Dental Insurance - What Is Covered, What Isn't Covered
What Does Dental Insurance Cover?
Dental insurance reduces the cost of dental care and helps patients maintain good oral health throughout life. Insurance allows patients to spend less “out of pocket” and catch signs of oral diseases early. Depending on the provider and plan, insurance typically covers some portion of preventive treatments, restorative procedures, and orthodontic treatment. According to CIGNA’s website, many insurance companies use the “100-80-50” plan, which covers:
- 100 percent of regular preventive care, such as teeth cleanings, dental exams, and fluoride treatment.
- 80 percent of basic dental procedures, such as dental fillings, extractions, and root canals.
- 50 percent of invasive dental procedures, such as bridges, implants, and crowns.
What Does Dental Insurance Not Cover?
Dental insurance does not cover cosmetic dental procedures, also known as esthetic dentistry. Cosmetic procedures are never covered by insurance because they are not considered “medically necessary.” Esthetic procedures include teeth whitening and veneers. Both of these treatments are used to improve a patient’s appearance, rather than restore damaged teeth. The most common age groups that undergo cosmetic dental procedures are patients between 31 to 40 years old (38 percent) and 41 to 50 years old (32 percent).
Insurance Terms to Know
Deductibles
The deductible is the amount patients pay “out of pocket” before treatment. Insurance providers pay for part or all of the expenses after treatment, and patients get reimbursed.
Copayment
A copayment, also called a “copay,” is the shared amount a patient pays for treatment. This amount is usually a percentage of the dentist’s fee.
Dual Coverage
Dual coverage means a patient’s treatment is covered by more than one dental insurance plan.
Treatment Limitations
Depending on the patient’s plan, procedures can only be completed a certain amount of times per year. For example, oral exams are typically only covered twice per year (every six months). If more exams are needed, they are not covered by insurance. Some policies do not cover pre-existing dental conditions, such as missing teeth that were lost or damaged prior to receiving insurance.
Insurance Coverage for Preventive Dental Treatments
These preventive dental treatments are typically covered 100 percent by insurance (after deductible):
Oral Exams
During oral exams, dentists examine the mouth for signs of cavities, gum disease, and other related conditions.
Routine Teeth Cleanings (twice a year)
During teeth cleanings, a dentist removes hard-to-reach plaque and calculus from the surfaces of teeth and between teeth.
Routine X-rays
X-rays aid in the diagnosis of oral diseases that are not visible during a normal dental exam.
Professional Fluoride Treatment (in-office)
Fluoride is a mineral that helps prevent tooth decay and strengthens enamel. Small traces of fluoride are found in tap water, toothpaste, mouthwashes, and professional dental materials.
Sealants
Sealants are thin coatings that form “physical barriers” on the pits and fissures of teeth. They prevent cavity formation early on.
Insurance Coverage for Minor Restorative Dental Procedures
With standard policies, these minor restorative dental procedures are partially covered by insurance (80 percent covered after deductible):
Dental Fillings
Dental fillings are used to fill minor dental cavities (decaying teeth).
Emergency X-rays
Any additional X-rays (more than twice a year) are not fully covered by insurance.
Emergency Dental Services
Mouth injuries resulting in knocked out, fractured, or damaged teeth.
Simple Tooth Extractions
Teeth that need to be removed due to severe decay, injury, or disease (non-surgical).
Insurance Coverage for Invasive Restorative Dental Procedures
With standard policies, these invasive restorative procedures are partially covered by insurance (50 percent covered after deductible):
Root Canal Procedure
Root canal therapy restores infected dental pulp in the roots of teeth and also relieves dental pain.
Scaling and Root Planing
Scaling and root planing involves the removal of plaque and calculus (hardened plaque) above and below the gumline.
Crowns are placed over chipped, broken, or damaged teeth. They protect weak teeth, typically caused by severe decay.
Inlays and Onlays
Inlays and onlays are indirect restorations, which means they are made outside of the mouth in a dental laboratory. They are typically used when a patient’s cavity is too large for a filling.
Dental Bridges
A dental bridge is a fixed restoration that replaces one or more missing teeth in a patient’s dental arch.
Dentures
Dentures are artificial substitutes that replace some or all of a patient’s natural teeth and surrounding tissues.
Repairs of Dental Restorations (Bridges and Dentures)
Repairs are covered by most insurance plans if they are needed more than 12 months after placement.
Oral Surgery
Many oral surgeries are covered by insurance. Surgical tooth extractions, such as impacted wisdom teeth removal, are also covered.
Anesthesia
A safe drug that alleviates pain and discomfort during a dental procedure.
Popular Insurance Providers
Cigna
CIGNA is a common dental insurance provider. There are three types of plans to choose from, depending on the patient’s needs and how many family members they have.
Cigna Dental Preventive (Lowest)
The lowest plan starts at $19 a month per person and covers 100 percent of preventive services. Restorative services and orthodontics are not covered. This plan does not include a deductible.
Cigna Quality Provider Network Dental Coverage (Cigna Dental 1000)
The middle plan starts at $30 a month per person and covers 100 percent of preventive services. Deductibles range from $50 (individual) to $150 (families). Restorative services are covered up to $1,000 per year (after deductible and coinsurance). Orthodontic treatment is not covered with this plan.
Cigna Highest Level of Dental Coverage (Cigna Dental 1500)
The highest plan starts at $35 a month per person and covers 100 percent of preventive services. Deductibles range from $50 (individual) to $150 (families). Restorative services are covered up to $1,500 per year (after deductible and coinsurance). Lastly, orthodontic treatment is covered up to $1,000 (lifetime limit). Orthodontic insurance has a separate coinsurance and deductible.
Other popular providers with similar dental insurance plans include:
- Delta Dental
- Aetna
- Humana
- United Healthcare