Believe it or not, an insurance plan might cover nearly one hundred percent of dental implant costs, with no waiting period or exclusions for missing teeth.
Plus, obtaining this generous benefit may cost you nothing extra in premiums because you might already have the coverage.
Now, the bad news. Only a tiny handful of patients with medically necessary reasons will qualify to have their health insurance pay the claims.
On the other hand, you can buy dental insurance that pays a much smaller percentage of implant costs while saving money via hidden PPO in-network discounts. However, several exclusions may apply.
Medical Insurance Covers Implants Right Away
Health insurance (not dental) is the only coverage that pays close to 100% of your tooth implant costs. Benefits begin immediately with no pre-existing exclusions for lack of dentition or annual maximums.
However, the odds that you will qualify are extremely low.
Although health insurance might cover dental implants close to 100% right away, you should be aware of several possible caveats associated with this option. Go into the process with the correct expectations.
- Medical insurance may cover dental implants in rare circumstances: when medically necessary(services appropriate to the evaluation and treatment of a disease, condition, illness, or injury).
- Because coverage approval is so uncommon, your healthcare plan may not publish a list of in-network prosthodontists or have a negotiated Allowed Amount (see below for details).
- Health insurance approaches 100% coverage but never reaches that figure because of the patient cost-sharing features built into every plan: deductible, coinsurance, and copayments.
Medical insurance might cover dental implants close to 100% immediately for medically necessary treatment. The Affordable Care Act requires health plans to honor claims payments with no waiting period before benefits begin.
Of course, your new policy will take effect on January 1 after you sign up during the annual open enrollment period in November or December if you buy through the exchange. Or, coverage could begin any time if your employer sets a different signup date or you recently experienced a qualifying life event.
No Pre-existing Conditions
Patients with missing teeth might get medical insurance to cover dental implants close to 100% for medically necessary treatment. The Affordable Care Act also requires healthcare plans to cover pre-existing conditions immediately.
In other words, you can buy a new policy that must pay benefits to replace teeth lost years ago – provided you can prove the procedure is medically necessary.
- Medicaid might cover dental implants following similar rules for pre-existing conditions when acting as health insurance for medically necessary treatments. However, the oral care component of the program will only pay for the least expensive alternative: removable dentures.
- Implant costs for seniors on Medicare are typically higher because this government-run health insurance program for people over age 65 explicitly excludes services concerning the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth.
Your medical insurance might cover dental implants close to 100% because they cannot limit claims payments on medically necessary services. The Affordable Care Act also prohibits healthcare plans from setting annual or lifetime maximums on benefits for essential services.
For example, the cost of full-mouth dental implants with health insurance approaches zero, even though the prosthodontist might charge $35,000 or more. Of course, the patient would still be responsible for the much smaller deductible, copayments, and coinsurance when applicable.
Dental Insurance Never Covers Implants 100%
Even the best dental insurance never comes close to paying for dental implants at 100%, even when you use an in-network prosthodontist. The coverage ranges up to 66% in some cases but is closer to 0% in more instances due to waiting periods, annual maximums, and missing tooth exclusions.
However, the odds that you will qualify are better because some (not all) dental plans cover implants that are not medically necessary.
PPO dental insurance comes the closest to paying for implants at 100%, reaching a maximum of 66% when factoring in two intersecting elements: the network discount and the coinsurance for major services.
For example, combine the two concepts to arrive at a payment rate of 66.6%, leaving the patient to fund the remaining 33.3% for a single tooth implant billed at $3,600.
- Network Discount: $1,200 (33.3%)
- 50% Coinsurance: $1,200 (33.3%)
Coinsurance defines what dental insurance pays for major services, limiting claims to 50% after applying the network discount in most cases. Coinsurance is the percentage of the Allowed Amount the plan pays for covered procedures and often breaks down as follows.
- Preventive: 100%
- Basic: 80%
- Major: 50%
Having coverage is how you get financial help with dental implants. Dentists are more likely to offer free services to attract new patients when a deep-pocket third party funds 50% of future oral care.
The network discount is a hidden feature of PPO dental insurance, accounting for approximately 33% of the coverage for tooth implants. You pay less for services when using in-network providers.
Dentists cannot charge more than insurance permits when participating in a network with a PPO plan. The Allowed Amount is a substantially lower fee negotiated by the issuing company.
Dental insurance often covers tooth implants at less than 50% of the Allowed Amount because you might have to satisfy a waiting period first or deal with graded benefits during the contract’s early years.
Dental insurance with no waiting periods for implants pays reduced benefits initially, while the member pays 100% of the premiums. Always read the fine print before making a financial commitment.
|Coinsurance *||Annual Max **|
* Coinsurance is the percentage of the Allowed Amount paid (see above)
** Annual maximum is the yearly limit paid by the plan (see below)
The annual maximum means that your dental insurance may cover implants well below the 50% suggested by the stated coinsurance percentage. These plans work more as pre-payment vehicles rather than insurance, protecting your finances from unforeseen and unaffordable hazards.
The annual maximum benefit means the plan stops honoring claims after reaching the yearly limit, which is often ridiculously low compared to dental implant prices.
Yearly Limits Affect Percentage Covered
|Annual Maximum||Single Tooth ($3,500)||Full-Mouth ($35,000)|
Missing Tooth Exclusions
Dental insurance often pays for tooth implants at 0% when the member files a claim to replace teeth that were missing before the coverage effective date. In other words, you must extract your teeth while the policy is in force to derive a benefit.
The missing tooth exclusion means that your plan will not pay benefits for this pre-existing condition. The Affordable Care Act rules do not apply to dental insurance, so the issuing companies avoid these claims.