Orlando Harmon
Whether your medical insurance covers dental work depends on your insurance provider and plan coverage. In most cases, medical insurance plans will cover some major oral surgery procedures, especially if they are deemed medically necessary. For example, if you are in an accident that results in broken teeth, or if you are the victim of violence, your medical insurance will usually cover the dental work needed after such a traumatic event.
| Characteristics | Values |
|---|---|
| Dental work covered by medical insurance | Traumatic events, such as accidents or violence resulting in broken teeth, motor vehicle collisions, sports injuries, falls, natural disasters, and other physical injuries |
| Medical conditions or treatments, such as radiation therapy for cancer patients, TMD orthotics, sleep apnea, or conditions affecting the temporomandibular joint (TMJ) | |
| Oral surgeries to correct non-dental physiological conditions resulting in severe functional impairment, e.g., complicated wisdom tooth surgery requiring general anesthesia | |
| Diagnostic procedures, evaluations, and surgical services to diagnose or treat medical conditions, including head and neck evaluations for orofacial medical problems | |
| Emergency treatments, such as infection or inflammation, incisions, and drainage of abscesses | |
| Custom treatments for patients with specific medical conditions, e.g., custom home fluoride trays for cancer patients | |
| Frenectomy (tongue surgery) for infants and children | |
| Clearance exams before chemotherapy or surgery | |
| Dental work not typically covered by medical insurance | Routine dental care, including cleanings, fillings, and standard check-ups |
| Cosmetic procedures, such as teeth whitening or veneers, which are not medically necessary | |
| Dental insurance | Can be purchased separately from dental insurance companies, with an average cost of $52 monthly for comprehensive care and $26 for preventive care plans |
| May be included in health insurance plans, but this is not typical | |
| May be offered by states and companies as adult dental insurance, though not required |
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What You'll Learn
Traumatic events and injuries
Dental insurance is typically purchased as a separate plan from health insurance. However, there are instances when health insurance may cover dental work, particularly in the case of traumatic events and injuries.
It is important to note that if the accident involved a motor vehicle, dental work may be covered under auto insurance instead. In such cases, it is best to consult an insurance specialist or your health plan to determine which plan is primarily responsible for the related dental care. Additionally, public venues such as restaurants, schools, and sporting arenas typically carry liability insurance that may cover dental injuries sustained on their premises.
To ensure coverage, dental practices must provide all the information required by medical insurance companies on their claims. This includes linking the treatment to a diagnosed medical condition and using the corresponding medical code. Certain medical conditions or treatments, such as radiation therapy for cancer patients or conditions of the temporomandibular joint (TMJ), may be covered by medical insurance instead of dental insurance.
Overall, while dental insurance is typically purchased separately, health insurance may cover dental work related to traumatic events and injuries. It is important to consult with insurance providers and dental professionals to understand the specific coverage and billing procedures.
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Medical conditions and treatments
Health insurance does not usually cover dental care, but there are exceptions when a health plan may pay for dental work. Certain medical conditions or treatments may be covered by medical insurance instead of dental insurance. For instance, if you are a victim of a traumatic event such as an accident or violence, the dental work required may fall under the scope of your medical plan. In such cases, dental work may be covered under auto insurance if the accident involved a motor vehicle.
Dental insurance is more easily positioned to cover preventative treatment. However, in some cases, medical insurance will cover dental work, especially if it is a diagnosed medical condition. Medical insurance will pay for a procedure if it is necessary to treat a diagnosed medical condition. All dental offices can bill medical insurance for evaluations, diagnostic procedures, and surgical services to diagnose or treat medical conditions.
There are specific categories of dental procedures that may be billed as medical. Before billing the treatment to medical, a dental billing service provider will make sure that it falls under one of the following categories:
- Diagnostic procedures: This includes any service to diagnose a medical condition, such as examinations, consultations, medical x-rays and scans, stents, and testing to discover the sources of pain.
- Non-surgical medical treatments: Dentists can bill non-surgical treatments used to treat a diagnosed medical condition.
- Surgical procedures: Medical insurance will cover some types of oral surgeries, such as those that correct a non-dental physiological condition that results in a severe functional impairment. If the procedure requires general anesthesia, it may be billed to the medical plan.
Additionally, your medical insurance may also pick up the cost in full or part for medically-related oral surgery procedures depending on your plan, medical health status, and the type and degree of difficulty of the surgery.
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Oral surgeries
Oral surgery can be expensive, so it is important to know how your insurance can help with the cost. Oral surgeries can include the removal of diseased or impacted teeth, wisdom tooth extraction, dental implants, biopsies, tumor removals, repair of trauma, and other surgical issues involving the bones and soft tissues of the face.
Your medical insurance may cover oral surgery in full or in part, depending on your plan, medical health status, and the type and difficulty of the surgery. Oral surgery is often considered a "major service" and may or may not be covered by your dental plan. If your dental plan does not cover major services, it may not cover any part of your oral surgery. In some cases, both your dental and medical insurance may pay a portion of your treatment.
If the oral surgery is to treat a diagnosed medical condition, it is more likely to be covered by medical insurance. Medical conditions that affect your dental and overall health are usually considered medical reasons for seeking dental services and may be payable under your health plan. For example, medical insurance will likely cover oral surgery to correct a non-dental physiological condition that results in a severe functional impairment. One example is complicated wisdom tooth surgery that may require more than standard dental procedures to complete. If the procedure requires general anesthesia, it may be billed to the medical plan. Other surgical procedures covered by medical insurance include soft and hard tissue biopsies, such as the excision of cysts and tumors of the maxilla, mandible, and surrounding tissues.
It is important to note that medical insurance typically does not cover routine dental care, including cleanings, fillings, and standard check-ups. Cosmetic procedures such as teeth whitening or veneers are also generally excluded.
To determine whether your oral surgery will be covered by insurance, it is recommended that you speak with your dentist or dental specialist office staff to see if they have experience filing medical claims. They can give you an idea of the likelihood of receiving coverage and help you obtain a predetermination of benefits. You can also talk directly with your insurance provider to get an estimate of how much they will pay and what out-of-pocket costs to expect.
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Dental insurance costs
Dental insurance is not typically covered by health insurance. However, there are some instances where your health insurance may cover dental work, such as in the case of an emergency or a medical condition.
The cost of dental insurance can also depend on your age, location, and the type of dental care you expect to need. For example, a full-coverage dental plan may be more expensive but will cover complex dental treatments. On the other hand, a Dental Health Maintenance Organization (DHMO) plan tends to be more affordable, but you will have a smaller network of dentists to choose from.
It is important to carefully review the details of a dental insurance plan, including coverage exclusions, waiting periods, and other limitations. Some plans may only cover a portion of the cost of dental treatments, and you may still be responsible for out-of-pocket expenses.
In addition to the monthly premium, other costs associated with dental insurance include the deductible, copays, coinsurance, and annual maximums. The deductible is the amount you pay for dental care before your insurance starts contributing. The coinsurance is the portion of the dental costs that you pay after meeting your deductible, and the annual maximum is the total amount your insurance will pay each year.
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Medical diagnosis
Health insurance does not usually cover dental care. However, there are exceptions when a health plan may pay for dental work. For instance, if you are in an accident that results in broken teeth or are the victim of violence, the dental work needed after such a traumatic event will usually fall under the scope of your medical plan. If your accident involved a motor vehicle, dental work may be covered under auto insurance. Certain medical conditions or treatments, such as radiation therapy for cancer patients or a medical condition of the temporomandibular joint (TMJ), may also be covered by medical insurance.
Dental insurance plans have a low annual maximum benefit. When treating a patient who has medical and dental issues that are related, the dentist can bill the patient’s medical insurance for the procedure. This will reduce financial stress for patients by maximizing their insurance coverage. Medical insurance plans typically cover treatment provided by dentists as medical procedures, not dental procedures. The key to successful dental medical billing is knowing when a dental procedure is considered medical and billable to medical insurance.
For a procedure to be covered by medical insurance, it must be necessary to treat a diagnosed medical condition. All dental offices can bill medical insurance for evaluations, diagnostic procedures, and surgical services to diagnose or treat medical conditions. The procedure should have a corresponding medical code to ensure it is classified correctly under medical insurance guidelines and show its relevance to the patient's overall health. There are specific categories of dental procedures that may be billed as medical, including diagnostic procedures, non-surgical medical treatments, and surgical procedures.
Some examples of surgical procedures covered by medical insurance include soft and hard tissue biopsies, such as the excision of cysts and tumors of the maxilla, mandible, and surrounding tissues. Extractions and placement of dental implants are also usually covered, although tooth root replacement falls under what is allowable by a patient's medical plan. In some cases, both dental and medical insurance may pay a portion of the treatment.
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Frequently asked questions
Health insurance doesn't usually cover dental care, but there are exceptions. Medical insurance will typically cover dental work related to an emergency or medical condition. For example, if you are in an accident that results in broken teeth, or you are the victim of violence, the dental work required after the traumatic event will usually fall under the scope of your medical plan.
Medical insurance will cover some types of oral surgeries, such as those to correct a non-dental physiological condition that results in a severe functional impairment. For example, complicated wisdom tooth surgery that requires more than a standard dental procedure to complete.
The treatment must be linked to a medical condition and have a corresponding medical code. It's important to check with your insurance company, as it will often come down to the company, dates of service, and the dental care you're requesting payment for.
