in MA plans offering mandatory dental benefits has grown from 9.8 million in 2019 to 17.5 million in 2022.1
To better understand the effect of this increased prevalence of dental benefits in MA plans on utilization of dental services, we used Milliman’s proprietary Consolidated Heath Cost Guidelines™ Sources Database, a membership and claim database for over 1 million Medicare Advantage beneficiaries with dental coverage, to analyze trends in the national average utilization rates for dental services for 2019 through 2022.
We concentrated our analysis on plans that offer comprehensive dental benefits, including coverage of at least one service in each of the three dental classes: (1) preventive services (oral exams, cleanings, x-rays, lab, and other tests and fluoride), (2) basic services (emergency palliative, simple and surgical extractions, oral surgery and anesthesia, restorations, periodontics, and endodontics), and (3) major services (inlays/onlays/crowns, dentures, bridges, other prosthetics, implants, and simple repairs). We summarized utilization by Current Dental Terminology (CDT) codes for members with such dental coverage from 2019 through 2022.
Total dental utilization per 1,000 rates (i.e., the annual number of services performed per 1,000 covered lives) increased 4.5% from 2019 to 2022, after adjusting for regional utilization differences.2 Adjusted dental services utilization decreased from 2019 to 2020 by 17.6% in this dataset. This is significantly larger than the 4.9% decrease in national dental expenditures observed for private insurers across all lines of business as reported by the American Dental Association (ADA).3 According to a study published in the Journal of the American Dental Association, dental office visits were 33% lower from March 2020 through August 2020 when compared to the same period in 2019 due to the COVID-19 pandemic.4 Figure 1 shows total dental utilization per 1,000 rates by year.
Figure 1: Medicare Advantage dental utilization per 1,000 rates, normalized for regional differences
The changes in utilization per 1,000 rates from 2019 to 2022 for preventive, basic, and major services are 7.2%, -0.9%, and -2.9%, respectively. Figure 2 shows utilization per 1,000 rates by service class and year.
Figure 2: Medicare Advantage dental utilization per 1,000 rates, normalized for regional differences by service class and year
All utilization per 1,000 rates have been normalized for regional differences.
Discussion
Preventive services consistently represented about 70% of dental services provided. X-rays and oral exam utilization increased 12.6% and 5.8% in 2022, respectively, as compared to 2019. Figure 3 shows normalized utilization per 1,000 rates for preventive services by year.
Figure 3: MA Dental preventive services utilization normalized for regional differences per 1,000 rates and percentage changed from 2019
| Service Category | 2019 | 2020 | 2021 | 2022 | Percentage change 2019 to 2020* |
Percentage change 2019 to 2022* |
|---|---|---|---|---|---|---|
| Oral Exams | 580 | 481 | 576 | 613 | -17.0% | 5.8% |
| Prophylaxis | 431 | 335 | 409 | 435 | -22.3% | 0.8% |
| X-Rays | 542 | 478 | 558 | 611 | -11.9% | 12.6% |
| Lab and Other Tests | 2 | 2 | 2 | 3 | 2.5% | 86.9% |
| Fluoride | 5 | 4 | 6 | 10 | -16.3% | 115.9% |
| Total Preventive | 1,560 | 1,300 | 1,551 | 1,672 | -16.7% | 7.2% |
| Preventive Services as Pct. of Total Dental Services |
68.8% | 69.5% | 70.1% | 70.6% |
* Percentages calculated on unrounded values.
Preventive service increases in 2022 could be due to:
- Broader scope of covered services (for example, introducing fluoride coverage or more types of x-rays)
- Increased limits on covered services (for example increasing the number of covered exams and cleanings from one to two per plan year)
- Increase in access via number of participating providers
- Heightened member awareness of the dental benefit
- Pent up demand for services deferred during the pandemic
Basic services represented approximately 23% of dental services performed during the study period. Surgical extractions, oral surgeries, and anesthesia utilization saw increases of 17.8%, 72.3%, and 48.2%, respectively, from 2019 to 2022 while simple extractions declined slightly. Figure 4 shows utilization per 1,000 rates for basic services by year.
Figure 4: MA Dental basic services utilization per 1,000 rates
| Service Category | 2019 | 2020 | 2021 | 2022 | Percentage change 2019 to 2020* |
Percentage change 2019 to 2022* |
|---|---|---|---|---|---|---|
| Emergency (Palliative) | 10 | 8 | 9 | 8 | -14.6% | -12.1% |
| Simple Extractions | 51 | 44 | 49 | 48 | -13.7% | -5.4% |
| Surgical Extractions | 46 | 41 | 49 | 54 | -9.4% | 17.8% |
| Oral Surgery | 2 | 2 | 2 | 4 | -14.4% | 72.3% |
| Anesthesia | 4 | 4 | 5 | 6 | -6.0% | 48.2% |
| Restorations | 241 | 187 | 219 | 227 | -22.3% | -5.9% |
| Periodontics | 163 | 124 | 152 | 168 | -24.2% | 3.1% |
| Endodontics | 23 | 20 | 21 | 19 | -12.1% | -14.5% |
| Total Basic Services | 539 | 430 | 506 | 534 | -20.3% | -0.9% |
| Basic Services as Pct. of Total Dental Services |
23.8% | 23.0% | 22.9% | 22.6% |
* Percentages calculated on unrounded values.
Surgical extractions, oral surgeries and anesthesia had the largest increases in utilization rates in 2022 over 2019, which may be a result of care deferred due to the COVID-19 pandemic or to changes in scope of covered dental services over that period. We also note that the proportion of members with coverage for emergency (palliative) services, endodontics, periodontics, and simple extractions increased 8.6%, 8.2%, 10.6%, and 7.7% in 2022 from 2019, respectively. Figure 5 shows the percentage of members covered by service type and the change from 2019 to 2022.
Figure 5: Percentage of members with basic covered services
| Service Category | Service Class | 2019 | 2020 | 2021 | 2022 | Percentage change 2019 to 2022 |
|---|---|---|---|---|---|---|
| Anesthesia | Basic | 84.4% | 90.0% | 92.3% | 87.3% | 3.4% |
| Emergency (Palliative) | Basic | 87.3% | 95.8% | 94.4% | 94.8% | 8.6% |
| Endodontics | Basic | 89.3% | 98.6% | 97.6% | 96.7% | 8.2% |
| Oral Surgery | Basic | 84.8% | 88.9% | 88.2% | 91.3% | 7.7% |
| Periodontics | Basic | 89.1% | 99.2% | 98.1% | 98.6% | 10.6% |
| Restoration | Basic | 97.4% | 99.9% | 99.3% | 99.7% | 2.3% |
| Simple Extractions | Basic | 91.0% | 98.8% | 98.5% | 98.0% | 7.7% |
| Surgical Extractions | Basic | 99.5% | 99.6% | 99.5% | 98.8% | -0.7% |
Major services comprise the remainder of dental services during the 2019-2022 period, approximately 7% of the total. Implants increased 87.5% from 2019 to 2022 while other services stayed flat or saw utilization drop. For 2020, implant services saw a slight increase in utilization (1.0% over 2019) while all other services had lower utilization rates. Figure 6 shows dental major services utilization per 1,000 rates and the changes from 2019 to 2020 and to 2022.
Figure 6: MA dental major services utilization per 1,000 rates
| Service Category | 2019 | 2020 | 2021 | 2022 | Percentage change 2019 to 2020* |
Percentage change 2019 to 2022* |
|---|---|---|---|---|---|---|
| Inlays/Onlays/Crowns | 81 | 66 | 73 | 76 | -18.3% | -5.6% |
| Dentures | 25 | 20 | 25 | 23 | -21.8% | -9.2% |
| Bridges | 15 | 12 | 14 | 15 | -15.5% | 1.7% |
| Repair (Simple) | 22 | 19 | 20 | 20 | -11.5% | -10.3% |
| Implants | 7 | 7 | 10 | 14 | 1.0% | 87.5% |
| Other Prosthetics | 18 | 14 | 16 | 16 | -20.6% | -14.3% |
| Total Major | 168 | 139 | 157 | 163 | -17.1% | -2.9% |
| Major Services as Pct. of Total Dental Services |
7.4% | 7.5% | 7.1% | 6.9% |
* Percentages calculated on unrounded values.
Similar to basic services, one driver of increased utilization of major services is the proportion of members with dental coverage for major services. Figure 7 shows the portion of members covered by service type and the percentage change from 2019 to 2022. Coverage for bridges, implants, inlays/onlays/crowns, other prosthetics, and simple repairs increased from 7.3% to 23.7% in 2022 from 2019 while coverage for dentures remained flat.
Figure 7: Percentage of members with major covered services
| Service Category | Service Class | 2019 | 2020 | 2021 | 2022 | Percentage change 2019 to 2022 |
|---|---|---|---|---|---|---|
| Bridges | Major | 78.5% | 89.9% | 88.8% | 90.4% | 15.1% |
| Dentures | Major | 97.1% | 98.9% | 98.3% | 98.2% | 1.1% |
| Implants | Major | 67.9% | 79.0% | 77.2% | 84.0% | 23.7% |
| Inlays/Onlays/Crowns | Major | 89.8% | 99.7% | 98.7% | 98.5% | 9.6% |
| Other Prosthetics | Major | 89.0% | 97.9% | 97.4% | 96.9% | 8.8% |
| Simple Repairs | Major | 91.1% | 98.3% | 98.7% | 97.8% | 7.3% |
Conclusion
Dental service utilization among Medicare Advantage beneficiaries covered under comprehensive dental plans has changed over time. These changes are most likely fueled by broader scope and benefit limits on covered services, increase in access via number of participating providers, heightened member awareness of the dental benefit, and/or lingering return of services deferred during the pandemic.
Methodology
Data
We used Milliman’s proprietary Consolidated Heath Cost Guidelines™ Source (CHSD 202309) database, which contains membership and administrative claim data for approximately 2 million Medicare Advantage beneficiaries where approximately 1 million Medicare Advantage beneficiaries have comprehensive dental coverage.
We summarized utilization by Current Dental Terminology (CDT) codes for members with comprehensive dental coverage during the 2019-2022 period. Comprehensive dental coverage includes preventive services (oral exams, cleanings, prophylaxis), x-rays, lab, and other tests, fluoride, basic services (emergency palliative, simple and surgical extractions, oral surgery and anesthesia, restorations, periodontics, and endodontics), and major services (inlays/onlays/crowns, dentures, bridges, other prosthetics, implants, and simple repairs). We mapped CDT codes to categories using the Milliman Dental Cost Guidelines™ mapping. We summarized member-months for MA members who had comprehensive dental coverage. We calculated utilization per 1,000 rates as the ratio of utilization divided by a utilization state-wide area factor and member-months multiplied by 12,000.
Limitations
The Milliman database represents a sample of the MA market and may not be representative of the entire marketplace. Also, our database does not contain information indicating whether the beneficiary has dental coverage under a mandatory or optional supplemental plan.
A different mix of plan designs with different covered services or member cost sharing would produce different results.
Results are not normalized for differences due to network size and plan design because our proprietary database does not include this data. Results were normalized to reflect regional dental utilization using Milliman’s Dental Rating Model™ state-wide area factors. The area factors reflect regional differences for a commercially insured population and may not accurately reflect regional differences in dental utilization in the MA population.
1 Youngblood, G. & Fontana, J.E. (25 October 2023). Dental Coverage in Medicare Advantage Plans: Nationwide Market Landscape, 2023 Update. Retrieved November 22, 2023, from https://www.milliman.com/en/insight/dental-coverage-medicare-advantage-plans-nationwide-market-landscape-2023-update. .
2 To adjust for regional utilization differences, we calculated a normalized utilization rate by dividing the allowed services by state by statewide utilization area factors in Milliman’s Dental Cost Rating Model™.
3 ADA. U.S. Dental Spending Down in 2020. Retrieved November 22, 2023, from https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/hpi/hpigraphic_1221_1.pdf?rev=ef3f323d5658428898562224a15845c8&hash=229A77542E921FAF5051608DA6336964.
4 Kranz, A.M. et al. (March 9, 2021). 2020 Trends in Dental Office Visits During the COVID-19 Pandemic. J Am Dent Assoc. Retrieved November 22, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7942140/.