Make sure to check with your dentist when seeking treatment so you know what to expect upfront. Read on to learn about some common exclusions, and don’t forget DexKnows dentists when starting your search.
FAIR Health, an independent not-for-profit corporation that helps consumers estimate and plan for medical expenditures, states that dental plans usually don’t cover cosmetic procedures. These are services meant to improve or enhance appearance, including teeth whitening.
Dental insurance’s main purpose is to treat tooth-related problems and disease.
Depending on the plan, conditions that existed before the start of dental coverage may not be covered. This can include missing teeth.
The American Dental Association (ADA) says that prior coverage may be used to reduce the length of the exclusion. Don’t wait, though. The ADA states that if there’s a break of 63 or more days in coverage, a plan doesn’t have to count the pre-existing coverage as credible.
Treatments covered by other insurance
Treatments of injuries, diseases or other problems may not be covered by a dental plan if they are covered by a major medical plan. The same goes if it is a work-related injury covered by workers compensation or other government or state insurance.
Treatments by an out-of-network dentist
Similar to health plans, dental insurance providers often prefer clients to use a dentist within the network. Going outside of network may mean no coverage unless it’s a dental emergency and in an area where there are no in-network dentists.
Procedures considered by an insurance provider to be experimental are commonly excluded. This may also include procedures still considered under clinical investigation.
Services considered not necessary
Just because a dentist prescribes a treatment doesn’t mean the insurance provider agrees. An insurance company can disagree that a specific service is necessary to treat or diagnosis a dental condition.
Treatments when a lesser alternative is available
The ADA states that dental plans may include what’s called a Least Expensive Alternative Treatment Provision. This limits how much will be paid when there’s a less expensive alternative available. Again, this can go against the dentist’s advice. It’s up to the patient to decide whether to go with the cheaper alternative or pay for what the dentist suggests.
It is better to ask up front about the policy and whether your condition qualifies so you don’t get any surprises later when you get the explanation of benefits.
Treatment beyond annual maximum
Dental insurance maximums are nowhere near medical insurance. They are closer to $1,000 to $1,500 per patient per year, though the ADA states that there are plans with maximums as high as $2,000 or $3,000.
Another thing to keep in mind that dental insurance is steered toward prevention. Preventive services get the most complete coverage while other treatments like restorative services and major services may be covered at a lower rate, as low as 50 percent for major services such as crowns.
Keep these possible exclusions in mind while you search for treatment. Read through your dental plan thoroughly, and ask questions upfront. Once the treatment is done, it’s too late to change your mind.