Health insurance plans may cover dental work, though it’s important to understand how coverage works. Most dental plans offer deductibles and copays with some offering annual maximums.
The Affordable Care Act mandates that Marketplace health plans offer dental benefits; standalone plans may also offer them. Costs, copayments and covered services for these plans vary significantly.
Preventive care
Dental care is often an integral component of maintaining overall wellness, but can be expensive. By planning ahead and finding suitable coverage that keeps your smile in good health without breaking the bank.
Preventive care benefits typically include routine exams and cleanings, bitewing X-rays, fluoride treatments and sealants; in some plans this also extends to additional procedures like fillings, crowns and bridges.
Additionally, standalone dental plans are also available on the Marketplace and usually feature lower premiums and provide more services than health plans with dental coverage.
Basic care
At one point in New York dental plans examined, 9 out of 10 covered regular cleanings without incurring a copayment, while 64 percent covered filling expenses; though these figures vary by plan type and provider.
Most Medicare Part A policies don’t cover routine dental care; however, some related procedures may qualify. There may also be stand-in dental plans available through Marketplace.
Direct reimbursement plans typically have limits set according to what are considered “usual, customary and reasonable,” yet do not exclude categories of service or require a deductible payment. They allow patients to choose their own dentist and work together on creating affordable treatment plans with them.
Major care
Many dental plans cover preventive care and basic procedures without waiting periods, though coverage maximums usually apply. Copays must also be paid along with an estimated portion of coinsurance (a percentage of bill).
Read your dental plan policy carefully as each contract varies significantly and negotiates differently. Some policies may request a treatment proposal prior to beginning any work costing over a certain dollar amount or require predetermination (also referred to as prior authorization). Marketplace plans often combine dental and health coverage into one premium payment.
Copays
Copays are set amounts that you pay when receiving covered services, which apply towards meeting your deductible and out-of-pocket maximum. When your dentist submits a claim for dental appointments, their insurance company will apply any outstanding deductible payments as well as copays you owe towards meeting that maximum.
Once they determine your coinsurance percentage, they’ll apply it to any remaining charges. For instance, if a dental bill of $250 and fillings coverage at 80% are covered under your plan, then $20 copay plus $60 in coinsurance would total $110.
Many dental plans offered on the Marketplace feature deductibles and copayments; however, certain preventive services may be covered without incurring an upfront deductible fee.
Coinsurance
Health and dental insurance differ significantly, yet both provide coverage against the costs associated with medical and dental care. Health insurance covers an array of expenses while dental coverage focuses on oral health; options exist through standard health plans, Marketplace plans or stand-in plans.
Dental plans typically feature an annual deductible and maximum, along with a payment model which details what preventive and basic procedures the plan covers; periodontics and prosthodontics coverage varies by plan.
Annual maximums
Annual maximums on dental insurance policies represent the amount that a plan will pay during any one benefit period, or year, and can usually be found either on its website or by calling up your provider directly. Preventive visits such as exams and cleanings typically do not count toward your annual maximum limit.
Most dental policies also feature copays, or fixed dollar amounts that patients must pay out-of-pocket, to help limit patient expenses and help contain costs for the dental insurer. Dental plans tend to include yearly maximums as opposed to health plans with out-of-pocket limits that reset annually.
Exclusions
Exclusions are services excluded from coverage by an insurance plan, such as experimental procedures or services not performed by licensed dentists. Some plans also exclude orthodontics and dental implants; however, most dental insurance plans allow you to cover them through co-pays or deductibles.
Insurance policies often feature waiting periods that could limit your choices for dental care services, so it is wise to do your research prior to enrolling in any plan.
Some exclusions on health insurance policies are permanent, such as those related to self-harming behaviors or terrorist attacks; other exclusions are temporary, such as those related to hospital stays.
