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What does dental insurance cover?

dental insurance
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Most full coverage dental insurance plans will cover two preventive maintenance visits per year without requiring a deductible payment; however, most will require a $50 deductible per person, per year to help cover costs beyond your preventive exams. If you need work done, most of the best dental insurance plans will cover a part of the costs. 

We looked at root canals specifically and found that the majority of dental plans will cover about half the cost, which may not seem like a lot, but paying half is better than paying upfront for an $800 root canal. Keep in mind that most insurance policies, depending on your plan, top out at about $1000 to $1500 per year. Using conservative estimates that might be one or two root canals. If you need extensive work done you might have to pay the remaining amount out of pocket.

Most dental insurance policies will cover a percentage of the following procedures: preventative care, fillings, crowns, root canals, oral surgery, some orthodontic, periodontic, and prothodontic visits. 

There are a few procedures that most insurance companies will not cover or only provide a discount for. Most individual dental insurance plans do not cover what might be considered cosmetic procedures, such as tooth-colored fillings on molar or bicuspid teeth, dental implants or adult cosmetic orthodontics. 

The majority of dental companies will also limit how often certain appliances can be replaced and, in most cases, will not replace lost items. The limitations are published in the disclosures and contracts for the plan, many of which you can peruse online. 

Keep in mind that a new dental insurance plan is not going to cover an emergency you are experiencing right now; most have a waiting period of six to 12 months for major work. However, some will waive the waiting period if you recently had dental insurance.

Dental groups that offer dental discount plans will let you use your benefits right away, but they only provide a discount and not full coverage. Full coverage plans will, however, cover your initial evaluation so you can start planning your dental procedures.

Does dental insurance cover cosmetic dental work?

According to a 2018 article on the Texas Center for Cosmetic Dentistry website, nearly all insurance plans handle “restorative” dentistry that is deemed to be medically necessary, but they don’t cover cosmetic work. They’ll only cover procedures that  are needed because of decay, disease or accidents. For example, insurance may cover medical interventions used to replace missing teeth or fix a patient’s bite, the article states.

If you want a more beautiful smile and there’s no medical reason for any particular dental work, then it’s unlikely you’ll find a dental insurance company to cover the procedure. Any dental work that simply makes you look better is considered elective.

However, there are gray areas. For example, if you’ve been in an accident that harmed your teeth and you need work done on them, most dentists want the outcome to be aesthetically pleasing as well as medically correct. You could also make a case for cosmetic work if you need crowns or veneers to take care of “diseased, injured, broken or missing teeth.” In addition, insurance may cover gum contouring surgery needed because of infection or injury and orthodontia to fix teeth that have been harmed in an accident.

If you think you have a legitimate reason for cosmetic dentistry, look over your dental insurance plan and check with the company.

Does dental insurance cover TMJ treatments?

Coverage for temporomandibular joint disorder (TMJ) depends on which dental insurance plan you choose and which treatment option or options you select. Costs vary dramatically, and intrusive measures like surgery can be expensive. Many dental insurance plans cap the amount they’ll spend on TMJ treatment because of uncertainties about the causes and correct treatments.

“Because there is no certified specialty for TMJ disorders in either dentistry or medicine, finding the right care can be difficult. Look for a health care provider who understands musculoskeletal disorders (affecting muscle, bone and joints) and who is trained in treating pain conditions. Pain clinics in hospitals and universities are often a good source of advice,” says the National Institute of Dental and Craniofacial Research (NIDCR).

The temporomandibular joint connects your upper and lower jaws, and if there is something amiss, you may be one of the many people who suffer from TMJ. TMJ  affects millions of Americans – possibly as many as 10 million, according to the NIDCR.

TMJ often consists of several joint and muscle disorders that cause mild to severe pain, headaches, jaw and neck aches, difficulty opening and closing your mouth, and numerous other unpleasant and frequently painful symptoms. There are indications it is caused by injuries to the jaw, a misaligned bite or arthritis, but experts have not pinpointed specific causes. Stress can exacerbate the condition, and it’s not uncommon for it to be accompanied by teeth grinding during sleep.

There are many treatments to prevent teeth grinding, including custom-made mouth guards, relaxation exercises, medications, teeth realignment options and jaw surgeries. It may take years to find a treatment plan that works for you. If you experience TMJ pain, you might need to visit different dentists to learn about the various ways to treat TMJ and investigate what your dental insurance plan will pay for.

Does dental insurance cover pre-existing conditions?

More often than not, you new dental insurance provider will not cover any dental issues you had prior to enrolling, even though you need treatment for the issue. Relatively minor issues, such as cavities, may be exceptions. Every policy has different restrictions and waiting periods, so consult your plan administrator and dentist for more information. 

Does dental insurance cover braces?

In short, the answer depends on your plan and the provider. For children under 18, some plans will partially cover orthodontics, while others will not. Others will not - in this case, you can purchase supplemental orthodontic insurance. 

For adults, most plans will not cover orthodontic procedures unless there is a medical need. Chances are, getting braces for purely cosmetic reasons will not be a sufficient reason for insurance companies to cover part of the cost. However, an acceptable alternative is Invisalign: while it's generally considered to be more expensive than traditional braces, many insurance companies and policies will cover a percentage of the cost. For the best answer, contact your insurance provider. 

Does dental insurance cover implants?

Just like for many popular procedures, some plans will reimburse a patient for part of the cost for implants, if at all. However, Medicaid recipients may not be eligible for reimbursement for implants. Reach out to your medical insurance provider too, as they may be able to assist in covering the cost of your implant surgery, if appropriate.