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Dental Coverage Explained

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Have you ever gone to the dentist, talked about fillings or other dental work that you needed, and then received a treatment plan that said your insurance covered more on certain procedures than others? The ins-and-out of dental coverage can be confusing…and as a result, very frustrating at times.

Your dentist, or the person in your dentist’s office who handles insurance issues, can usually explain the benefit breakdown for your particular plan. But understanding the levels of coverage prior to your appointment or signing up for a new insurance plan can help you anticipate what your treatment may cost.

Preventive Procedures

By design, most dental insurance plans are intended to help enrollees prevent oral health problems before they start. As such, they typically cover 100% of preventive services such as:

  • Cleanings every six months
  • Comprehensive and periodic exams
  • Dental x-rays
  • Protective sealants
  • Fluoride treatments

Regular visits allow you and your dentist to be proactive about your dental care. As an example, fluoride or sealant treatments can prevent cavities from forming. During your cleaning, your hygienist will remove tartar buildup that could cause future gum disease and tooth loss. Regular preventive care is the best way to maintain excellent oral health – and avoid the high costs of restorative dental care.

Most dental insurance plans cover preventive visits every six months – you don’t pay anything out of pocket for preventive care. It is in your best interest to take advantage of these included procedures.

Basic Procedures

A simple filling for a small cavity would be considered a “basic” procedure. Other examples of basic treatments include simple extractions (removal of teeth that are visible in the mouth and can be easily accessed) and deep cleanings (Scaling and Root Planing) to treat gum disease by removing plaque and tartar from below the gum line. Check your plan for details on what is defined as basic procedures.

Depending on your plan, your coverage for basic treatments may be somewhere around 80%. A deductible may also be involved. After you meet the annual deductible (usually around $50), your insurer pays for 80% of the cost of basic dental treatments, until you reach your annual maximum spending limit (usually $1,000-$1,500).

It is in your best interest – from a health and budget standpoint – to treat cavities or dental infections as early as possible.

Major/ Restorative Procedures

“Major” dental treatment (sometimes described as “restorative” treatments) involves complex procedures like crowns, implants, or dentures to restore natural teeth or the function of natural teeth with a replacement. Your insurance coverage for a major dental procedure often drops to somewhere around 50% – you’re responsible for paying half of the cost of your care. Although not always, major treatments are often the result of a lapse in dental care or delaying procedures that could have been more affordable to treat if they were addressed earlier on. There’s no sense feeling guilty about it – or being embarrassed to see a dentist because of the condition of your teeth – just get the help you need ASAP. Dental decay and disease can lead to serious medical issues such as heart disease, clogged arteries, and stroke, respiratory conditions, pregnancy complications even cognitive conditions such as Alzheimer’s disease.

Deductibles and Maximums

The deductible is the initial down payment that your insurance carrier requires for you to pay before they start to pay out on your dental treatment. Let’s say you need to have a filling for $200 and have a $50 deductible, with 80% coverage on basic treatment. You would first pay $50, and then 20% of the remaining $150.

Maximum allowable spending limits is most that your insurance will pay in any year. Most policies max out somewhere around $1,500. You will be financially responsible for any treatment costs that go beyond this set annual amount. While some people never reach their coverage limit, the cost of a single root canal and crown can wipe out your annual maximum.

Exclusions and Limitations

Your dental coverage may have limitations about covering certain procedures for certain people. For instance, orthodontic treatment may only pertain to individuals under certain ages. Pre-existing conditions like replacing teeth that were missing before you joined the insurance plan may also not be covered.

Sometimes a waiting period may also be involved if you are a new enrollee to your insurance policy. New enrollees may need to wait up to six months for something like a crown, and up to 12 months for coverage on dentures.

Traditional dental insurance does not cover cosmetic procedures either. Treatments like dental veneers or whitening are considered elective, and as such, they are the financial responsibility of the patient. This includes dental implants, as dentures can replace missing teeth for less, and insurance coverage may mandate the use of less expensive treatments.

Get a Breakdown or Pre-approval

If you provide your insurance information to your dentist, their office should be able to provide you with an estimate of your total out of pocket expenses and what your insurance will cover. You can also request a pre-approval for a written quote from your insurance company prior to beginning any major dental work to ensure you’re covered

Aetna dental insurance helps you maintain your healthy smile. Depending on your dental care needs you may want to look into an Aetna dental savings plan. Dental savings plans are an alternative to dental insurance that can help make expensive dental treatments more affordable. To find out more about Aetna dental savings plans, contact us today!

Let’s see what you could save.

Our savings calculator is designed to show you what you can save with a dental savings plan. We’ll automatically include your preventive care and show you how quickly your plan can pay for itself. Get started below.

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How many family members should be included?

Select the procedures that you need.

Sources

Mayo Clinic, “Oral health: A window to your overall health” 

Cleveland Clinic, “How Your Oral Health Affects Your Overall Health”