Can Health Insurance Cover Dental?

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by Jeffrey A.
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In general, dental coverage is covered through health insurance under the guidelines of the Affordable Care Act. This allows an individual to search through the Health Insurance Marketplace, find an insurance plan, and compare the prices of dozens of plans that offer dental coverage. 

While there are many health insurance plans in the marketplace, it is important to note that not all of them will include dental coverage. In the event that you don’t find the right plan for you, you can always opt to purchase a standalone dental insurance plan.

Marketplace Dental Categories 

The marketplace divides dental coverage into two separate categories: High and Low. Both of these categories were implemented in order to facilitate the comparison and purchases of dental plans. 


What does it mean for a dental plan to be sorted into this category? It means that the coverage level will be higher alongside increased premiums. In effect, copayments and deductibles will be much lower. So, although the insuree pays more every month, they’ll be paying less when utilizing dental services.


In the low coverage category, the opposite happens where premiums are low, but copayments and deductibles are higher. Under these circumstances, the consumer pays less every month yet will pay more when making use of the dental services provided.

What Are The Types of Dental Plans?

For any consumer that is shopping for a new dental plan, there are a variety of options to choose from. The types of options available in the marketplace for the consumer can range from a complex plan such as a Dental Health Maintenance Organization plan to a simpler one like a referral dental plan. The list of options available for purchase includes:

Dental Health Maintenance Organization (DHMO)

A Dental Health Maintenance Organization (DHMO) plan offers a network of dentists, similar to the network of an HMO, that accepts your plan with either an established copayment fee or no fee in the end. Unfortunately, a DHMO does not cover out-of-network fees. 

Preferred Provider Organization (PPO)

In the case of a Preferred Provider Organization (PPO) plan, the consumer is offered a set list of dentists from a provider network that accepts your plan. Unlike a DHMO, a PPO will allow you to seek treatment with dentists outside of the network. The downside to this is that you will be paying a much higher out-of-pocket fee when compared to using the PPOs network providers.  

Referral Dental Plan

With a discount or a referral dental plan, the consumer is offered an alternative form of “coverage” which differs from that of a health insurance plan. Instead of having your cost of treatment covered under the insurance, the referral dental plan provides the individual with a discount on the dental services offered by a specific group of dentists. As a result, how much you pay will be dependent on the discount offered by the dentist. 

What Are The Services Covered By These Plans?

All of these dental plans cover many different aspects of dental care. In general, these plans will offer coverage for preventative care alongside essential services such as root canals, oral surgery, fillings, tooth extractions, and crowns. Depending on the plan you choose it is possible services such as orthodontics and prosthodontics fall under coverage. 

The coverage structure for most of these plans falls under a 100-80-50 support system. The system is designed to provide 100% of preventative care coverage, 80% of basic services, and at least 50% of essential operations coupled with a copayment. 

For this reason, when considering the payment cap for a dental plan, the annual maximum, or how much the insurer is willing to pay for your treatment isn’t that high. If you were to surpass this payment cap, any expense after that will come out-of-pocket. So before opting for a specific plan, it best you review the services covered and how much that insurance company is willing to pay.

Does Medicare Offer Dental Coverage?

For the most part, Medicare does not offer coverage for all dental services such as fillings, tooth extractions, dental devices, or cleanings (among other things). However, under Medicare Part A, any inpatient hospital services are covered in case of an emergency or a situation that requires immediate dental treatment. 

In order to receive the services and coverage provided by inpatient hospital care, the patient should go to a long-term care hospital, inpatient rehabilitation facility, critical access hospital, or an acute care hospital.

How Can I Find Dental Coverage?

When attempting to find dental coverage, one of the most basic yet useful ways of doing so is through the health insurance marketplace. In this marketplace, dental coverage is offered in numerous plans. You can contrast and compare the services each plan has to offer in order to ensure that you pick the plan that is most suitable, but affordable for you or your family.  

The services, costs, and the number of plans offered will vary according to the state in which you live. Additionally, there are certain services established by the Affordable Care Act that you must remember when browsing through the marketplace. For instance, when searching for a plan for your child, you must choose a plan with dental coverage that is available for children under the age of 18. The ACA established that dental coverage is an essential service for children. Therefore, while it is not an essential need for insurers to provide dental coverage for adults, it is a must for children. 

Do You Want To Cancel Your Dental Plan?

If by any chance you wish to cancel your dental plan, you are more than free to do so. However, if you want to cancel your dental plan, yet retain your health insurance plan, there could be some obstacles depending on the plan you have. For example, if you’re opting to cancel a stand-alone dental plan that is separate from your health insurance plan, then you can cancel any time you want.

On the other hand, if you wish to cancel a dental plan that is part of a broader health insurance plan, then you can do so under special circumstances known as a Qualifying Life Event (QLE). This means that unless you pass through a QLE such as marriage, loss of health insurance, or having a baby, then you won’t be allowed to switch to a new health insurance. 

If you do qualify, however, you’ll be able to opt for a plan with or without dental coverage, but not with dental coverage as a stand-alone component. 

Are Pre-Existing Conditions Covered By Dental?

Attempting to find a dental plan that offers coverage for pre-existing conditions can be quite difficult. For the most part, you won’t be able to find a plan that offers coverage, and as a result, you are forced to pay out-of-pocket. 

In contrast to medical insurance which is heavily regulated, and thus requires plans to offer coverage for pre-existing conditions, the same can’t be said for dental insurance plans. In the world of dentistry, the main focus is on the prevention of conditions such as gum disease or tooth decay. 

Unfortunately, dependent on the condition you may have, the out-of-pocket costs in order to treat any already existing oral disease will vary significantly.


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