The Business of Medicare: How Understanding Medicare Benefits Your Patients (and Your Practice)

As you look at your schedule for the week, you may be surprised to find that you have one or more patients who rely on the single largest health insurance program in the country: Medicare. 

Medicare plays a pivotal role in the American healthcare system, both in terms of the population it serves and its profound influence on how healthcare is delivered. In 2023 alone, Medicare provided health insurance to approximately 66.7 million Americans. Since its implementation, Medicare has achieved nearly universal health coverage for American seniors by establishing it as an earned benefit of reaching the age of 65. This shift didn’t just increase access to care; it fundamentally changed the social fabric of the country, dramatically dropping poverty rates among seniors who were no longer being bankrupted by their medical bills.

Because Medicare is an entitlement program, anyone who meets the eligibility criteria is entitled, by law, to enroll. For most, this milestone is reached at age 65, provided they or their spouse paid Medicare payroll taxes during their working years. However, the program also extends its reach to younger individuals living with End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS), as well.

The four parts of Medicare each play a specific role.

Part A: Hospital Insurance covers inpatient hospital stays, care in a skilled nursing facility, hospice care for the terminally ill, and some home health care visits.

• The Cost: Most Americans receive Part A without paying a monthly premium if they or their spouse paid Medicare taxes while working.
• The Dental Impact: Dentists are not likely to submit charges directly to Medicare Part A. Its coverage is restricted to dental services provided in a hospital setting that are inextricably linked to a medical procedure.

Part B: Medical Insurance is the “outpatient” portion of Medicare, covering things like doctor’s visits, outpatient surgery, laboratory tests, and medically necessary radiographs. It also covers certain durable medical equipment (DME) and various preventive screenings.

• The Cost: Unlike Part A, Part B is voluntary and requires a monthly premium.
• The Dental Impact: While routine dentistry is excluded, Part B is where certain “medical” dental procedures live. For example, oral appliances for the treatment of obstructive sleep apnea are considered by Medicare to be DME and can be a covered benefit under specific circumstances.

Note: dental providers must submit a separate enrollment to become a DME supplier to file claims for sleep apnea devices.

Part C: Medicare Advantage plans are offered by private insurance companies approved by Medicare. These plans are required to at least cover everything that Parts A and B cover, with the addition of other benefits, such as vision services, hearing services, prescription drugs (when applicable), and dental.

• The Cost: This is a premium-based plan purchased directly from commercial payors. While federally regulated, these plans are not federally funded.
• The Dental Impact: This is the most relevant part of Medicare for most dental offices. Unlike Original Medicare, many Part C plans offer dental benefits that cover routine services like cleanings, evaluations, fillings, and even dentures.

Part D: Prescription Drug Coverage helps cover the cost of outpatient prescription drugs. Like Part C, these plans are run by private insurance companies.

• The Cost: This plan is provided through Part C or as a standalone Prescription Drug Plan to supplement Original Medicare (Parts A and B).
• The Dental Impact: As a prescriber, your patients will rely on their Part D plans to cover prescription medications you might write for them. Notably, dentists are not required to be enrolled in Medicare for their patients’ Part D plans to cover these prescriptions.

For the modern dental professional, Medicare is no longer a “medical-only” concern. As Medicare continues to evolve and its influence on patient expectations grows, understanding its business fundamentals has become essential. Whether it’s navigating the rise of Medicare Advantage or identifying when dental care is “inextricably linked” to covered medical procedures, understanding the basics is the key to serving your patients effectively while safeguarding the financial health of your practice.

For more on Medicare, see the 30-page section on Medicare in our 2026 publication of Dental Administration with Confidence.

Source:

Practice Booster (2026). Dental Administration with Confidence (pp. 119-126). 2025 eAssist Publishing, LLC.