Does Medicare Cover Jaw Surgery?

Medicare Benefits Solutions
Dec 13, 2020

Jaw surgery, known as orthognathic surgery in the medical world, is usually a procedure that is medically necessary if you have jawbone irregularities that affect your daily life functions.

An oral or maxillofacial surgeon can perform jaw surgery to help people overcome problems with biting and chewing, swallowing, or speaking. This type of surgery can also correct a bite fit or jaw closure issue like over, under, and crossbites.

TIP: Jaw surgery may also help relieve pain from jaw abnormalities, and even relieve obstructive sleep apnea.

Medicare Benefits for Jaw Surgery

Orthognathic surgery costs vary but are generally expensive. If your dentist or orthodontist recommends that you have jaw surgery, you might be wondering if your Medicare benefits cover the cost and what your out-of-pocket expenses might be. Here’s a look at how Medicare’s coverage assists beneficiaries.

If you need oral surgery done on your jaw, your Medicare benefits may assist you with coverage if your healthcare provider certifies that it is a medically necessary procedure which is performed by a doctor or surgeon who accepts Medicare assignment.

Medicare considers a treatment or procedure as medically necessary if it treats a specific injury, disease, illness, or condition. Jaw surgery could be medically necessary if you have fractures in your face or jaw from an injury, or if jaw abnormalities hinder normal body functions such as chewing, biting, or breathing, for example.

Top Reasons Why You May Need Jaw Surgery

  • Correcting speech or swallowing problems
  • Minimizing excessive wear of teeth
  • Relieving pain due to temporomandibular joint disorder
  • Repairing facial injury
  • Providing relief for obstructive sleep apnea
  • Correcting facial asymmetries like underbites or overbites

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When Does Medicare Cover Orthognathic Surgery

How your Medicare insurance pays for your jaw surgery depends on where the surgery takes place.

If you are admitted into a Medicare-affiliated hospital as an inpatient, Original Medicare Part A (hospital insurance) covers its share of the costs of surgery and the following:

  • A semi-private room and meals
  • General nursing care
  • Drugs that you get for inpatient treatment
  • Some other hospital services and supplies but no personal supplies

While you are an inpatient, all care from your physicians and surgeons is covered by your Original Medicare Part B (medical insurance) benefits, not Part A benefits.

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Jaw Surgery Coverage Limits

Through your Original Medicare Part A coverage you are responsible for the Part A deductible which is $1408.00 per benefit period in 2020. There is no coinsurance for the initial 60 days of a hospital stay per benefit period. If you stay longer than 60 days, you must pay coinsurance according to Medicare’s rates.

Your Part A coverage for orthognathic surgery extends to care in a skilled nursing home if you need to have special monitoring during your recovery. Skilled nursing care is covered when it follows an inpatient hospital stay of three days. This coverage doesn’t include custodial care if that is the only care you need.

If you have orthognathic surgery as an outpatient, Original Medicare Part B (medical insurance) covers a percentage of the surgery. You are responsible for your annual deductible – $198.00 in 2020 – and your monthly Part B premium. Medicare pays 80 percent of the final approved cost of the surgery and you pay the remaining 20 percent. If you have a Medigap plan, you may have coverage for the copayment as well as the Part B deductible. This depends on which Medigap plan you have.

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Jaw Surgery and Medicare Advantage

If you have a Medicare Advantage (Part C) plan, your provider is required by law to cover whatever Original Medicare Parts A and B cover. Many Part C plans also have extra benefits for routine dental care that Original Medicare doesn’t have.

Dental care plans can cover oral exams, teeth cleaning and filling, extractions, x-rays, root canal, diagnostics, periodontics, and some plans include dentures, bridges, etc. Many Part C plans require that you visit dentists and oral surgeons that are in the plan’s network of healthcare providers. Make sure you check with your provider before seeing a dentist or oral surgeon so your expenses are covered.

If you need prescription medication after you leave the hospital as an inpatient, or after outpatient surgery, you must have separate coverage either with a Part D plan or included in your Part C plan. Otherwise, you must pay for prescription medications out-of-pocket.

If you aren’t sure about your Medicare coverage for jaw surgery, or if you don’t know if your surgery is considered medically necessary, you should discuss your concerns with your healthcare provider.

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