Can an individual buy full coverage dental insurance with no waiting periods for pre-existing conditions? You know – something that is real and not a discount plan.
For most people, the answer is probably not for anything beyond exams, X-rays, and cleanings.
The companies lose money by offering instant benefits. Patients frequently cancel after the dentist completes the work (adverse selection). Therefore, they add exclusions to discourage this behavior.
However, there are exceptions to every rule. Some people will find what they need, for certain dental work, at specific times.
- Options for emergencies, major services, orthodontic, and cosmetic procedures
- How dual plans can help with yearly maximum benefit limits
- Federal government help for low-income families and veterans
Full Coverage Dental Insurance for Individuals
Individuals find it difficult to purchase full coverage dental insurance with no waiting periods outside of their employer. The private insurer does not have the opportunity to pool risks with a large group of co-workers or control adverse selection through open enrollment periods.
Patients turn to finance programs to fund the oral care they need right away. Afterward, buying a private plan that covers everything after 3, 6, 12 or 24 months can reduce expenses across the spectrum of care: preventive, basic, and major services.
Full coverage dental insurance for individuals typically covers preventive services without waiting periods. Preventive care does what it suggests. It keeps your mouth, teeth, and gums healthy and minimizes future claims for the carriers.
Therefore, expect most private companies to offer these immediate preventive benefits.
- Oral exams
- Bitewing X-rays
- Prophylaxis (cleaning)
Health insurance covers emergency dental work with no waiting period for any medically necessary treatment. Of course, this holds true only if the person has a policy already in force.
Traumatic injuries to teeth resulting from non-biting accidents are medically necessary. A medical plan should pay emergency claims to remove, repair, replace, restore, or reposition natural teeth and/or bodily tissues of the mouth. This includes X-rays to diagnose possible fractures.
Uninsured patients who need to fill a cavity to alleviate a toothache pain must pay-of-pocket. Financing and discount plans are the best alternatives for help with fillings.
Full coverage individual dental insurance will often pay for major services without waiting periods when the person had prior qualified coverage. Private carriers will waive the pre-existing condition exclusions if the applicant can verify that the old plan expired no more than 60 days earlier.
Two groups of people fit into this category and can enjoy instant benefits for major services.
- Anyone who recently lost coverage after changing employment or other reasons
- Those with existing plans seeking a second policy (see annual maximum section below)
People falling outside of these two groups need to be creative to find immediate help with other major services such as root canals, oral surgery, and implants.
Your medical insurance plan may offer instant benefits for antibiotic treatment before a root canal. Antibiotics can suppress symptoms such as biting pain temporarily. However, they cannot cure the root canal infection permanently.
Uninsured patients will have to “bite the bullet” and pay the endodontist out-of-pocket. Do not delay until an abscess forms and makes matters worse.
- Borrow the money to get started right away
- Purchase a discount plan to reduce expenses
Medical insurance will cover portions of any oral surgery expense with no waiting period. Oral and maxillofacial surgery required because of non-biting accidents or related diseases are medically necessary.
- Wisdom tooth extractions are included
- Erupted teeth
- Soft tissue impacted
- Jaw surgeries are included for a non-biting accident, disease, or defect
- Skeletal deformities that contribute to chewing dysfunction
- Facial discrepancies associated with sleep apnea and other airway obstructions
- Cleft palate causing severe speech defects
- General anesthesia when localized numbing is inadequate
Dentures & Implants
Patients searching for individual dental insurance without a missing tooth clause have fewer options and more restrictions. Borrowed funding and discount plans are the best alternatives for those who need immediate tooth replacement.
- Health insurance rarely pays for dentures, bridges, crowns, or implants. Treatments addressing function, comfort, and appearance are not medically necessary.
- The missing tooth clause is often a stronger exclusion for implants, crowns, or dentures. The delay can be much longer and is sometimes indefinite.
Supplemental dental insurance covers implants without a missing tooth clause. However, the 24-month exclusion for all patients rules out anyone wanting prompt help.
Buying full coverage individual dental insurance covering braces without a waiting period should be unnecessary.
- A visit to the orthodontist is not an emergency. Crooked teeth do not happen overnight. The need should be apparent well in advance. Do the right thing. Purchase a plan with enough lead-time. The math works in your favor.
- Health insurance often covers orthodontia without delay after a non-biting injury. This includes braces to reposition teeth after an accident.
- Medical insurance also covers braces right away for medically necessary treatment such as a malocclusion caused by a cleft palate.
Orthodontic financing and assistance programs can help parents that need to start with braces at once. Supplemental plans are most effective for those who act in advance.
Seeking cosmetic dental insurance also should be unnecessary. Cosmetic procedures address appearance rather than decay, infection, malalignment, or tooth pain. Patients can schedule these elective procedures at their convenience.
Cosmetic dentistry riders are optional features that patients can purchase as part of a full-coverage plan. A rider could make these services more affordable after a 24-month delay.
- Labial veneers
- Occlusion adjustments
- Enamel microabrasion
- Internal and external bleaching
Dental Insurance with No Annual Maximum Limit
Patients looking for dental insurance with no waiting period and no annual maximum sometimes fit into a different category. Many people asking this particular question do so because they have reached the limit on their existing plan – but still have ongoing work needed this year.
If this describes your situation, you meet the criteria for creditable coverage. This means that the new company may waive the exclusions for pre-existing conditions. Therefore, dual coverage is a viable option to minimize the yearly limit problem.
Dual coverage is one method to obtain dental insurance with a higher annual maximum limit. The two can work together to double the yearly limit. However, be careful when choosing between secondary and supplemental designs. Know the key distinctions.
- Secondary dental insurance coordinates benefits with the primary plan (the one considered creditable coverage without waiting periods on pre-existing conditions). The plan design is less important than making sure your provider(s) are in-network with both plans.
- Indemnity plans (fee-for-service) have larger networks (most dentists accepting) but smaller reimbursement levels.
- Preferred Provider Organizations (PPO) have smaller networks (fewer dentists accepting) but higher reimbursement levels
- Health Maintenance Organizations (HMO) is a prepaid plan where one dentist coordinates care within a tight network (least dentists accepting) of providers.
- Supplemental dental insurance can also boost the annual maximum benefit limit. You can use these policies at any provider regardless of network. However, they may not waive exclusions for pre-existing conditions for prior creditable coverage.
No Limit Caveats
Read the fine print on the outline of coverage before buying any dental insurance promising no annual maximum benefit limit – especially if combined with immediate benefits.
Plans with no yearly benefit limit all have unique features designed to keep claims small. Most people are looking for a cheap policy. These ceilings make the option affordable. Look for legal language spelling out the actual boundaries and disincentives.
- Unlimited preventive services (exams, cleanings) only with caps on other services
- Large deductibles to discourage patients from seeking care initially
- Smaller reimbursement percentages for each service boost patient investment
Federal Government Dental Insurance No Waiting Period
The federal government offers two options for patients to find dental insurance without waiting periods. Eligibility for these programs depends on the state where you live, and household income.
The lowest income families (and some pregnant women) who qualify for Medicaid may have an untapped option. Each state has different rules for adult oral care. People with slightly higher incomes also get federal government help to pay premiums for combination coverage (medical with dental).
Combining medical and dental insurance together during an open enrollment can be the cheapest way to get oral care with no waiting period. The federal government may help pay a portion of the premium cost via subsidy. Families with incomes above 100% and below 400% of the federal poverty guidelines qualify for this help.
The Affordable Care Act rules work as follows.
- Dental care is an essential health benefit for children age 18 and younger. The company must cover pre-existing conditions immediately.
- Dental care is not an essential health benefit for adults. Companies are not required to cover oral care for adults – however many do. A sample plan in New Jersey covered all major services right away.
- Families must buy the dental plan in conjunction with medical insurance. They cannot purchase a stand-alone policy without the other.
- Individuals can start a new policy only during the open enrollment period (November and December). The exception is people experiencing a qualifying life event. They can enroll any time of the year.
Visit your state exchange to view options, costs, and features.
Medicaid covers dental work for some adults and all children without waiting periods for pre-existing conditions. Low-income families that meet the eligibility criteria can enroll at any time of year. In fact, this public program will often agree to pay claims three months retroactively for new enrollees.(1)
Medicaid is a federal government program run by the states. Each state determines what the entitlement will cover. Therefore, expect to find plenty of variety across all 50.
- Emergency extractions only: 18
- Medically necessary (non-biting accidents): 50
- Preventive (exams, X-rays, cleanings): 27
- Restorative (fillings, root canals): 25
- Periodontal (gum surgery, scaling): 18
- Full & Partial Dentures: 25
- Oral Surgery (wisdom tooth extraction): 24
This state-by-state chart depicts possible coverage for the three most common procedures. Contact the company managing the plan in your state to verify benefits. Do not rely on the information in this chart.
The U.S. Department of Veterans Affairs operates two dental insurance programs for retired service members and their families. Be careful to note that both options require advance enrollment and do not cover pre-existing conditions without a waiting period.(2)
- Former service members may be eligible for VA dental care under Class IIA, IIC, IV, or I for any necessary treatment to maintain or restore oral health and masticatory function.
- The VA Dental Insurance Program (VADIP) is available for enrollment in the program beginning November 15, for coverage to start December 1.
Private companies also market programs aimed at veterans, which follow the same parameters already noted.