Here is everything you need to know about how various kinds of U.S. health plans tend to cover--or, in many cases, not cover--dental care.
Standard health insurance covers a lot of medical treatments and services.
Most plans offered to Americans these days pay for trips to the doctor, prescription drugs, outpatient as well as inpatient surgical procedures, pregnancy and childbirth, physical and occupational therapy, mental health care, and all kinds of preventive care.
Something the vast majority of U.S. health insurance plans fail to cover, however: dental care.
That's a big deal, and for a couple of reasons.
One reason is dental care can be expensive. Yearly checkups and routine fillings may not be so bad on their own, but procedures like bridges, crowns, implants, root canals, and periodontal or gum surgery can put a dent in anyone's bank account.
Another reason: poor oral health can lead to poor overall health. Specifically, studies have shown that poor oral health can lead to or exacerbate diabetes, heart disease, and stroke. It also can cause complications during pregnancy.
Despite the above, most health insurance policies currently sold in or provided to Americans don't include dental care coverage. At best, they cover only the most severe or serious treatments or procedures--and even then policyholders are liable to be on the hook for a good portion of resulting bills.
Which plans are we talking about here? A lot of the ones sold through the health insurance "marketplace" created by the Affordable Care Act (or Obamacare), for starters. Most types of Medicare and Medicaid coverage, too.
Many U.S. companies and organizations provide employees with dental coverage, but it's not usually included as part of a health plan. Instead, it's offered separately.
Speaking of which, your best bet if you need or want dental care coverage is to buy a separate plan that specifically focuses on it.
We'll get to those dedicated dental insurance plans in just a minute. First, though, here's some more information on how employer-sponsored, marketplace, Medicare, and Medicaid plans do and don't cover dental care.
If you get your health insurance from an employer, you're more likely than most Americans to have some sort of dental care coverage.
As suggested a few paragraphs ago, though, that doesn't necessarily mean dental care coverage is included as a part of your health plan. In most cases, it's provided by some sort of separate dental insurance plan. Or at least a separate dental insurance plan provides most of that coverage.
This is because health insurance usually only covers dental treatments and procedures that are medically necessary to keep you in good health.
Don't take that to mean your job-based health plan will pay to have your cavity filled or your crown replaced. Typically, the situation needs to be a lot more serious than that.
According to pocketsense.com, standard health insurance policies usually limit this kind of coverage to dental or oral surgeries that involve:
Some health plans cover more common types of oral surgery, too, such as the removal of wisdom teeth. Even then, though, those wisdom teeth often have to be impacted before they'll pay part of the bill.
As for the separate dental insurance plans mentioned earlier--the ones that probably provide your employer's dental coverage--here's what you need to know about them:
Don't assume the dental coverage or plan your employer offers is identical to what's described above. Review your policy, talk with someone in human resources, or call the insurance company directly before you make an appointment with a dentist so you know which treatments or procedures it will or won't cover.
You may have heard that the Affordable Care Act, also known as the ACA or Obamacare, requires all plans sold via the government-run health insurance marketplace to cover a slew of "essential health benefits."
What you may not have heard: dental care isn't among them. Or at least dental care for adults isn't among them.
(A handful of the categories of care the ACA says are essential and must be covered to some extent: doctors' services, emergency services, hospitalizations, prescription drugs, pregnancy and childbirth, preventive services, and mental health services.)
Dental care for children, however, is among the essential health benefits Obamacare requires marketplace plans to cover.
Actually, the law says that Americans 18 years old or younger must have access to dental coverage via the marketplace. As a result, sometimes that coverage is included in marketplace health plans, and sometimes it's provided by stand-alone plans.
Also worth noting here: the law doesn't say children must have dental insurance coverage. It simply says they need to have access to it. So, you don't have to buy it for your child if you can't afford it or don't want it.
Going back to adult dental coverage, Obamacare doesn't prohibit marketplace plans from providing it. It just doesn't require them to provide it. Given that, it's quite possible you'll find one or more plans that cover dental care the next time you shop for health insurance using your state's marketplace or exchange.
Don't be surprised if you encounter a couple of different options while checking out the marketplace, by the way. For example, you may come across health plans that include dental coverage or stand-alone dental plans.
And when it comes to stand-alone dental plans, you should find two different categories of them on the marketplace. "High" coverage level plans usually have higher monthly premiums but lower deductibles and copayments. "Low" coverage level plans have--you guessed it--lower monthly premiums but higher deductibles and copays.
Which kinds of dental treatments and procedures do these marketplace policies cover? It depends. What one plan in one state offers is sure to be different from what another plan in another state offers. Because of that, you really need to do your homework and research all of your options in this area before settling on any one policy.
Something to keep in mind if you're thinking of buying a stand-alone dental plan through the marketplace: you can only do so if you also enroll in a standard health plan at the same time. For whatever reason, you can't just go to the marketplace and buy stand-alone dental coverage on its own.
Also, you have to buy this coverage during either the annual open enrollment period or during a special enrollment period.
A good percentage of the "dentally uninsured" are Americans over the age of 65. Why? Because Original Medicare doesn't cover dental care. (OK, that's not completely true. Medicare does cover some forms of emergency dental care. It doesn't cover any kind of routine dental work, though.)
In fact, according to a 2016 National Association of Dental Plans survey, only about 53 percent of Medicare recipients have dental coverage. Considering almost all seniors in the U.S. are on Medicare, that's a pretty shocking statistic.
If you're looking for reasons why Medicare doesn't cover dental care, you've come to the wrong place. For whatever reason, when President Lyndon Johnson signed into law the bill that led to the program's creation, it ignored dental coverage. More than 50 years later, Medicare continues to snub such coverage.
Thankfully, today's seniors have quite a few other options if they want insurance that'll help them pay for dental care or work. One option is Medicare Supplement Insurance, sometimes shortened to MedSup or even Medigap. Another option is a Medicare Advantage plan. And then, of course, there are the stand-alone dental insurance policies that already have been discussed a number of times.
Here's what you need to know about Medicare Advantage and MedSup plans and how they tend to cover--or not cover--dental work. (You'll learn more about private or individual dental plans in a few minutes.)
When you enroll in a Medicare Advantage plan, it provides all your Original Medicare--or Medicare Part A and Part B--benefits. (Read all about these benefits in our extensive Medicare guide.)
If yours is like most Medicare Advantage plans, though, it'll provide a lot more than that. Many of these plans also cover prescription drugs, not to mention vision, hearing, or dental care.
They don't have to cover dental care, though, so not all do. As such, thoroughly research any Medicare Advantage plan that catches your eye before you go ahead and buy it.
For more information on this kind of coverage, check out our "Guide to Medicare Advantage Plans."
MedSup or Medigap policies supplement the costs of Original Medicare coverage. To put it another way, they help people pay some of the health and medical expenses that Medicare Parts A and B don't cover.
Like Medicare Advantage plans, private companies sell these plans to Medicare enrollees.
Unlike Medicare Advantage plans, they don't often include dental coverage. Some do, but most don't.
Still, finding a MedSup or Medigap policy that covers dental work isn't impossible, so shop around if it's important to you.
Learn more about Medicare Supplement Insurance in our MedSup FAQ. Or scroll through this article of ours: "When Does it Make Sense to Get a Medicare Supplement Plan?"
The same law that brought about the Medicare program also brought about the Medicaid program.
As a result, it shouldn't be too surprising to hear that Medicaid isn't known for providing dental care coverage.
In fact, Medicaid is a lot like Medicare in that state agencies are only required to provide dental coverage to children. There are no minimum requirements for adult dental coverage.
States can choose whether or not they offer dental benefits to adults via their Medicaid programs. Unfortunately for those adults, many offer the bare minimum in this area.
What does that mean? Most state Medicaid programs that cover dental care limit that coverage to emergency dental services. Some also cover preventative procedures, like cleanings and X-rays. Others expand their benefits a bit more to include the occasional filling or extraction.
That said, a handful of state Medicaid programs go the extra mile and cover enrollees' crowns and root canals as well as their cleanings, fillings, and extractions.
Before you say to yourself, "that sounds pretty good to me," consider this: Medicaid recipients often have a hard time getting a dentist to even examine them. Many U.S. dentists don't accept Medicaid patients. Others accept them, but limit how many they'll see.
Given that, the dental coverage some Medicaid programs provide adult enrollees isn't always as great as it seems on paper--even if that coverage usually is free.
If you have kids, though, Medicaid should help take care of their teeth no matter which state you call home. The same is true of the related Children's Health Insurance Program (CHIP).
According to medicaid.gov, both programs cover dental services for child enrollees as part of something called the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit.
This benefit "requires that all services must be provided if determined [to be] medically necessary. States determine medical necessity," the site explains. "If a condition requiring treatment is discovered during a screening, the state must provide the necessary services to treat that condition, whether or not such services are included in a state's Medicaid plan."
Note: only states that make CHIP coverage available to children through a Medicaid expansion program need to provide those kids with the EPSDT benefit. States with separate CHIP programs have a bit more flexibility in terms of how they cover the dental care of child enrollees. (Basically, they can offer a package of dental benefits that meets the CHIP requirements, or they can offer a dental benefit package that's "substantially equal" to one of a handful of federal or state dental plans.)
Every state handles this kind of child dental coverage differently, so contact your local Medicaid or CHIP agency to learn more about its particular offering.
If you don't get dental coverage through an employer, the health insurance marketplace, a Medicare Advantage or MedSup plan, or Medicaid, your only option is to get it directly from an insurer.
The good news here: all sorts of insurance companies sell individual dental plans these days.
Even, better, most of these companies sell a range of dental plans. So, if you want "full coverage" that'll help you and your family pay for the treatment of any dental or oral problems you may encounter, you can get that. And if you just want the basics--routine checkups, cleanings, X-rays, and the occasional filling--covered, you can get that, too.
Now for the bad news: you'll pay quite a bit more for a "full coverage" dental insurance plan than you will for one that only covers the basics. How much more? Well, your "typical" dental insurance plan costs about $350 a year, according to dentalplans.com. Full-coverage plans often cost more than twice that amount--or around $780.
Also, most private or individual dental plans include annual benefit limits of between $1,000 and $1,500. That means once you reach that amount, you have to pay for the rest of your dental care until the next policy year begins. All of it. Out of your own pocket.
And of course you'll be paying for quite a bit of your dental care well in advance of that point. After all, each of these plans come with deductibles that have to be reached before your plan kicks in and pays its portion. Also, most of these plans only chip in about 80 percent of the cost for fillings and root canals, and they often cover just 50 percent of bridges, crowns, and other "major" procedures.
Combine all of the above with the fact that private dental coverage rarely pays for cosmetic or even orthodontic procedures and it should be clear that you have to approach buying this type of insurance with eyes wide open.
Granted, shopping around and comparing coverage options as well as rates is important whenever you're looking to buy insurance. Why should dental insurance be any different?
Do your research and don't be shy about asking questions and you'll put yourself in the best position possible to walk away from the experience with a dental plan or coverage that keeps your teeth--and the rest of you, too--healthy and doesn't break the bank.
A: Usually only in extreme or emergency situations. For example, if you're involved in a car accident that results in trauma to your jaw, teeth, or gums, your standard health insurance plan probably will pay for the medical and dental work that'll fix it.
Your health plan may pay for more common types of oral surgery, too. Some cover the removal of wisdom teeth, for instance--although usually only if they're impacted.
In general, though, you shouldn't expect your health insurance to pay for any kind of dental or medical care that's specifically related to or focused on your teeth. For that, you need dedicated dental coverage.
A: It's difficult to say for sure why health insurance in the U.S. has never embraced dental coverage. Most historians and other experts will tell you, however, that the likeliest answer to this question is that medical care and dental care have long been thought of as completely separate issues, entities, and professions.
Another possible (and probable) reason: although poor dental health can lead to poor overall health, it’s not all that common for a person to wind up in the hospital due to a tooth or gum problem.
A: It depends on the plan. At the bare minimum, a dental insurance plan should cover routine checkups, cleanings, and X-rays. It might cover procedures like fillings, extractions, crowns, and bridges, too. Multiple kinds of oral surgery may be included as well.
Due to how varied dental coverage can be, don't assume all plans are the same. Do your homework and make sure you understand what a particular policy will and won't cover before you start paying for it.
A: As mentioned above, some dental plans don't cover anything beyond the basics, so keep that in mind while shopping for this type of insurance.
Besides that, most dental plans don't cover cosmetic procedures. So, if you want veneers, or if you want your teeth whitened, you'll usually have to pay for it out of your own pocket.
Also, most dental plans don't cover orthodontic work. And they rarely cover mouth guards for clenching or grinding.
Considering how many procedures and treatments dental insurance plans tend to exclude, thoroughly read a policy's fine print before you agree to buy it.
A: The best reason to buy dental insurance: going to the dentist can be expensive. And it can be especially expensive if you ever go in for more than a checkup or a cleaning.
That said, if you've never--or rarely--had a cavity filled, you may be better off paying for dental care out of your own pocket. If you see your dentist regularly, though, or if you have more crowns in your mouth than can be found in the museums of Europe, well, dental insurance might make a lot of financial sense.
A: If your employer doesn't offer dental insurance, of if you're enrolled in Original Medicare (and as such don't have dental coverage), don't fret.
A stand-alone plan is one option for you. Premiums usually cost just a few hundred dollars a year, though that's only a fraction of what you'll probably end up paying for any dental care you have done down the road. Why? You'll have to deal with deductibles and copayments or coinsurance costs of various amounts before your plan pays for its portion of the work.
A few other options are your state's dental association, local health departments, area dental schools, and clinical trials. Many of these entities offer or can direct you to affordable--sometimes even free--dental care if you meet certain income or financial requirements.
For more pointers on where you can turn for assistance with dental care needs and bills, read our article about dental, vision, and hearing care with Medicare.
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