Traditional Medicare, which provides medical (Parts A and B) and prescription drug (Part D) coverage to people aged 65 and older as well as younger people who are disabled or have end-stage renal disease (ESRD), does not cover routine dental care. However, Medicare beneficiaries may opt for Part C Medicare Advantage (MA) plans, private managed care plans that generally include additional value-add coverages beyond standard Medicare; many MA plans offer dental coverage as one of these supplemental benefits. Enrollment in MA general enrollment plans offering mandatory supplemental dental benefits (i.e., dental coverage embedded in the MA plan offering) has grown from 14.9 million in 2021 to 19.0 million in 2023,¹ making MA plans a significant source of dental benefits for Medicare beneficiaries.

To better understand the effect of the increased prevalence of dental benefits in MA plans on utilization of dental services by that population, we used Milliman’s proprietary Consolidated Heath Cost Guidelines™ Sources Database, a membership and claim database including data for over 1.1 million Medicare Advantage beneficiaries with dental coverage, to analyze changes in the national average utilization rates for dental services for 2021 through 2023. We mapped Current Dental Terminology (CDT) codes to Medicare’s Plan Benefit Package (PBP) categories to categorize dental claims. PBP service categories include preventive (oral exams, prophylaxis, x-rays, and fluoride) and comprehensive (diagnostic, endodontics, extractions, implants, nonroutine, oral surgery, periodontics, prosthodontics, and restorative) services.

We calculated the total annual utilization rates per 1,000 covered lives (i.e., the annual number of services performed per 1,000 covered lives) by first determining the annual utilization rates per 1,000 for each PBP service category. We then summed these rates to obtain the total. The utilization rates per 1,000 for each PBP category were derived using the number of services in that category and the number of member-months assigned to a Medicare Advantage plan with an allowed claim in that category. It is important to note that we did not use a common denominator to determine the total annual utilization rates per 1,000; each PBP category’s utilization per 1,000 is denominated using only members with coverage of that service category.

We found that total dental utilization rates per 1,000 increased by 29% from 2021 to 2023, after adjusting for regional utilization differences. Figure 1 shows the total dental utilization rates per 1,000 by year.

The increases in utilization per 1,000 rates from 2021 to 2023 for preventive and comprehensive services are both 29%. The distribution of services was consistent during the time period, at approximately 70% preventive and 30% comprehensive. Figure 2 shows utilization per 1,000 rates by service type 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. All preventive service utilization saw double-digit increases in 2023 compared to 2021. The table in Figure 3 shows normalized utilization per 1,000 rates for preventive services by year.

Comprehensive services represented approximately 30% of dental services performed during the study period. Implants and oral surgeries utilization doubled from 2021 to 2023. The table in Figure 4 shows utilization per 1,000 rates for comprehensive services by year.

The observed increases in utilization of both preventive and comprehensive services 2023 could be due to:

• Broader scope of covered services within each PBP category (for example, introducing fluoride coverage or more types of x-rays)
• Increased frequency 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 the number of participating providers
• Heightened member awareness of the dental benefit
• Other benefit changes such as higher dollar benefit maximums or higher plan coinsurance
• Lingering demand for dental services following the COVID-19 pandemic

Conclusion

Dental service utilization among Medicare Advantage beneficiaries with dental coverage has changed dramatically over time. These changes are most likely fueled by broader scope and benefit limits on covered services, increases in access via number of participating providers, and heightened member awareness of the dental benefit. The results presented are national; utilization patterns will vary significantly from these averages by region, by plan type—e.g., general enrollment versus special needs plans (SNPs)—and by specific plan benefit coverages and levels.

Data and Methodology

We used Milliman’s proprietary Consolidated Heath Cost Guidelines™ Source (CHSD 202403) database, which contains membership and administrative claim data for approximately 2 million Medicare Advantage beneficiaries where approximately 1.1 million Medicare Advantage beneficiaries have dental coverage.

We summarized utilization by Current Dental Terminology (CDT) codes for members with dental coverage during the 2021-2023 period. We mapped CDT codes to PBP categories using our understanding of dental code nomenclature and judgment. We summarized member-months for MA members who are covered by plans with claims in each dental PBP service category. We calculated utilization per 1,000 rates as the ratio of utilization divided by a utilization state-wide area factor and member-months (covered confirmed and all covered) multiplied by 12,000.

Caveats and Limitations

Donna Wix, ASA, MAAA, associate actuary, and Joanne Fontana, FSA, MAAA, consulting actuary, for Milliman, are members of the American Academy of Actuaries, and meet the qualification standards of the Academy to render the actuarial analysis contained herein. To the best of our knowledge and belief, this information is complete and accurate and has been prepared in accordance with generally recognized and accepted actuarial principles and practices.

The material in this report represents the opinion of the authors and is not representative of the view of Milliman. As such, Milliman is not advocating for, or endorsing, any specific views contained in this report related to the Medicare Advantage program.

The Milliman database represents a sample of the Medicare Advantage (MA) market and may not be representative of the entire marketplace. Additionally, our database does not contain information indicating whether the beneficiary has dental coverage under a mandatory or optional supplemental plan. Furthermore, our database lacks demographic details of the MA population covered by dental benefits, such as general enrollment and special needs plan (SNP) status. We did not consider or measure the effect of member cost sharing on utilization.

In performing this analysis, we relied on data and other information provided by contributors to our proprietary database. We have not audited or verified this data and other information but reviewed it for general reasonableness. If the underlying data or information is inaccurate or incomplete, the results of our analysis may likewise be inaccurate or incomplete

A different mix of plan designs with different covered services or member cost sharing would produce different results.

Utilization per 1,000 rates shown may be overstated due to the use of claim data to determine coverage across PBP categories.

Historical changes in utilization may not be a good indicator of future experience.

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.

This report is intended to summarize changes in Medicare Advantage dental utilization from 2021 through 2023. This information may not be appropriate, and should not be used, for other purposes. We do not intend this information to benefit, and assume no duty of liability to, any third party that receives this work product. Any third-party recipient of this report that desires professional guidance should not rely upon Milliman’s work product, but should engage qualified professionals for advice appropriate to its specific needs.

¹ Youngblood, G. & Fontana, J.E. (October 25, 2023). Dental Coverage in Medicare Advantage Plans: Nationwide Market Landscape, 2023 Update. Retrieved August 20, 2024, from https://www.milliman.com/en/insight/dental-coverage-medicare-advantage-plans-nationwide-market-landscape-2023-update.