Do Health Insurance Plans Include Dental Care?
Dental services are not included as part of the Affordable Care Act’s (ACA) essential health benefits. Therefore those services are not mandated to be included in ACA-compliant plans. However, your health insurance might cover dental work in extreme cases requiring surgery. Doctors reserve these procedures for severe injuries and disorders, including disease to the facial bones, physical trauma to the structure of the face, jaw disorders, and facial deformities.
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The Importance of Dental Care
According to a new report from the World Health Organization, nearly half of the world’s population suffers from untreated oral diseases. The WHO asserts that universal health care should include dental coverage, noting that conditions like gum disease and untreated cavities affect more people than cancer, diabetes, heart disease, lung disease, and mental illness combined.
Dental hygiene is an essential aspect of any person’s health, as the mouth is the primary gateway to the rest of the body. Built-up oral bacteria can lead to severe medical conditions like endocarditis, cardiovascular disease, and pneumonia. While simple care and upkeep can prevent these issues from spreading, many people avoid the dentist due to a lack of insurance coverage.
What Dental Care Is Included in Health Insurance?
The procedures most people associate with dental care, such as fillings, root canals, and cleanings, are not covered by standard ACA-compliant health insurance plans. However, ACA plans will bend the rules to accommodate children and emergency care.
Children’s Dental Care
ACA regulations require all ACA-compliant plans to make dental care available for children up to age 19. While requirements vary from state to state, most should include the following:
- One dental exam every six months
- Cleanings, fluoride treatments, X-rays
- A percentage of the cost of braces
Those who qualify will need to see a dentist within an ACA-compliant network. Insurers cannot exclude children with dental issues from coverage nor charge parents for out-of-pocket costs exceeding an annual cap.
Dental Care as Part of Another Major Procedure
ACA health insurance will additionally make allowances for major, dental-adjacent procedures that affect your overall health, including:
- Surgical treatments, like jaw surgery or impacted wisdom tooth removal.
- Facial trauma resulting from an accident.
- Diagnostic techniques used to uncover more significant medical issues.
- Non-surgical emergency procedures to treat infection and inflammation.
Dental Insurance: Your Main Option for Dental Care Coverage
While ACA health insurance must legally offer children’s dental coverage, adults do not typically qualify. Most people will need some dental work in their lifetime, and even basic procedures can burden the uninsured with enormous bills. Luckily, many states provide standalone dental insurance on the ACA marketplace.
What Does Dental Insurance Cover?
While the dental coverage included with health insurance typically only covers children and emergency procedures, a standalone, full-coverage dental plan will help pay for most medically necessary oral maintenance.
Attending to the teeth and gums while still healthy can help bypass more expensive procedures later on. Examples of preventative care include:
- Fluoride treatments
Regular checkups and basic preventative measures significantly reduce the risk of cavities, gum diseases, and more severe disorders stemming from poor oral hygiene.
Basic Routine Procedures
Even people with immaculate hygiene who see a dentist regularly may need routine work at some point. Typical procedures include:
- Fillings for cavities
- Non-impacted extractions
- Root canals (occasionally classified as “major,” depending on severity)
- Periodontal scaling
- Root planning
Most insurance providers classify all complicated, lengthy dental work, surgery, or any technique requiring anesthesia as a major procedure. Examples include:
- Impacted tooth extraction
- Denture work
- Oral surgery
Patients can avoid most of these procedures by practicing proper oral hygiene and scheduling routine preventative care.
Orthodontists perform long-term work to help straighten and set teeth in their proper position. Standard orthodontic services include:
- Space maintainers
- Mouth guards
Most insurance providers view orthodontic care as “major” and charge accordingly under PPO plans.
What Is Not Covered?
Dental insurance will not cover any non-medical, purely aesthetic procedures. Examples include:
- Teeth whitening
- Porcelain veneers
- Dental bonding
- Tooth or gum contouring
- Chipped tooth repair (if merely a cosmetic issue)
Dental insurance will only cover procedures that help prevent or immediately attend to issues that could cause more significant problems over time. Patients should expect to pay for vanity work out-of-pocket.
How Does It Work?
Standalone dental plans function just like traditional health insurance. Some companies provide dental insurance through their “group benefit,” a generalized program available to all employees who meet eligibility requirements. If you pay for private dental insurance, you must choose the level of coverage you wish to pay for, as well as the plan type and associated pricing breakdown.
Basic vs. Full Coverage Plans
Basic dental insurance typically only covers preventative care and routine dental procedures. Full coverage plans offer wider-reaching benefits for lower out-of-pocket costs during your visit, though they will significantly increase your premium. This coverage distinction can exist in any of the following plan types.
Dental Health Maintenance Organizations (DHMO)
Dental Health Maintenance Organizations function much like a healthcare HMO plan. For a small copay (or no fee at all), you can see dentists within an approved network for essential services. DHMO plans do not set deductibles or annual coverage maximums but will also not allow you to see any out-of-network specialists.
Preferred Provider Organization (PPO)
PPOs cost notably more than DHMOs, set annual coverage maximums, and require patients to meet a deductible in exchange for a broader range of benefits. Typically, PPO networks include more dentists and do not require a referral from one to see an outside specialist. Additionally, PPOs often partially cover services from out-of-network practitioners.
Exclusive Provider Organizations (EPO)
EPOs require policyholders to stick to dentists within their network and will not reimburse any out-of-network costs. While this can significantly limit access to care, EPOs typically cost much less than PPOs and DHMOs.
Point-of-Service Plans (POS)
POS policies allow patients with managed care dental plans to seek out-of-network care for partial reimbursement. Reimbursement gets determined against a “low table of allowances” that encourage policyholders to remain within the network. POS plans do not charge deductibles for patients who settle on a primary care provider.
Fee-for-Service, or Indemnity Plans
In indemnity plans–aka “traditional insurance” or “fee-for-service plans“– your provider pays claims based on the procedures undergone, typically as a percentage of the cost. You or your dentist sends them a bill, and they decide how to pay it based on their UCR (“usual, customary, and reasonable”) allowance.
Direct Reimbursement Plans
Direct reimbursement plans allow patients to see any dentist they choose using their own money. Patients must then provide a receipt as proof of treatment to their employer or insurance provider, who should pay them back a portion of the cost.
How Much Does It Cost?
What you pay for your dental plan depends on the level of coverage and type of plan you choose. Each plan charges varying premium rates, deductibles, copays, coinsurance, and out-of-pocket restrictions.
Dental premiums can range from $18 to $50 per month, averaging about $360 annually.
Your premium represents the amount you pay annually for dental insurance. Providers determine your premium based on various factors, including age, location, previous claims filed, and the type of coverage.
The average deductible for a dental plan sits around $65.
Your deductible represents the amount you must personally pay for dental service before your insurance kicks in to cover the rest.
Copay and Coinsurance
The average copay falls around $25.
Providers often require patients to pay a copay (fixed cost) or coinsurance (percentage of service) with each dental visit. Coinsurance fees vary broadly depending on your policy type and the services performed, making an average cost harder to pin down.
Average out-of-pocket maximums for dental work sit between $1000-$1750.
Most insurers set an out-of-pocket maximum equal to the amount they willingly reimburse annually. Once your annual service costs exceed your out-of-pocket maximum, the financial responsibility for any further care falls on your shoulders.
How to Get Dental Insurance
While picking the right dental insurance plan might seem confusing at first glance, following these steps should help guide you toward a policy that best suits your needs.
1. Explore your options
Look up your state’s online Health Insurance Marketplace to compare dental policies and bounce questions off trusted insurance agents. The three most common dental plans to choose from include:
Employer Group Dental Plan
Employer group dental plans offer generalized coverage for qualified employees and their families, typically through a fixed network of dentists. Group rates make it easier for policyholders to get the coverage they need at a discount, making employer plans ideal for eligible individuals without particular coverage preferences.
Purchasing an individual dental plan allows you to choose one that appropriately suits your needs and budget, best suiting single people with particular needs who may not be affected by coverage expectations.
A family dental plan would cover your spouse, children, and yourself, typically for less money per person than an individual plan. Family plans make the most sense for families without employer coverage.
2. Consider your coverage needs and evaluate your plan options
After settling on the type of insurance, consider your coverage needs. Do you think you’ll need any major procedures performed? Do you want the flexibility to see out-of-network dentists? These questions determine the type of plan and amount of coverage you should choose. Compare how much you feel comfortable paying in deductibles and copays against how much you can afford as your annual premium.
3. Apply for coverage
Once you’ve decided on a plan, apply for coverage through the ACA marketplace or a private insurer. Expect to answer a litany of personal and health questions and provide sensitive details like your address and social security number.
4. Receive confirmation of enrollment and make a dentist appointment
Once your application goes through, look out for an email or paper letter confirming your enrollment and explaining the benefits of your specific insurance plan. Once you understand your policy details, schedule an appointment with a dentist in your network.
Is Dental Insurance a Good Idea to Supplement Your Health Insurance?
Going to the dentist without insurance can break the bank, especially if you need more than routine preventative care. According to the CDC, 1 in 4 adults has untreated tooth decay, and nearly half of people over thirty show signs of gum disease. Supplementing your health insurance with a dental plan can save you a lot of money and pain, as most tooth and gum issues only get more expensive to fix as they worsen over time.
Other Options For Dental Care Besides Dental Insurance or ACA Health Insurance
If dental or ACA health insurance does not make sense for you and your family, consider these alternative pathways to securing coverage.
While Medicaid provides free healthcare to millions of lower-income Americans, it typically only covers comprehensive dental care for children and emergency surgery for adults. That said, Medicaid programs in certain states have expanded to include basic care for adults, though finding a dentist that accepts government-subsidized insurance can often prove difficult.
Designed to expand Medicaid coverage to people under 18, the Children’s Health Insurance Program (CHIP) requires states to provide early and periodic screening, diagnostics, and treatment (EPSDT) benefits for kids. States must additionally cover procedures “necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions” in children.
You can find participating dentists and benefits packages at InsureKidsNow.Gov.
Though Original Medicare does not cover non-emergency dental work, some privately-owned companies that offer Medicare Advantage include dental insurance in their benefits package. Thoroughly research your Medicare Advantage options before committing to a purchase, as only some plans incorporate dental coverage.
Dental School Clinics
Student dentists at dental school clinics often work for free or at a reduced cost under professorial supervision. The American Dental Association maintains an up-to-date, nationwide registry of qualified dental schools on its website.
Local Health Clinics and Programs
Sometimes, local health clinics and initiatives offer free or reduced-cost dental care. Inquire about dental care with clinics in your area, or call your local or state health department to learn more about their financial assistance programs.
Putting It All Together
Although standard ACA-compliant health insurance plans do not include dental care, many alternative roads to coverage exist worth exploring. While purchasing annual standalone insurance can help cover most crucial dental procedures, individuals with less spending power can research local programs and clinics offering free or cheaper service options.
If you purchase a standalone dental insurance policy, consider the kind of care you need and compare all available plan options to maximize your investment. Your oral hygiene directly affects the rest of your holistic health and well-being, so getting the best care possible at a price you can afford is best.