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September 28, 2021

As Congress Weighs Expanded Coverage, Medicare Patients Bear Large Out-of-Pocket Costs for Dental, Hearing Care

Author Affiliations
  • 1Consulting Editor, JAMA Health Forum
JAMA Health Forum. 2021;2(9):e213697. doi:10.1001/jamahealthforum.2021.3697

Millions of Medicare beneficiaries pay substantial out-of-pocket costs for dental and hearing care—costs that generally are not covered by traditional Medicare—and many forgo needed services because of such costs, according to a new analysis by the Kaiser Family Foundation (KFF).

The problem is not limited to people enrolled in traditional Medicare, however, the analysis shows. Although privately run Medicare Advantage plans typically offer coverage for these services and for vision care, the scope of that coverage is limited. As a result, many patients enrolled in these plans also have high out-of-pocket costs for the uncovered share of services and sometimes go without care.

The KFF analysis was issued last week as Congress considers adding dental, hearing, and vision benefits to traditional Medicare as part of budget reconciliation legislation. Efforts to add these benefits to Medicare, which would increase federal spending, “will be competing against other priorities in the budget reconciliation debate,” the authors of the KFF analysis noted.

About 90% of the US public says that expanding Medicare to include these 3 types of service is a “top” or “important” priority for Congress, according to findings from a recent KFF poll. A considerable body of research shows that untreated dental, vision, and hearing problems “can have negative physical and mental health consequences,” the authors said.

The KFF analysis, which examined traditional Medicare and Medicare Advantage beneficiaries’ self-reported data from the 2018 and 2019 Medicare Current Beneficiary Survey, found that average annual out-of-pocket spending in 2018 was $914 among the 4.6 million Medicare beneficiaries (8%) who used hearing services, $874 among the 31.3 million Medicare beneficiaries (53%) who received dental care, and $230 among the 20.3 million beneficiaries (35%) who received vision care.

However, out-of-pocket costs varied considerably, with a small proportion of individuals spending significant amounts, which the authors said was likely associated with buying expensive devices, such as hearing aids, or undergoing costly dental procedures, such as getting dental implants. Among those who were in the top 10% in terms of out-of-pocket expenses for such services, 2.7 million beneficiaries spent $2136 or more on dental services, and 360 000 beneficiaries spent $3600 or more on hearing care.

Medicare Advantage plans typically offer varying degrees of coverage of dental, hearing, and vision services. Nearly all plans with a dental benefit cover preventive care, and although most include access to more extensive dental services, those generally involve cost sharing (typically 50% for in-network care) and have an annual dollar limit on how much is covered.

For hearing services, almost all Medicare Advantage plans cover hearing exams and partially cover the cost of hearing aids, but the coverage generally has an annual maximum dollar cap, frequency limits on how often plans cover services, or both. Similarly, almost all Medicare Advantage enrollees with a vision benefit have access to preventive services, such as eye exams, and have some coverage for contact lenses or eyeglasses, though coverage generally has limits, averaging about $160 per year.

Thus, because of cost sharing or limits on coverage of procedures or devices such as hearing aids, Medicare Advantage enrollees, like those enrolled in traditional Medicare, often face high out-of-pocket costs. In 2018, the analysis found, average out-of-pocket costs among those who used dental services were $766 among those covered by Medicare Advantage vs $922 among those enrolled in traditional Medicare.

For many individuals, the prospect of incurring such out-of-pocket costs for dental, hearing, or vision care meant forgoing it. About 1 in 6 Medicare beneficiaries (16%)—9.5 million people—reported in 2019 that there was a time in the previous year that they were unable to access dental, hearing, or vision care, and the majority of these individuals (70%) said that cost was a major barrier. Nearly equal proportions of traditional Medicare and Medicare Advantage beneficiaries (16% and 17%, respectively) reported access problems in the last year for dental, hearing, or vision services, with roughly 7 in 10 beneficiaries in both groups citing cost as a barrier to getting such care.

Dental care posed the largest challenge, with 12% of beneficiaries reporting they were unable to access dental care (71% because of cost). In addition, 6% said they had problems accessing vision care (66% because of cost), and 3% for hearing care (75% because of cost).

Medicare beneficiaries in racial and ethnic minority communities or those with disabilities or with low incomes were disproportionately likely to have difficulty accessing these services during 2019. Those reporting problems accessing care included about 35% of beneficiaries younger than 65 years with long-term disabilities, 35% of dually eligible beneficiaries enrolled in both Medicare and Medicaid, 31% of individuals with income under $10 000, 25% of Black and 22% of Hispanic beneficiaries, and 20% of Medicare beneficiaries living in rural areas.

In addition to the current congressional effort to expand Medicare coverage of services, another measure might help patients with impaired hearing. In July, President Biden issued an executive order for a proposed rule to allow hearing aids to be sold over the counter, which could help make the devices more affordable.

The KFF authors said that according to a 2019 Congressional Budget Office estimate, expanding Medicare to include dental, hearing, and vision benefits would result in higher federal spending—$358 billion over 10 years, including $238 billion for dental and oral health care, $89 billion for hearing care, and $30.1 billion for vision care.

“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,” they wrote.

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Article Information

Published: September 28, 2021. doi:10.1001/jamahealthforum.2021.3697

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Stephenson J. JAMA Health Forum.

Corresponding Author: Joan Stephenson, PhD, Consulting Editor, JAMA Health Forum (Joan.Stephenson@jamanetwork.org).

Conflict of Interest Disclosures: None reported.