Oral health is a vital part of your well-being, but that doesn’t mean it’s always covered by insurance. You may have some procedures covered by your provider, while others need their own coverage.
Understanding the Difference: Medical vs. Dental Insurance
Medical insurance, or health insurance, is a type of insurance policy that generally covers doctor’s visits, cancer and disease screenings, mental healthcare, and surgical procedures.
Dental insurance is a type of insurance that solely covers oral healthcare services, including cleanings, crowns, implants, root canals, tooth extraction, and more.
Some medical insurance providers allow you to add dental coverage to your policy, while others do not offer any dental coverage as part of their services. You may need to purchase separate dental insurance from the same or a different provider if you would like coverage.
However, medical insurance may cover some types of dental procedures depending on their purpose and impact on your overall health.
Types of Dental Procedures Potentially Covered by Medical Insurance
While the Affordable Care Act (ACA) requires dental coverage for children as part of essential health benefits, it does not mandate dental coverage for adults. However, adult medical insurance may still cover certain dental-related procedures when they are considered medically necessary and directly tied to a diagnosed medical condition or injury.
To qualify for medical coverage, the procedure must typically address a functional health issue, not just routine dental care or cosmetic improvement. In these cases, your dental provider may be able to bill your medical insurance using specific diagnosis and procedure codes. Common examples include:
Oral Surgery
Certain oral surgeries may be covered under medical insurance if they address a medical condition or cause significant functional impairment. For example:
- Wisdom tooth removal due to impaction, infection, or nerve involvement
- Biopsies for suspected oral cancers or lesions
- Surgical drainage of oral abscesses related to systemic infection
In contrast, if the surgery is purely dental, like elective extractions for orthodontics, it likely won’t be covered.
Treatment for Trauma or Injury
Medical insurance often covers dental procedures required as a result of traumatic injuries. This includes:
- Accidents involving falls, collisions, or sports injuries
- Emergency care for fractured jaws or teeth
- Surgical reconstruction or bone grafts following trauma
Services such as X-rays, CT scans, tooth repair, or implants may be reimbursed if they’re part of treating a broader injury, not standard dental wear or decay.
Procedures Related to Medical Conditions
When a systemic medical condition affects your oral health, certain dental procedures may be eligible for medical insurance coverage. Examples include:
- Sinus lifts are required for reconstructive surgery due to chronic sinus conditions
- TMJ (temporomandibular joint) treatments when they address functional jaw impairment
However, coverage for these procedures depends heavily on your insurer’s policies and may require extensive documentation. In the case of TMJ, insurers often require that non-invasive treatments be attempted first, like splints or physical therapy, before approving surgical intervention. The condition must be medically diagnosed, and the treatment must have a valid medical billing code.
Procedures Requiring a Hospital Setting
If your dental procedure must be performed in a hospital or under general anesthesia, your medical insurance may cover related hospital and anesthesia costs. This is more likely when:
- You have an underlying medical condition (e.g., heart disease, epilepsy, developmental disabilities)
- The dental procedure involves surgical risk that necessitates a controlled hospital environment
- The treatment is part of managing a larger health issue or emergency
The main determining factor in this case is whether the treatment is required because of an underlying physical condition. The condition and treatment must have a corresponding medical code that can be billed to your insurance provider.
Procedures Requiring a Hospital Setting
If you need dental treatment that requires going under general anesthesia or being hospitalized, medical insurance could cover it. This treatment could be due to an emergency, trauma, or an ongoing medical condition.
Factors Determining Coverage by Medical Insurers
- Medical necessity
- Insurer policies and rules
- State law
Check your insurance plan details to know specifically what types of treatment they cover, including any services related to dental care or oral health. While routine dental healthcare is not covered by medical insurance, treatment for specific conditions, such as TMJ or periodontal disease, often are.
How to Verify Coverage for Your Procedure
Speak with the billing department at your dentist’s or oral surgeon’s office. Ask them if they accept your insurance or if they are able to bill your insurer after treatment. You can also read your policy, contact your insurer, and confirm if they cover the treatment you are planning to have.
It’s important to verify insurance coverage from your provider and the dentist or oral surgeon to make sure there are no misunderstandings. Taking the time to determine coverage beforehand can reduce stress and help you make any necessary adjustments to your budget.
Procedures Not Usually Covered by Medical Insurance
Elective care is never covered by medical insurance, and it’s often not covered by dental insurance either. Cosmetic dentistry is performed to enhance the appearance of your smile, but it is not medically necessary. Examples include teeth whitening, gum grafting, and veneers.
Orthodontic treatment is also not often covered by medical insurance, especially if the tooth or jaw misalignment do not cause any functional impairment. You should always discuss coverage options with your insurer and care provider to be fully aware of potential costs prior to scheduling treatment.
FAQs: Medical Insurance and Dental Coverage
How do you get medical insurance to pay for dental work?
You will have to demonstrate that the dental treatment is medically necessary and part of treatment for a diagnosable medical condition. Your dentist’s billing department must also be able to provide a billable code for the treatment you receive.
Is oral surgery covered by medical insurance?
Medical insurance may cover oral surgery if it is required to treat facial trauma, oral cancer, or an underlying medical condition. It’s important to understand the limitations of medical insurance when treating oral health conditions and review your options. In most cases, dental insurance will offer more comprehensive coverage for oral surgery.
What is the highest limit on dental insurance?
Dental insurance plans typically have a maximum limit they’ll pay each year for coverage. The highest is around $5,000, while the average maximum ranges from $1,000 to $2,000. Every policy is unique, and you should ask an insurer about their annual maximum when budgeting for your dental care.
How much does most dental insurance pay for implants?
The amount of coverage a dental insurer will pay for dental implants depends on whether they are medically necessary. If the implants are solely for cosmetic restoration, most insurers will not cover the costs. While some dental plans offer partial coverage for medically essential implants, many exclude them entirely or only contribute up to your plan’s annual maximum, which is often between $1,000 and $2,000.
