Whether or not insurance covers the cost of a custom night guard depends on the specific insurance plan. While some insurance companies provide full coverage for bruxism treatment, others only offer partial coverage, and some don't pay for any bruxism-related treatment. The average insurance policy will pay for roughly half of the cost of a night guard.
The cost of a custom-fitted night guard ranges from $300 to $1,000, depending on the dentist, location, oral health concern, and insurance plan. Night guards are typically not considered preventative care, and insurance companies often prioritise coverage for medically necessary procedures.
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Insurance coverage depends on the specific insurance plan
Another factor influencing insurance coverage is whether the night guard is deemed medically necessary. Dental insurance plans often prioritize coverage for procedures and treatments that are considered medically necessary. While a night guard can effectively address teeth grinding or clenching (bruxism), some insurance providers may not view it as a medical necessity and, consequently, may not offer coverage. In such cases, you may need to provide documentation or a prescription from a healthcare professional to demonstrate medical necessity and improve your chances of coverage.
The type of insurance plan you have also plays a role in determining coverage. For example, Medicaid, a health insurance program for low-income individuals and families, may cover night guards in certain circumstances. If bruxism is causing harm or damage to your teeth, Medicaid may deem the night guard as medically necessary and provide coverage. However, this coverage can vary depending on the specific Medicaid plan and the state you reside in. Therefore, consulting your state's Medicaid website or directly contacting your Medicaid provider is advisable to understand your specific coverage.
Additionally, insurance coverage for a night guard can be influenced by the provider or dentist you choose. If you obtain your night guard from an out-of-network provider or dentist, your insurance coverage may be limited or non-existent. In contrast, in-network providers typically have pre-negotiated rates with the insurance company, which can result in better coverage and potentially lower out-of-pocket costs for you. Hence, checking with your insurance provider to confirm whether your preferred dentist or provider is in-network is essential.
Lastly, the extent of insurance coverage for a night guard can also depend on other factors, such as deductibles, co-pays, and waiting periods. Even if your insurance plan covers night guards, you may still be responsible for deductibles or co-pays, which are out-of-pocket expenses that must be paid before insurance coverage takes effect. Additionally, some insurance plans may have waiting periods, requiring you to wait for a specified period before night guard coverage becomes available. Therefore, reviewing your insurance policy or contacting your provider to understand these specific details is crucial in determining your overall coverage and out-of-pocket costs.
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Insurance may cover the cost if deemed medically necessary
A custom night guard is a comfortable, non-invasive way to alleviate symptoms associated with TMD and bruxism. It creates a flexible but durable barrier between the teeth, preventing excessive wear due to bruxism. They also reposition the jaws, relieving the jaw joints and surrounding muscles, and reducing orofacial pain associated with TMD.
If you experience any of the following, a custom night guard might be the solution for you:
- Tenderness or pain in the face, jaw, neck, shoulders, or around the ears
- Difficulty opening the mouth or chewing
- Clicking or popping when you close or open your mouth
- Swelling on the side of your face
- An uncomfortable bite
- Teeth grinding or clenching
Your dentist might recommend wearing a custom night guard to help alleviate morning headaches, relieve TMJ jaw pain, and prevent damage to the teeth, jaws, and dental restorations.
Custom night guards are generally anywhere from $300 to $1,000, depending on your dentist, location, oral health concern, and insurance plan. Although a night guard is an investment, most dental insurance plans allow at least some coverage, helping defray the overall cost. Wearing a night guard saves you time and money in the long run, preventing costly dental treatment due to untreated bruxism or TMD. Plus, a custom night guard can last for many years, especially if you take good care of it, clean it, and keep it stored safely when not in use.
Your insurance should cover the cost as long as your dentist deems a night guard medically necessary. To be sure, check with your insurance company. In most cases, you can review your plan online, or you can call your dental insurance customer service and ask for a representative to explain your benefits. They will be able to tell you whether night guards are fully covered, partially covered, or not covered at all.
Most dental insurance plans cover preventative care such as cleanings and x-rays, but not all plans cover major care such as crowns and night guards. If your plan covers other major care such as crowns, bridges, or dentures, it likely covers night guards, but always be sure to check first.
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There may be a waiting period before coverage is available
When it comes to insurance coverage for a custom night guard, it's important to understand that there may be a waiting period before coverage is available. Dental insurance plans can vary significantly, and it's essential to carefully review your specific plan or consult your insurance provider directly to determine the exact terms and conditions of your coverage.
Waiting periods are a common feature of dental insurance plans, and they can apply to various services and appliances, including custom night guards. This means that after purchasing your insurance plan, you may need to wait for a certain period before you are eligible to receive coverage for your night guard. The duration of this waiting period can differ depending on the insurance provider and the specific plan you have selected. In some cases, you might have to wait several months or even up to a year before coverage for custom night guards becomes available.
The purpose of waiting periods is to mitigate the risk of adverse selection for insurance companies. Without waiting periods, individuals could potentially purchase insurance only when they need it, such as right before getting a custom night guard, and then cancel the policy afterward. Waiting periods encourage long-term commitment to insurance plans and help insurance companies manage their financial risks more effectively.
During the waiting period, it's important to understand that you will be responsible for covering the full cost of the custom night guard. This can be a significant financial burden, especially if you require a high-quality, custom-made night guard to address issues such as bruxism or TMJ disorders. However, it's worth noting that some insurance plans may offer partial coverage for these devices even during the waiting period, so be sure to review your plan's specifics.
To make the waiting period more manageable, you can explore alternative options for obtaining a custom night guard at a more affordable price. For example, you could consider purchasing a boil-and-bite night guard, which is a less expensive option available over the counter. While it may not provide the same level of comfort and durability as a fully custom-made night guard, it can be a temporary solution until your insurance coverage kicks in. Additionally, some online dental labs offer direct-to-consumer services for custom-fitted night guards at more affordable prices, and payment plans or financing options may be available from dental offices or labs.
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Out-of-network providers may not be covered
In some cases, your insurance plan might pay part of the bill, but you will be responsible for the remaining amount. This is especially true if your plan only covers in-network care or if you haven't met your out-of-network cost-sharing limit. Even if your insurance company agrees to pay, the out-of-network provider can still bill you for the difference between their charge and the insurance company's payment, a practice known as "balance billing".
To avoid unexpected costs, it is important to understand the difference between in-network and out-of-network providers. In-network providers have signed a contract with your insurance company, agreeing to accept the insurer's discounted rates as payment in full. This means that if the provider charges $160 for a service, but has agreed to accept $120 from patients with your insurance, the remaining $40 is written off, and the patient only pays their copay, with the insurance company covering the rest.
However, if you go to an out-of-network provider for the same service, you will likely be billed the full $160, and your insurance company may not cover any of it. Even if they do cover part of it, you will still have to pay the remaining amount, which can be significantly more than what you would have paid with an in-network provider.
There are some situations in which you may need to go out-of-network, even though it will cost more. For example, if you or a family member has a rare illness, such as a genetic disorder, and no provider in your network has the necessary training or experience to treat it effectively. In these cases, you can request prior approval from your insurer to receive care out-of-network at the in-network rate.
Additionally, in an emergency, you may need to seek care from the closest available provider, which might be out-of-network. In these cases, the Affordable Care Act (ACA) requires insurers to cover emergency care as if it were in-network, and the No Surprises Act prohibits out-of-network providers from sending you a balance bill for emergency services.
Furthermore, if you are already being treated by an in-network doctor for a serious condition and you switch to a new health plan or the doctor leaves the network, you may be able to continue seeing the same doctor at the in-network rate for the duration of your treatment.
In conclusion, while out-of-network providers may not be covered by your insurance, there are some circumstances in which you can receive care out-of-network and still pay in-network rates. It is important to understand the difference between in-network and out-of-network providers and to carefully review your insurance plan to know what is covered and what your costs will be.
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It's not usually considered preventative care
Night guards are not usually considered preventative care by insurance companies. Preventative care typically refers to routine services that aim to prevent dental problems, such as regular check-ups, cleanings, and X-rays. These services are often covered by dental insurance plans at a higher percentage or even fully.
On the other hand, night guards are primarily used to protect teeth from damage caused by grinding or clenching, which is a habit rather than a preventive measure. While night guards can help prevent further damage to teeth and alleviate symptoms associated with bruxism, they are generally considered a treatment for an existing condition.
However, it's important to note that dental insurance plans can differ in their coverage policies, so it's always a good idea to review your specific plan or contact your insurance provider to understand how they categorize night guards and what coverage may be available.
Some insurance plans may cover night guards if they are deemed medically necessary by a dentist. Additionally, Medicaid may cover night guards in certain cases, depending on the state and specific plan. If you are experiencing symptoms of bruxism, such as tooth pain, jaw pain, or headaches, it is best to consult with your dentist to determine if a night guard is the right treatment option for you.
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Frequently asked questions
A custom night guard is a small dental device that you wear on your teeth while sleeping to protect them from grinding or clenching together, which can result in permanent damage to the tooth anatomy and surrounding components (such as gums and jaw muscles).
Insurance companies may consider a custom night guard as a treatment for an existing condition, such as bruxism or sleep apnea, rather than preventive care. The extent of coverage can vary depending on the specific insurance plan, with some plans offering full or partial coverage for bruxism treatment, while others do not cover it at all.
To determine if your insurance covers a custom night guard, review the details of your specific insurance policy or contact your insurance provider directly. They can provide information on coverage, limitations, exclusions, and potential out-of-pocket costs.