While more than 3 out of 4 Americans have dental insurance1, many don’t fully understand what dental insurance does and doesn’t cover. This quick guide to dental insurance can help you get a better understanding of how coverage usually works.
The purpose of dental coverage
Dental insurance is designed to help you offset the cost of your dental care and to help you maintain good overall oral health. That’s why we focus on preventive care to catch signs and symptoms of dental disease early. This could reduce the chance that you will need more complex treatment later. If an issue does arise, dental insurance will usually help cover a portion of the treatment cost, so you don’t have to pay the full bill yourself. This combination of preventive services covered at 100% and lower out-of-pocket costs makes dental insurance a valuable benefit.
What is covered: 100-80-50 coverage structure example
The emphasis on preventive coverage and sharing of costs on other procedures is reflected in the structure for most dental insurance plans. As part of this structure, an example of dental coverage may be:
100% of routine preventive and diagnostic care such as cleanings and exams.
80% of basic procedures such as fillings, root canals and tooth extractions.
50% of major procedures such as crowns, bridges and dentures.
Be aware that a deductible — the amount you pay before your dental insurance kicks in — may apply to these services, although it may be waived for preventive and diagnostic services.
What may not be covered
- Select procedures: While it differs from plan to plan, some dental insurance may not cover select procedures such as orthodontia.
- Cosmetic procedures: Coverage for cosmetic dental procedures like teeth whitening may not be covered.
- Pre-existing conditions: Some policies don’t cover certain pre-existing conditions such as missing teeth. If you had a condition before you got your dental plan, you may be required to pay treatment costs out-of-pocket.
Additional plan information
These limitations may also apply to your dental insurance:
- Waiting period: This is the period of time before you are eligible to receive benefits for all or certain dental treatments. Waiting periods are more common with individual plans2 but also apply to employer-sponsored plans in some industries. This can sometimes be waived if you prove you had no gap in your dental coverage before purchasing a plan.
- Other restrictions: In addition to some procedures not being available right away, your plan may require time limits between services like fillings, crowns and bridges on the same tooth or fluoride treatments for children. For example, a policy may only pay for a full set of X-rays once every five years3.
- Annual maximum: This is the total amount your dental insurance will pay for your coverage during a 12-month period. For instance, if your annual maximum is $1,500, you pay for all additional costs after your dental insurance has paid $1,500 for your care. However, only 2% to 4% of Americans typically exceed their annual maximums4.
Important terms to know
It helps to become familiar with the following terms to get a greater understanding of why some services are covered and others are not:
- Coinsurance/Copay: The patient’s share of payment for a given service. The copayment is usually expressed as a percentage of the dentist’s fee, but can be expressed as the enrollee’s preset share of payment for a given service.
- Dual coverage: If you have coverage from more than one dental plan through a spouse, more than one job, both parents or other means, it is called dual coverage. While dual coverage does not double your coverage or pay more than 100% of expenses, it may help you reduce your out-of-pocket costs.
- In-network dentist: Dentists who have agreed to accept pre-established costs for services, saving you money over an out-of-network dentist are referred to as in-network dentists. You will save the most by visiting a dentist in your plan’s network. In fact, a dentist participating in your plan’s network generally won’t be able to bill you for the difference between what they usually charge and the fee they have agreed upon with Delta Dental.
View your dental coverage specifics by logging in to your Member Account here.
1. 2018 National Association of Dental Plans Dental Benefits Report 2. 6 dental insurance plans no waiting period. Investopedia 3. Dental insurance coverage – WedMD4. Is Dental Insurance Worth It – Money Under 30When you go to a dentist, you�re used to your dental insurance covering the services that you need. But with oral surgery is it any different? Are there instances where your health insurance covers Lafayette oral surgery and your dental benefits do not?
What We Usually See
In most of our Lafayette oral surgery cases, health insurance will only cover the treatment if it�s due to trauma.
For example, let�s say you were in an automobile accident and suffered facial lacerations due to the airbag or maybe have a broken jaw. Perhaps teeth were even broken. Although all of these injuries are related to the face and mouth, it�s a balancing act as to whether the treatment is covered by your dental or health insurance. Since this particular case is related to trauma, your medical benefits are more likely than not to cover your oral surgery.
Other types of traumatic injuries could include a ski accident, domestic violence, or any blunt trauma (as opposed to a dental disease.)
Facial Deformities
Another instance where health benefits help to cover oral surgery is when there are atypical developmental concerns or facial deformities. Such situations are usually present from birth, such as a cleft lip or palate. Although initial surgery is needed to help babies born with this condition be able to nurse and eat, children will require periodic surgeries as they grow and their facial characteristics mature.
What About Wisdom Tooth Extraction or Dental Implants?
Dental procedures are filed against insurance based on a series of �codes� used to describe them. Wisdom tooth extractions and dental implants are generally only included in dental codes and accepted by dental insurance, rather than a medical plan.
However, some overlap may exist. For instance, if you require a particular medical procedure or sedation in order to undergo a medically necessary dental procedure, there may be supporting data that allows your health benefits to include a portion of the treatment (such as the sedation, for example.)
Talk to Our Treatment Coordinators
Our Lafayette, CO oral surgery coordinators will gather all of your dental and health insurance benefit information prior to scheduling treatment. As we call to verify your coverage, we�ll be able to provide you with an estimate as to what�s covered, how much it is, and by which insurance company. Although this is only an estimate, it can provide you with the information as to which types of oral surgery are covered by your unique plans.
Since we�ve worked with numerous types of oral surgery cases over the years, we have a good understanding as to which types of treatments tend to be covered under health benefits, especially if you�re experiencing something similar to other patients in the past.
Flexible financing options are also available to help fill in any difference between what�s covered by your dental and health insurance, making it more convenient to get the care you need.
Contact us today to schedule your Lafayette, CO oral surgery consultation for more information.
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