Does Medicare Cover TMJ Treatment?
Medicare covers TMJ treatment, including jaw surgery, if it’s medically necessary. Orthognathic surgery is a procedure that is medically necessary when you have jawbone irregularities that affect your daily life functions.
If you have orthognathic surgery as an outpatient, Part B covers 80% percent of the surgery. If your surgery is more complicated, and you require a hospital stay, it will be covered under Part A.
In this article, we’ll help you estimate what jaw surgery could cost you if you have Original MedicareOriginal Medicare is private fee-for-service health insurance for people on Medicare. It has two parts. Part A is hospital coverage. Part B is medical coverage..
Key Takeaways
- Jaw surgery is used to fix injuries and issues with the jaw and mouth that impair your ability to speak, eat, and rest comfortably.
- A jaw surgery that requires you to stay at a hospital would be covered under Medicare Part AMedicare Part A is hospital coverage for Medicare beneficiaries. It covers inpatient care in hospitals and skilled nursing facilities. It also covers limited home healthcare services and hospice care..
- If your jaw surgery doesn’t require a hospital stay or you require other outpatient services after your surgery, Medicare Part BMedicare Part B is medical coverage for people with Original Medicare benefits. It covers doctor visits, preventative care, tests, durable medical equipment, and supplies. Medicare Part B pays 80 percent of most medically necessary healthcare services. will provide coverage.
- Part B covers medication that is administered by your doctor, while Part D covers prescription medication costs that your doctor orders for you.
- A Medigap policy will assist with your remaining out-of-pocket costsOut-of-Pocket Costs for Medicare are the remaining costs that are not covered by the beneficiary's health insurance plan. These costs can come from the beneficiary's monthly premiums, deductibles, coinsurance, and copayments. for Medicare-approved services, including surgical and hospital costs.
- While Medicare Advantage PlanMedicare Advantage (MA), also known as Medicare Part C, are health plans from private insurance companies that are available to people eligible for Original Medicare (Medicare Part A and Medicare Part B). members can expect their necessary surgical procedures to be covered, the out-of-pocket costs will vary between plans and are often great than Original Medicare if you require a hospital stay.
What Jaw Problems Can Be Fixed By Surgery?
Jaw surgery corrects irregularities of the jawbones. Also known as orthognathic (or-thog-NATH-ik) surgery, the procedure realigns the jaws and teeth to improve the way they work. Orthognathic surgery may be an option if you have jaw problems that your doctor can’t fix with orthodontics. Jaw surgery may help to:1Mayoclinic.org, “Jaw Surgery: About”, Accessed January 4, 2022
- Make biting easier and improve chewing
- Correct problems with swallowing and/or speech
- Minimize excessive wear of the teeth
- Correct bite fit or jaw closure issues
- Correct facial imbalance (asymmetry)
- Improve the ability of the lips to fully close comfortably
- Relieve pain caused by temporomandibular joint (TMJ) disorder
- Repair facial injury or birth defects
- Provide relief for obstructive sleep apnea
Average Costs For Jaw Surgery
Jaw surgery is a complex reconstructive procedure and has a price tag to prove it. Jaw surgery costs can range between $20,000 to $40,000 without coverage, depending on the procedure’s complexity and if you need to spend time recovering in the hospital. If you are covered by Medicare Part B and your surgery doesn’t require a hospital stay, you will pay 20 percent of the total cost for the procedure. That’s the Medicare Part B copayment amount, which could range from $4,000 to $8,000 for this procedure. That staggering out-of-pocket cost is why a Medicare supplementMedicare Supplements are additional insurance policies that Medicare beneficiaries can purchase to cover the gaps in their Original Medicare (Medicare Part A and Medicare Part B) health insurance coverage. is so important.2Health.costhelper.com, “Orthognathic Surgery Cost”, Accessed January 4, 2022
How Does Medicare Cover Jaw Surgeries?
Medicare does cover jaw surgery in most circumstances. As with most Medicare-covered services, the surgery must be medically necessaryServices or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice.. Cosmetic jaw shaping does not qualify. If you require surgery due to an injury or a worsening medical condition, the procedure and rehabilitation costs are covered by Medicare Part A and Part B.3Medicare.gov, “Surgery”, Accessed January 4, 2022
Medicare Part A
If your jaw surgery requires you to recover at the hospital or a skilled nursing facility due to the severity of the procedure, Medicare Part A will pay its share for:4Medicare.gov, “Inpatient rehabilitation care”, Accessed January 4, 2022
- Semi-private room and board
- Meals
- Skilled nursing care
- Medications needed for your treatment
Medicare Part A also helps cover the first 100 days of your post-surgery recovery care at a skilled nursing facility, including physical therapy sessions.5Medicare.gov, “Skilled nursing facility (SNF) care”, Accessed January 4, 2022
Medicare Part B
If your jaw surgery doesn’t require inpatient careInpatient care refers to care provided in a hospital or other inpatient facility. Inpatients are admitted and stay at least one night depending on their condition., it will be performed in an outpatient surgical center. Medicare Part B covers 80 percent of the cost for outpatient surgeries and services, including follow-up doctor visits, physical therapy for your jaw, and durable medical equipmentDurable medical equipment (DME) is equipment that is designed to last and can be used repeatedly. It is suitable for home use and includes wheelchairs, oxygen equipment, and hospital beds. (neck brace, headgear, etc.) you will need while you recover.6Medicare.gov, “Outpatient hospital services”, Accessed January 4, 20227Medicare.gov, “Physical therapy”, Accessed January 4, 20228Medicare.gov, “Braces (arm, leg, back, & neck)”, Accessed January 4, 2022
Will Medicare Cover My Prescription Drugs After Jaw Surgery?
Original Medicare (Parts A and B) only covers medication that requires administration by your doctor 9Medicare.gov, “Prescription drugs (outpatient)”, Accessed January 4, 2022. If you need coverage for prescription drugs post-surgery (pain medication, antibiotics, etc.), you will need a Medicare Part DMedicare Part D plans are an option Medicare beneficiaries can use to get prescription drug coverage. Part D plans provide cost-sharing on covered medications in four different phases: deductible, initial coverage, coverage gap, and catastrophic. Each... plan. Part D plans will provide coverage for prescription drugs once you have paid the plan’s annual deductible (if any). Once coverage starts, you will only pay a fraction of the drug’s cost in the form of a copayment.10Medicare.gov, “What Medicare Part D drug plans cover”, Accessed January 4, 2022
Medicare Supplement Insurance
We mentioned a $4,000 to $8,000 estimate in out-of-pocket costs for outpatient jaw surgery with Medicare coverage. That’s better than the full $20,000 to $40,000, but is still a significant cost for anyone to pay out-of-pocket. However, you can get help with out-of-pocket costs for Medicare-approved services by getting Medicare supplement insurance (Medigap). A Medigap plan can help protect you from unforeseen out-of-pocket costs after Medicare pays its share, such as:11Medicare.gov, “How to compare Medigap policies”, Accessed January 4, 2022
- DeductiblesA deductible is an amount a beneficiary must pay for their health care expenses before the health insurance policy begins to pay its share.
- CoinsuranceCoinsurance is a percentage of the total you are required to pay for a medical service.
- CopaymentsA copayment, also known as a copay, is a set dollar amount you are required to pay for a medical service.
- Blood (the first three pints)
Medicare Advantage Plans
Medicare Advantage plans will provide coverage for your jaw surgery costs, just as Original Medicare (Part A and Part B) covers it. However, Medicare Advantage out-of-pocket costs can differ compared to what you get with Original Medicare and are infamous for being significantly higher for hospital stay costs after the first three days. Please read our article on the topic here if you are interested in how Medicare and Medicare Advantage cover hospital stays.12Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed January 4, 2022
In Summary
Like most medically necessary services, Medicare will provide coverage for your jaw surgery if your doctor orders it. With that said, surgeries are expensive and the out-of-pocket costs can still be frightening even after Medicare has paid its share. You should consider looking at Medigap plans available in your area and purchasing to protect your finances in the long term against sudden medical expenses.
Citations
- 1Mayoclinic.org, “Jaw Surgery: About”, Accessed January 4, 2022
- 2Health.costhelper.com, “Orthognathic Surgery Cost”, Accessed January 4, 2022
- 3Medicare.gov, “Surgery”, Accessed January 4, 2022
- 4Medicare.gov, “Inpatient rehabilitation care”, Accessed January 4, 2022
- 5Medicare.gov, “Skilled nursing facility (SNF) care”, Accessed January 4, 2022
- 6Medicare.gov, “Outpatient hospital services”, Accessed January 4, 2022
- 7Medicare.gov, “Physical therapy”, Accessed January 4, 2022
- 8Medicare.gov, “Braces (arm, leg, back, & neck)”, Accessed January 4, 2022
- 9Medicare.gov, “Prescription drugs (outpatient)”, Accessed January 4, 2022
- 10Medicare.gov, “What Medicare Part D drug plans cover”, Accessed January 4, 2022
- 11Medicare.gov, “How to compare Medigap policies”, Accessed January 4, 2022
- 12Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed January 4, 2022