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The High Coverage of Dental, Vision, and Hearing Benefits Among Medicare Advantage Enrollees

While the traditional Medicare program does not cover dental, vision, and hearing services, Medicare Advantage (MA) plans have been given the flexibility to do so. However, it is not known how many MA enrollees are in plans that cover these services. The 2016 Medicare Current Beneficiary Survey linked to MA plan benefit data is used to examine enrollment levels in plans that cover dental, vision, and/or hearing services in MA. Medicaid beneficiaries are excluded from this analysis as coverage of supplemental benefits is largely determined by the state. The highest coverage of supplemental services is vision, followed by hearing and dental (71%, 56%, and 41%, respectively). Across all supplemental services, coverage for supplemental benefits is highest among low-income beneficiaries and those who have not completed high school. Hispanic Medicare beneficiaries had the highest enrollment in plans that offered a supplemental benefit, and white Medicare beneficiaries tended to have the lowest enrollment in these plans. Unlike in traditional Medicare, MA enrollees have access to health plans that offer supplemental benefits, including dental, vision, and/or hearing services. This analysis shows that enrollment in these plans is highest among low-income MA enrollees who may not have the means to purchase stand-alone insurance for these services in traditional Medicare. More analysis is warranted to examine the generosity of the coverage of these services in MA plans. However, for federal policy makers to consider offering supplemental coverage in traditional Medicare, the MA experience suggests this type of benefit would be valuable.


Introduction
The fee-for-service (aka traditional) Medicare program does not provide coverage of dental, vision, and/or hearing services. For those in traditional Medicare, there are limited options to purchase coverage for dental and/or vision services through stand-alone insurance plans and no standalone plans for hearing. 1 In the Medicare Advantage (MA) program, which currently covers just over a third of Medicare beneficiaries, plans are able to offer supplemental coverage for dental, vision, and hearing services. The costs of these supplemental benefits must either be covered through the rebates that MA plans receive or must be charged in the form of a premium. MA plans may be incentivized to offer these supplemental benefits if they think it may attract enrollees, or if covering these services may lead to downstream savings.
There is a wealth of evidence that shows poor oral health, vision loss, and hearing loss are associated with poor health outcomes, including diabetes, 2 cardiovascular disease, 3 pulmonary disease, 4 falls, 5-8 dementia and cognitive impairment, 9-12 depression, 5,13,14 social isolation, 15 as well as higher health care utilization and costs. 16 Historically, coverage of dental, vision, and hearing services has been abysmally low. 1,17 With increasing enrollment in MA plans among Medicare beneficiaries, and with more and more of those plans offering supplemental benefits, it is important to assess whether this has translated into greater coverage of dental, vision, and hearing services among MA enrollees and whether enrollment is higher or lower among certain subpopulations.

Methods
The 2016 Medicare Current Beneficiary Survey (MCBS), a nationally representative survey of Medicare beneficiaries, linked to publicly available 2016 MA benefit data published by Centers for Medicare and Medicaid Services, was used to examine the percentage of MA beneficiaries enrolled in plans that include supplemental benefits, as well as the type and number of supplemental benefits available. The MCBS contains information on 5040 individuals continuously enrolled in MA in 2016. Enrollees were assigned to the plan that they spent the majority of the year with. Those with exactly 6 months in each plan were assigned to their plan from January to June. Enrollees dually eligible for Medicare and Medicaid (n = 1095) were excluded from the analysis, as the availability of and enrollment in supplemental benefits by Medicaid enrollees are determined by the state Medicaid program, not the enrollee. The final analytic sample included 3567 MA enrollees which, with survey weights applied, represents 14 832 386 MA enrollees. All analyses reported have applied survey weights to account for the MCBS survey design.

Results
Sixty-five percent of MA enrollees were in plans with at least 1 supplemental benefit; more than one-quarter of MA enrollees were in plans in 2016 with all 3 dental, vision, and hearing benefits included (data not shown). Vision is the most common supplemental benefit among MA enrollees, followed by hearing and then dental (71%, 56%, and 41%, respectively; Table 1). As shown in Table 1, among the nondual MA population, enrollment in plans with dental and vision benefits was highest among those below age 65; hearing coverage was highest among enrollees 85 and older. Enrollment in plans with supplemental benefits was highest among those who have not completed high school. Hispanic Medicare beneficiaries had the highest enrollment in plans with supplemental benefits, and white Medicare beneficiaries the lowest enrollment in vision and hearing plans. Enrollment in plans with supplemental benefits was lowest among higher income and higher educated MA enrollees.

Discussion
The needs of older adults have evolved since the enactment of the Medicare program in 1965. Dental, hearing, and vision services are integral to maintaining health, 12,18,19 and their cost put them out of reach for many. 1,17 This analysis shows that many MA plans are offering these important services and that the majority of MA enrollees are in plans with supplemental benefits. The high prevalence of supplemental coverage among low-income enrollees compared with highincome enrollees suggests that low-income enrollees are looking for financial protection from the costs of these services. A recent study by the Kaiser Family Foundation examined the availability of dental coverage across MA enrollees but did not distinguish between those who received benefits because of the state Medicaid plan requirements. 20 To the author's knowledge, this study is the first to quantify the enrollment in supplemental benefits among MA enrollees who do not have access through state Medicaid benefits.
Limitations of this analysis are that coverage is considered as a binary measure (any coverage vs no coverage) and the analysis does not explore the generosity of plans or the use of these services across MA enrollees. Further research into the generosity of these supplemental benefits is required to better understand the extent of coverage (eg, services covered) and financial protection (eg, co-pay and deductible structure) for enrollees as a result of this coverage. The MA program has been granted the flexibility to meet those evolving needs of older adults by offering supplemental benefits. Policy makers can look to the experience of the MA program when considering the dental, vision, and hearing needs of the more than 38 million Medicare beneficiaries in traditional Medicare. 21

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.