Sometimes, people ask overly broad questions of the wrong source.
“Does Blue Cross Blue Shield (BCBS) cover dental implants,” is one such query.
You need to narrow the question considerably. Also, ask your plan administrator for specific details instead of relying on Internet answers.
Critical Points
- The BCBS system consists of independently owned and locally operated companies.
- Each organization issues many different plans serving different markets.
- Each plan will have unique benefits, rules, exemptions, and procedures.
- We can only illustrate broad principles in this article.
- Your BCBS plan administrator makes final claims decisions.
BCBS Medical Insurance
Blue Cross Blue Shield medical insurance rarely covers dental implants. Many individuals, families, and workers at employer groups have this private coverage.
You must prove that the dental implants are medically necessary: they treat an illness, injury, or symptom. Otherwise, health care does not extend to your teeth and gums.
Necessary Accidents
If you lose teeth in an accident that your BCBS medical insurance covers, it might pay for some dental implant services. Treating an injury is medically necessary.
For example, suppose you fall, fracture your jawbone, and dislodge one or more teeth.
Your plan should cover the emergency dental work to relieve pain, stop bleeding, reduce jaw fractures, and remove remaining tooth fragments. If your accident is covered, your plan might also pay for a prosthesis to replace the lost teeth.
Necessary Illnesses
If you have cancer of the head or neck, your BCBS medical insurance might cover dental implants. Treating a sickness is medically necessary.
For example, suppose you need teeth removed before radiation therapy.
Your health insurance should cover the extractions as part of your cancer treatment. The plan might cover bone grafting, dental surgeries, and even replacing lost teeth after you recover from a covered illness like cancer.
BCBS Dental Insurance
This article does not confirm Blue Cross Blue Shield dental insurance coverage for tooth implants. With over thirty independent companies issuing many plans, there are too many possibilities.
However, we can help you navigate common issues.
Plan Document
Your plan documents define whether your BCBS dental plan includes tooth implant coverage. Look at your member ID card and follow one of these steps to verify benefits.
- Call the customer service number on your insurance card and ask.
- Log into the online member portal and find the coverage overview.
Your plan may cover certain services while excluding others. Check for waiting periods, frequency limits, and exclusions that apply to these services.
- Imaging studies
- Extractions
- Bone grafting surgery
- Alveoloplasty
- Implant body placement
- Abutment insertion
- Denture or crown
Missing Tooth Clause
Many BCBS dental plans have a missing tooth clause. This exclusion means they won’t pay to replace teeth lost or extracted before your coverage begins.
Edentulous patients have a problem: their missing teeth are a pre-existing condition.
It’s challenging to bypass the missing tooth clause. The Affordable Care Act requires health insurance to cover pre-existing conditions with no waiting period. Still, it does not apply to dental plans.
Annual Maximum
Many BCBS dental plans have annual maximums that are often less than the cost of a single tooth implant.
Even with coverage, dental implant costs can far exceed the annual maximum, which might be as low as $1,500. Consider these average retail prices.
- Single tooth implant: $3,500
- Full-mouth reconstruction: Over $35,000
- All-on-Four implants: $20,000 per arch
You can circumvent the dental insurance annual limit by planning your treatment over two years. You can optimize your benefits by scheduling treatments to align with natural healing periods.
- Your gums need time to heal after tooth extractions and abutment insertions.
- Your jawbone requires a healing period after grafting and ridge augmentation, also known as alveoloplasty.
- Osseointegration, where the implant fuses with the jawbone, can take up to six months.
BCBS Medicaid Plans
Dental implants are seldom covered under Medicaid plans managed by Blue Cross Blue Shield. Medicaid is a joint federal and state government-run insurance program for low-income families and children.
Many states outsource administration and claims processing functions to private insurance companies with this expertise.
Medicaid coverage for adult dental implants varies as each state adopts unique policies.
Medicaid Health Insurance
Medicaid primarily provides health insurance with fairly consistent nationwide benefits, as mandated by the federal government.
Your BCBS-administered Medicaid plan may include dental implant coverage if it’s medically necessary. If you need oral care due to tooth loss from a covered accident or illness, promptly request pre-certification.
Medicaid Dental Insurance
While Medicaid sometimes includes dental insurance, the federal government doesn’t mandate oral care benefits, so coverage varies by state.
Your state’s Medicaid plan, administered by BCBS, will cover dental procedures included in your state’s benefits. However, due to the “least costly treatment” rule, which favors the most economical option, Medicaid plans often exclude coverage for implants.
Low-income adults may be eligible for free dentures through Medicaid. Medicaid covers removable dentures in at least 34 states, often the most affordable solution for replacing missing teeth.
BCBS Medicare Advantage
Many Blue Cross Blue Shield companies offer Medicare (Part C) Advantage Plans. Retired seniors over 65 and individuals with disabilities can purchase this coverage instead of the government-run Parts A, B & D.
Medicare Advantage Plans covering tooth implants are rare. A BCBS plan will include features similar to those described before for medical and dental coverage.
Advantage Medical
Medicare Advantage Plans (Part C) is primarily health insurance. Covered services mirror the government-managed Part A (hospitalization) and Part B (medical care).
If you lose teeth due to an accident or illness that your BCBS plan covers, request pre-certification for dental implants immediately, as they may be covered when medically necessary.
Advantage Dental
Medicare Advantage Plans often include additional benefits not offered under the government-run Parts A & B. For instance, dental and vision care are frequently covered extras.
Contact your BCBS plan administrator to verify benefits before starting dental implant work. Your member ID card gives you the information needed to confirm what your plan includes.
- Call the customer service number on the card to ask about benefits.
- Log into the online member portal to view the details of your coverage.
BCBS Federal Employees
The Blue Cross Blue Shield Federal Employee Program (FEP) covers dental implants. Still, coverage limits under the plan’s medical and dental parts restrict benefits.
Most civilian workers and retired uniformed service members and their families can enroll.
FEP Medical
Patients with only the BCBS FEP medical insurance will receive dental implant coverage solely in medically necessary cases. However, qualifying for such benefits is rare.
If you experience tooth loss due to a covered accident or illness, promptly contact BCBS FEP for pre-certification of necessary oral care.
- Call 1-800-411-BLUE (2583) to speak to customer service
- Use the My Blue online portal to submit your dental claim.
FEP Dental
The BCBS FEP dental insurance covers tooth implants. However, the out-of-pocket costs federal employees pay for tooth implants vary by their chosen plan and the prosthodontist’s network status.
Enroll in coverage during the open season, which runs from mid-November to mid-December, or at any point in the year if a qualifying life event occurs.
The contrasting examples show that your provider and plan choices will impact your out-of-pocket costs.
- Single tooth ($3,500 average retail price)
- Full-mouth ($35,000 average retail price)
In-Network
Federal employees typically pay less when they choose an in-network prosthodontist and pick a plan that covers more.
In-network providers must accept the allowed amount as full payment. This figure is often a substantial discount compared to what the dentist typically charges. In this example, the assumed savings are 40% off the average retail price.
- Single tooth ($2,100 average wholesale price)
- Full-mouth ($21,000 average wholesale price)
| Standard Option | High Option | |
|---|---|---|
| Deductible | $0 | S0 |
| Coinsurance | 65% | 50% |
| Annual Maximum | $1,500 | Unlimited |
| Single Tooth Cost | $1,365 | $1,050 |
| Full-Mouth Cost | $19,500 | $10,500 |
Out-of-Network
Federal employees who see a prosthodontist outside their network will pay much more themselves, and this is even more true for those with the basic insurance plan.
Providers outside the network may charge patients the difference between the total cost and what the insurance allows.
| Standard Option | High Option | |
|---|---|---|
| Deductible | $50 | $75 |
| Coinsurance | 80% | 60% |
| Annual Maximum | $750 | $3,500 |
| Single Tooth Cost | $2,800 | $2,100 |
| Full-Mouth Cost | $34,250 | $31,500 |
Covered Services
Federal employees should expect their BCBS dental plan to cover many implant treatment steps. Your dental specialist should know the specific billing codes for each service, as set by the American Dental Association.
Below is a sample of covered services.
| ADA Code | Service Description |
|---|---|
| D7311 | Alveoloplasty in conjunction with extractions |
| D7953 | Bone replacement graft for ridge preservation |
| D6010 | Surgical placement: endosteal implant |
| D6040 | Surgical placement: eposteal implant |
| D6050 | Surgical placement: transosteal implant |
| D6057 | Custom fabricated abutment – includes placement |
| D6058 | Abutment-supported porcelain/ceramic crown |
| D6084 | Implant-supported crown fused to titanium |
