How to Know When Health Insurance Will Cover an Oral Procedure
How to know when an oral procedure is actually a medical procedure and not dental.
Your employees might be able to save money on dental work if they understand the difference between dental care and medical procedures performed in a dentist’s office.
Most dental insurance covers routine cleanings at 100 percent. However, policies usually have a low annual maximum benefit and only pay a small fraction of the cost of other treatments.
The good news is that health insurance might cover certain dental procedures. When health insurance pays for oral surgery it typically pays as the primary payer with no yearly maximum. Dental coverage coordinates benefits as the secondary payer.
Employees who understand the difference between a dental and a medically necessary procedure can remind their provider to bill medical insurance when applicable so the patient can afford to get additional coverage.
Dental coverage is the primary insurance when the procedure is not medically necessary or integral to a covered service under medical insurance.
Dental care focuses on preventive and basic procedures. Preventive procedures are those that keep your mouth healthy, such as cleaning, flossing and taking x-rays. Basic procedures are usually straightforward and don’t involve a significant laboratory expense for the dentist. They include a wide range of services such as:
- Fillings to treat teeth for cavities or decay or to repair teeth that have fractures.
- Dental crowns to repair teeth damaged by decay or injury.
- Tooth extractions when a decayed tooth can’t be saved.
- Dental implants to replace real teeth.
- Braces to reposition teeth.
A medical procedure is treatment for a diagnosed medical condition that treats an illness, non-biting injury to a sound tooth, condition, disease or its symptoms. An example of an injury that would not fit this definition would be if someone bit into a popcorn kernel and fractured their tooth. That would not be covered by health insurance.
However, if a dentist treats a traumatic injury to a patient’s mouth, it is considered a medical treatment and is probably covered under medical insurance.
Most medical insurance excludes payments for the routine care, treatment and replacement of teeth and related structures such as gums and jawbones. In addition, most health insurance policies exclude dentures, bridges, or crowns because these procedures are viewed as cosmetic, even when they restore function.
Examples of medical procedures include:
- Jaw surgery to correct sleep apnea or Temporomandibular Joint Disorders (TMJ); note that medical plans usually will not pay for orthodontic braces to correct TMJ.
- Extraction of wisdom teeth in some cases
- Repair of cleft-palate and other congenital abnormalities
- Removal of teeth before radiation therapy of the head and neck
- Excision of cysts or tumors of the jaws or facial bones
- Reconstruction following surgical procedures for cancer
- Reduction of facial bone fractures
- Removal of broken teeth necessary to reduce a jaw fracture
- Dental services following non-biting accidents in certain circumstances
- General anesthesia when local anesthesia is not enough; employees should check their policy for a list of qualifying conditions
Encourage your employees to talk to their broker for guidance and to find out how to get the most out of their dental and medical insurance policies.