Demystifying Medicare Advantage Plans for Oral Appliance Therapy

by Rose Nierman and Courtney Snow

 How important is Medicare billing to oral appliances for obstructive sleep apnea (OSA) treatment? Very important! To avoid a potentially disappointing outcome, dentists billing Medicare plans for oral appliances for OSA need to know the difference between original Medicare and Medicare Advantage plans. Our hope is that if we can save even one office from having a disappointing result, we have done our job as medical billing geeks in dentistry!

How do you know whether your patient has a Medicare Advantage plan or original Medicare? The first clue will be the patient’s medical insurance ID card. Original Medicare ID cards all look the same, colored red, white, and blue, and “Medicare Health Insurance” spans across the top of the card. On the other hand, Medicare Advantage plan ID cards look different depending on what insurance company administers the plan. Medicare Advantage ID cards will typically have the word “Medicare” somewhere on the front and another insurer’s name, for example, “Aetna Medicare”.

Identifying original Medicare vs. Medicare Advantage is critical to set proper expectations for patients. Here are 5 essential differences between the two.

Deductible and Coinsurance

Medicare Advantage plans have varying deductible and coinsurance figures. Original Medicare plans all have the same deductible ($226 for 2023) and the same coinsurance (20%). Confirming the deductible and coinsurance for Medicare Advantage plans will help estimate the patient’s out-of-pocket expenses.

Durable Medicare Equipment (DME) Coverage

Original Medicare plans have coverage for DME if “Medicare (Part B)” is listed on the front of the card. Medicare Advantage plans may or may not have DME coverage. Because custom oral sleep appliances fall under the DME benefit category, verifying DME coverage is critical.

Pre-authorization

Original Medicare plans do not offer pre-authorization for custom oral sleep appliances. On the other hand, Medicare Advantage plans may require pre-authorization. This difference is especially crucial to understand, as we have seen practices move forward with delivering a custom oral sleep appliance under the assumption the patient has an original Medicare plan, only to find out when the claim is returned the patient has a Medicare Advantage plan that requires pre-authorization to be eligible for coverage.

Enrollment

Original Medicare will only reimburse for custom oral sleep appliances to dental practices enrolled as a Medicare DME supplier. While some Medicare Advantage plans do require the dental practice to be enrolled as a DME supplier with original Medicare to reimburse, not all do.

Supplement Plan

It is common for a patient with original Medicare to also have a supplement plan. On the other hand, Medicare Advantage plans are the patient’s sole policy.

Here at Nierman Practice Management, we advise our clients to treat Medicare Advantage plans as you would a commercial policy, meaning always perform a thorough benefit verification and submit a pre-authorization when required. Knowing the differences between original Medicare and Medicare Advantage plans will allow you to successfully treat your Medicare patients and avoid a potentially frustrating and expensive situation.