Taking care of your teeth is as important as taking care of the rest of your health. If you visit the dentist regularly, you’re more likely to catch disease in its early stages and avoid expensive treatments, making the cost of dental care much less than medical care.
Dental insurance plans encourage patients to get regular preventive care. This post looks at insurance coverage for various aspects of preventive care as well as coverage for treatment of dental conditions.
Preventing eye disease is just as important to your total health picture as dental care is. Vision care coverage encourages you to take preventive measures, such as having regular eye examinations, to keep your eyes healthy and diagnose problems at an early stage. This post closes with examples of what vision care plans may offer.
Although many health insurance plans exclude dental care, some plans may cover routine office visits or orthodontia (straightening of the teeth). When a plan doesn’t cover dental care, it may offer an option to buy separate dental insurance to add to your health insurance policy. Dental insurance plans may use a network of dental care providers, similar to health care networks.
To control costs, a dental insurance plan may impose a dollar limit (cap) on the amount of benefits the plan pays. Plans may also restrict — or even exclude — the number and/or types of services that are covered to keep costs down.
Dental care coverage varies and may include the following:
Crowns and bridgesEndodontics (root tips, nerves)Oral surgery, periodontics (gums, bone)Orthodontia (braces)Prosthetics (bridges, dentures, partials)Restorative services, such as fillingsRoutine diagnostic and preventive services, such as examinations, X rays, and cleaningIf you use dentists within a network of dental care providers, you may receive full coverage for routine exams and cleanings, and you may pay lower prices for other treatments. Dental networks usually require you to file a claim.
Another way to control costs is with a dental discount card program, which is often offered in conjunction with — but separately from — your health insurance plan. Dentists who participate in a dental discount card network provide discounts on several of the most common dental services such as examinations, fillings, and gum treatments. If you’re a member of a dental discount card program, just show your card each time you visit the dentist.
If you choose a dental insurance plan that uses deductibles and coinsurance (as opposed to the discounts that a dental discount card program provides), look for a plan that covers diagnostic and preventive services, such as those shown in Table 4-1, at 100 percent.
Table 4-1: Dental Diagnostic and Preventive Services
Service Frequency
Initial oral examination Once per dentist
Teeth cleaning Twice per year
Complete X rays Once every three years
Bitewing X rays (crowns Once per year of top and bottom molars to show decay between teeth and under fillings)
Fluoride treatment Twice per year
Routine restorative care is a fancy way to refer to dental fillings. Check to see what types of services your plan considers routine restorative care and what benefits the plan pays for these services. In the examples in Table 4-2, Plan 1 covers 80 percent of restorative treatment, and Plan 2 covers 100 percent.
Oral surgery embodies a variety of procedures, including the following:
Endodontics (treating root canals for diseases of the pulp and bone, removing tooth nerves, bleaching discolored teeth, managing traumatic injuries to the teeth, and performing related surgery to help preserve the natural teeth in a healthy state)Periodontics (treating complicated periodontal disease involving bone grafts or underlying tissues)Placing or restoring dental implantsRemoving impacted teeth, tissue biopsy, and draining minor oral infectionsBecause many dental insurance plans emphasize and encourage preventive care, some plans may pay only 50 percent of expenses for oral surgery. Other plans, as Table 4-2 shows, may pay 80 to 100 percent. Examine your plan in detail to learn what the oral surgery benefits are.
Orthodontia involves straightening teeth and treating problems related to the growth and development of the jaws. The sample plans in Table 4-2 cover orthodontia at 50 percent, with no deductible, and impose a $1,000 lifetime maximum.
Treatments for temporomandibular joint (TMJ) syndrome, which affects the joints at the jaw, is usually covered under medical, rather than dental, insurance.
Your dental insurance plan may pay benefits for oral surgery and/or orthodontia procedures based on reasonable and customary fees.
Some insurers may write plans to include a separate deductible for dental care and an annual maximum on payments. You may have a waiting period after the policy takes effect for some major dental procedures.
If your plan has a provision that sets an annual maximum benefit for dental care, think about dividing up and receiving treatment over several years, if feasible. Watch for lifetime maximums on certain types of dental care, such as orthodontia.
Table 4-2 shows two examples of dental coverage in a dental insurance plan. Plan 2 has lower deductibles and a higher annual maximum benefit than in Plan 1, but Plan 2 restricts its members to using services from providers within the network.
Table 4-2: Examples of Dental Coverage
Plan 1 Plan 2
Annual deductible $50 per person, $25 per person,
$150 per family $75 per family
Annual maximum $1,750 per person $2,500 per person benefit
Diagnostic, teeth Covered at 90 to Covered at 100%.
cleaning, X rays, 100% if patient No deductible.
fluoride treatment uses PPO dentist.
No deductible.
The following percentages of coverage are payable after the patient meets the deductible.
Restorative Covered at 80% Covered at 100%
treatment
Crowns and caps Covered at 50% Covered at 80%
Oral surgery Covered at 80% Covered at 100%
(simple and
surgical extractions, excluding
impacted teeth)
Plan 1 Plan 2
Other oral surgery Covered at 80% Covered at 50%
(including impacted teeth)
Endodontics/ Covered at 80% Covered at 80%
apicoectomy
(removal of root
abscess), root canal
Periodontics Covered at 80% Covered at 80%
Mouth-prop Covered at 80% Covered at 100%
devices, space maintainers, and sealants
Prosthodontics Covered at 50% Covered at 50%
(replacement of missing teeth)
Crowns when Covered at 50% Covered at 50%
inserted to affix bridges
Orthodontia Covered at 50%, $1,000 lifetime
$1,000 lifetime maximum benefits.
maximum benefit No deductible.
Coverage for vision care through employer-sponsored health insurance plans may vary widely. Vision care plans most often cover examinations, lenses, and frames on a scheduled basis, paying a fixed dollar amount for each benefit and perhaps discounted fees for eyeglasses and contact lenses. Some plans spell out the procedures and services that they exclude, such as the following:
Corneal modulation (changing the shape of the cornea through surgery or with corrective contact lenses)Eye exams for corrective lenses, including contact lenses, eyeglasses, and their fittingRadial keratotomy (a surgical procedure to correct nearsightedness)Refractive keratoplasty (corneal grafting)A group health insurance plan may not provide vision care coverage at all, in which case you may opt to buy separate vision care insurance to add to your health insurance policy. A separate vision care insurance plan may use a network of vision care providers, similar to the networks in health insurance and dental insurance plans.
The major medical part of a health insurance plan, rather than a vision care plan, most likely covers eye surgery.
Vision care plans may establish a percentage or a flat fee for eye exams and limit the frequency of the exams (such as once every 12 or 24 months). For example, a plan may pay 100 percent of the cost for a vision exam if you use a provider within a network, and up to $40 for an out-of-network provider. Depending on the premium you want to pay, you may be able to choose a deductible amount, such as $10 or $25: The higher the deductible, the lower the premium.
In some cases, you may have to use providers within your plan’s network to be eligible to receive coverage for eye-care services. If you need additional care, your plan may require a referral from a specific provider, such as your primary care physician, or ophthalmologist.
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