While most people have healthcare coverage, only a minority have dental plans. Therefore, looking for nearby dentists who accept medical insurance is a popular approach to possibly saving money on oral care.
However, there are two enormous problems with this tactic.
First, almost every provider will gladly accept and cash a check issued by an insurance company. However, only in-network dentists will take the allowed amount as full payment.
Second, health insurance covers only a tiny fraction of dental treatments. Therefore, you will want to know how to establish medical necessity to get claims paid and identify alternatives if you cannot.
Understanding When Dentists Accept Medical
You will want to understand two critical concepts in determining whether you can find a local dentist taking your medical insurance. Healthcare plans rarely cover oral care, and accepting payment is not the equivalent of participating in-network.
Many use online search engines to surface a list of local family dentists accepting their medical plans. However, this approach is off because health insurance does not cover routine dental care such as checkups, cleanings, x-rays, fillings, and simple extractions.
If you need dental care but have no money, assistance programs for low-income households might work better than attempting to bill your healthcare. Your plan will reject claims for most procedures a family dentist performs because they are not medically necessary.
Finding a nearby dentist accepting your medical plan is not about the distance from your home. It is about whether the insurance will pay for the proposed treatment, which occurs rarely.
Getting health insurance to pay for dental work is not easy. You must prove that the procedure is medically necessary: care arising from non-biting accidents, certain diseases, and treatments considered integral to other services included in the plan.
Accepting Versus Participating
Finding a dentist that accepts your medical insurance for covered treatments is easy, while locating one that participates in-network is challenging. Use the correct terminology when asking questions to avoid unpleasant surprises.
- Dentists cannot charge more than insurance allows for covered services when participating in-network with your plan. The authorized amount is a negotiated fee representing a significant discount over retail prices.
- Out-of-network dentists gladly accept insurance benefit checks and cash them immediately. However, they have no contractual agreement to discount their prices to the lower allowed amount.
Most dentists will be out-of-network since these plans rarely cover oral care. Therefore, expect an enormous balance bill after treatment for the difference between the submitted and allowed amounts.
The provider directory published by your insurance company is the ideal way to find local specialty dentists participating in-network with your medical plan. This way, you can take advantage of the discounted fee structure.
Dentists accepting monthly payment plans might be another criterion to add to your search since most providers will be out-of-network and unlisted in the directory. You might need the extra edge because they charge more than the discounted allowed amount.
Dental Specialists Accepting Medical Insurance
Your ability to find neighborhood dentists that accept your medical insurance varies by specialty area because the type of treatment dictates whether the service falls into the medically necessary category for claims payment.
Oral surgeons are the only dental providers who might participate in-network with your health insurance and charge the lower allowed amount. Many of the procedures they perform are medically necessary.
Oral surgeons accepting Medicaid offer a framework for what to expect.
- Medicaid is a nationwide healthcare plan covering medically necessary oral surgeries such as bone-impacted wisdom teeth removal and specific orthognathic jaw corrections.
- Medicaid covers dental work for adults over 21 differently in each state. About half include benefits for oral surgeries that do not meet the medically necessary standard, such as gum-impacted wisdom teeth extractions.
Prosthodontists might take your health insurance for medically necessary treatments as an out-of-network provider. A prosthodontist is a dentist specializing in restoring missing tooth and jaw structures.
You might get medical insurance to cover dental implants if your prosthodontist can document the medically necessary reason for the treatment. However, it rarely works. Some of these health conditions could satisfy the claims underwriter.
- Prevent further bone atrophy from osteoporosis
- Restore chewing function after a non-biting accident
- Replace teeth extracted before radiation treatment
- Lack of dentition worsens digestive disorders
Endodontists might accept your medical insurance check for medically necessary treatments as out-of-network providers. An endodontist is a dentist specializing in diagnosing and treating tooth pain and performing root canal treatment.
If you cannot afford root canal treatment, your health insurance has a long-shot chance of paying for the procedure after a covered accident breaks or dislodges one or more of your teeth.
As for out-of-network providers, few periodontists will take your health insurance check for medically necessary services. A periodontist is a dentist specializing in preventing, diagnosing, and treating gum disease.
Prescription drug costs to treat gingivitis might be the only periodontal services covered by your medical insurance. You will have to pay out of pocket for gum surgeries if you do not have a dental plan.
As an out-of-network provider, more orthodontists will accept health insurance benefits for medically necessary treatment. An orthodontist is a dentist specializing in the correction of mal-positioned teeth and jaws and misaligned bite patterns.
You might get braces covered by medical insurance if your orthodontist can establish a valid medically necessary reason in a letter. The criteria are laxer for children than for adults.
- Cleft Lip and or Cleft Palate
- Crouzon Syndrome/Craniofacial Dysostosis
- Hemifacial Hypertrophy/Congenital Hemifacial Hyperplasia
- Parry-Romberg Syndrome/Progressive Hemifacial Atrophy
- Pierre-Robin Sequence/Complex
- Treacher-Collins Syndrome/Mandibulofacial Dysostosis
- Reposition teeth after an accident
- Temporomandibular Joint Disorders (TMJ or TMD) requiring bite adjustments
- Sleep apnea caused by crooked teeth restricting airflow
Finally, pediatric dentists might take your medical insurance as an out-of-network provider, charging more than the allowed amount. However, parents might have additional avenues to afford oral care for their children.
- Medically necessary pediatric dental care possibly covered by health insurance might include services needed to correct congenital deformities such as ectodermal dysplasia, cleft defects, cysts, and tumors) and malformed or missing teeth.
- Medicaid covers pediatric dentistry nationwide through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. EPSDT, at minimum, provides dental services, including relief of pain and infections, teeth restoration, and dental health maintenance.
- Children’s Health Insurance Program (CHIP) covers dental services “necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions.” Parents who make too much money to qualify for Medicaid enroll in CHIP often.