Most medical plans do not include coverage for many dental services. Often, dental services are covered under a separate plan.
Like medical plans, most dental plans have specific out-of-pocket costs, like coinsurance, copayments and deductibles. Some dental plans allow you to visit a wide range of dentists. Others have smaller networks and ask you to choose one primary dentist for all your care.
Unlike medical plans, dental plans pay for care based on the “class of service.” For example, preventive and diagnostic services, like cleanings, are often fully paid. Basic restorative service, such as fillings, may be 80 percent covered. Major services like crowns may be only 50 percent covered. There may also be limits, such as two cleanings each year. There may be a limit on what the plan will pay in a plan year. (That may differ from a calendar year.)
There are also discount dental plans. These are not insurance. Instead, your plan contracts with a network of providers who have agreed to care for you at discounted rates. You pay the full cost for each service at the discounted rate.
Orthodontics (braces) are covered by some but not all dental plans. Federal and state-run health insurance exchanges must offer dental coverage for children.
Before choosing a dental plan, ask your insurer:
Is your current dentist in the network?
How many network dentists are close to where you live or work?
What will you pay for each class of service?
Does your insurer need to approve certain services in advance? Which ones?
If you need major dental care, ask your dentist for a treatment plan in advance. Make sure it includes the estimated cost. Send it to your insurer for a pre-treatment estimate showing how much they will pay.
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Dental Coverage for Children
Regular dental care is important for all people, but especially for children. The Affordable Care Act (ACA) requires federal and state-run health insurance exchanges to offer children’s dental coverage. Suppose you buy a medical plan for your child through one of these public marketplaces. The exchanges must also offer you the option of buying a dental plan. Just like with your medical care, you will have to make choices about the type of plan you buy and how much coverage you’ll have. Those choices will affect how much you’ll have to pay.
Though plans in the exchanges have to offer children’s dental coverage as an option, parents do not have to buy it. (That is, unless they live in Kentucky, Nevada or Washington.) Are you buying a medical plan straight from an insurer and not through an exchange? Then, you must offer “reasonable assurance” that you will also buy a dental plan for your child.
Your costs for dental coverage will depend on the type of dental plan you choose. They will also depend on how much cost sharing the plan requires. Orthodontics (braces) may not be covered by all plans.
Before enrolling yourself and your family in a dental plan, make sure your dentist is in the plan’s network. Make sure there are plenty of in-network dentists near you. You may not be able to afford dental coverage for your child. If so, visit www.insurekidsnow.gov to learn about enrolling your child in Medicaid or the Children’s Health Insurance Program (CHIP).
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Paying for Orthodontics (Braces)
Orthodontics is the field of dentistry that fixes misaligned teeth and jaws using braces and other corrective procedures. Many dental plans cover orthodontics, but the coverage often differs from other dental services. You will most often pay a higher share of the cost for orthodontic care. Coverage is typically limited to children, and there is often a lifetime maximum. Orthodontic services usually go on for many months, or even years. The lifetime maximum is usually separate from the yearly maximum the plan will pay for other dental care.
Plans that cover orthodontics often pay up to 50 percent of the charge. To help you pay the rest, most orthodontists offer payment options like installment plans or financing. They may also offer discounts for paying the full cost up front. Do you have a flexible spending plan through your employer? If so, you may be able to use it to pay for orthodontic costs your plan doesn’t cover.
Like medical plans, dental plans have networks of providers who have agreed with the insurer to be paid set rates for specified services. Different types of dental plans have different rules about going to a provider outside the network. But, you will most often pay more if you do. Ask your dentist to send you to an orthodontist in your plan’s network.
To help manage the cost of orthodontics:
Talk about the cost and your payment options with your orthodontist.
Find out if you can use the funds in your flexible spending plan. If so, make sure you know how much you are going to have to pay, and when. That way, you will know how much money to put away. You can only use these accounts after the services have already been given, so planning is important.
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