What Does Dental Insurance Not Cover? #1

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Statistics from the American Dental Hygienist Association show that 80% of Americans have some form of gum disease currently, and those looking to get insurance for dental treatment would likely ask a question like “What does dental insurance not cover?”. We are here with your answer!

Generally, insurance doesn’t cover cosmetic procedures, some basic and major procedures, orthodontics, and pre-existing conditions. Knowing what your dental insurance does not cover helps you save a lot on costs.

In this article, we will help you learn about what dental insurance doesn’t cover and why. In addition, you will learn how to maximize your dental coverage and get the most out of your insurance plan.

Hope you’re ready!

What Does Dental Insurance Not Cover?

Well, dental insurance usually does not cover:

  • Cosmetic procedures
  • Basic and Major procedures,
  • Orthodontics
  • Pre-existing conditions.

Let’s discuss them quickly;

#1. Cosmetic Procedures:

Since dental insurance plans typically provide insurance strictly for medical procedures, this means that cosmetic procedures are not covered. Some of these procedures include;

  • Teeth Whitening: These are procedures that usually involve the use of gels to brighten your teeth. They are simply for aesthetic purposes only and do not contribute to the overall health of your teeth.
  • Veneers: These are light porcelain shells that are used to mask chipped, misaligned, and discolored teeth.
  • Bonding: This is used to fix minor chips and cracks. They are primarily done for aesthetic reasons.

#2. Orthodontics (Brace/Aligners):

This is about correcting the placement of one’s jaw and mouth. Sometimes, they could be considered medically necessary procedures. But generally, they are considered cosmetic and are only covered by dental insurance plans for children.

#3. Basic and Major Procedures:

Dental insurance plans offer a percentage of coverage for basic and major procedures. They often cover 80% of basic procedures and 50% percent of major procedures. If you get this kind of offer, you will have to cover the rest of the bill.

#4. Pre-existing Conditions:

If it is discovered that you have pre-existing conditions after you have enrolled in the plan, you are likely not to get coverage for them. It is best to deal with any issues you might have before enrolling in a plan.

In the next section, we will discuss extra costs that you would have to cover if you’re getting a dental insurance plan. These are called exclusions.

See this to know if oral surgery is covered under dental or medical insurance.

Exclusions That are Not Covered By Dental Insurance

Dental insurance companies sometimes include clauses called “exclusions” in their plan document. These exclusions amount to expenses you will have to pay out-of-pocket.

This could be ascertained from the type of plan, treatment required, or just the fixture in every plan document. They are:

  • Frequency and Annual Maximums
  • Deductibles
  • Copayment, and

Let’s talk about them for a bit.

  • Frequency and Annual Maximums:

Each dental insurance plan has a fixed amount that it allows patients to use yearly for dental treatments. There could also be a limit to the number of times a patient can access some dental services like cleanings, fillings, etc. When dental services exceed these limits and maximums, they are not covered by dental insurance.

  • Deductibles:

This is the initial amount you are expected to pay for a service before your insurance kicks in. This is usually considered if you have to undergo treatment. Depending on your dental insurance plan, you could get reimbursed. Keep in mind that this is not often the case.

  • Copayment:

A “copay” is a part of a dental treatment bill paid to the patient. This is usually the dentist fees; covering for office visits. A copay is put in place to ensure patients do not overuse the insurance service.

Beyond the type of procedure and exclusions, coverage can also be affected by the type of insurance providers you use. We will discuss that in the next section.

How Do Providers Affect Your Dental Insurance Coverage?

The type of provider you use is often a key factor that decides how much dental coverage you can get. The two types of network providers are in-network and out-of-network.

In-network providers already have an established rate that they collect from your insurance company. In addition to having lower rates, you won’t have to worry about issues like deductibles and you even get lower copayments.

With out-of-network, you have to cover several expenses out-of-pocket. The rates of your treatments may be too high for your dental insurance plan to cover adequately, and you would have to foot bills for deductibles, and copays. You would also have to pay any extra bill that comes after you exceed your annual maximum.

This means that you cannot overstretch the role providers play in your dental insurance coverage. And the wise choice for better coverage would be to choose an in-network provider.

Why Some Procedures Are Not Covered By Dental Insurance

Insurance companies could provide coverage for all of your expenses but it would be a heavy financial burden. This is why they consider the cost of each procedure and then include other factors before accepting or declining your request for coverage. This is in order for them to run adequately.

Does dental insurance cover implants? Check this out!

6 Proven Ways To Maximize Coverage and Get The Most Out of Your Dental Insurance Plans

Now that you know that dental insurance does not cover cosmetic procedures, some basic and major procedures, orthodontics, and even pre-existing conditions. You will certainly be interested in how to get the best out of what you’ve got left!

Here are six ways you can do that:

  • Know the best plan for you
  • Preventive care
  • Understand your insurance plan
  • Wellness benefits
  • Get Pre-authorization
  • Consider waiting periods

Let’s talk about each one briefly

1. Know The Best Plan For You:

Don’t pick a plan on the go! It may seem a bit hectic but try to get good knowledge about the different plans and how they can benefit you.

For example; HMO plans offer cheaper rates, but your services are restricted to their in-network providers. If you need to see a specialist outside their network, you will have to pay out-of-pocket.

If you consider a PPO plan, you will get the best specialist care, but this comes at the cost of higher premiums, copays, deductibles, and other out-of-pocket costs.

2. Preventive Care:

You know the maxim “prevention is always cheaper than cure” is really true. Simple dental care services like cleanings are completely covered by dental insurance and are cheaper still!

The best part is that you actually keep your mouth protected from any future disease that could require you to go through the rigors of trying to get a significant percentage of coverage for a procedure.

3. Understand Your Insurance Plan Document:

You could choose the best plan type and still gain little or nothing. Several benefits are hidden in the little clauses of your dental insurance plan document. Do well to unravel them.

4. Wellness Benefits:

You can only know what wellness benefits are if you’ve taken the time to give your dental insurance plan a little more than a cursory glance.

With wellness benefits, you could get discounts on products like electric toothbrushes or mouthwash (no saved penny is too small).

5. Get Pre-authorization:

This could save you a whole lot of stress in the long run. Getting pre-authorization is key to having your dental insurance plan cover your claim without a fight.

If you ignore the pre-authorization process put in place by your insurance company, you could be at risk of a denied claim. It becomes worse if you have to pay out-of-pocket and seek reimbursement.

What Does Dental Insurance Not Cover? - Pre-authorization
Be sure to know that your dental insurance plans cover.

6. Waiting Periods:

Some dental insurance companies have waiting periods of about 12 months after enrollment before a patient can undergo a major surgery that would require them to foot the bill.

Waiting periods can be frustrating, but it gets more frustrating if you do not entirely grasp the concept and stand a risk of being denied your dental claim.

How To Pay Your Dental Bills Without Dental Insurance

Here are some ways to pay your dental bills without dental insurance:

  • Government aid
  • Dental Saving plans
  • A Dentist Payment plan
  • Medical Credit Card
  • Government Aid:

Yes! Health programs like Medicaid and Medicare were created to help you when insurance cannot. Payment for a dental procedure through this method could be a bit tricky, but it is worth the try.

Find out how to be eligible for aid from a health service provider in your state. You could be lucky to get full coverage for your dental procedure!

  • Dental Saving Plans:

Consider saving through a specialized dental savings plan. This could be a long route, but it is definitely better than doing nothing at all.

Most dental saving plans allow you to save tax-free dollars to get your dental procedure done!

  • A Dentist Payment Plan:

This might be your easiest option. It only involves conversing with your dentist and coming to an agreement. You may be surprised to find that most dentists allow their patients to pay by installment. Some have even come to anticipate it, and they have drafted agreement plans already in place.

  • Medical Credit Card:

This is only advised if you’ve exhausted all your options and you’re confident about paying back the debt with the interest attached to it. Although this is not the best route, you could consider it if you need your procedure done urgently.

Frequently Asked Questions

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Important Recommendation


Although you might want it differently, it is unfortunate that dental insurance does not provide coverage for cosmetic procedures, orthodontics, pre-existing conditions, and some basic and major procedures. But we have put in other ways to get your treatment done regardless. Try one out and let us know how it works for you!

You can read up on other topics too!


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