Dental Implant Insurance: How Plans Treat Implants and What to Ask

It depends on the plan. There is no standard rule, and two plans with similar premiums can treat implants very differently. In general, plans fall into a few groups:

• Plans that exclude implants. The plan documents list implants under exclusions, and the plan pays nothing toward the implant itself.
• Plans that cover implants as a major service. The plan pays a percentage of its allowed fee, often 50 percent, after the deductible and any waiting period.
• Plans that cover some parts and not others. For example, a plan might help with the crown that goes on top while excluding the surgical placement, or the reverse.
• Plans that pay an alternate benefit. The plan pays what it would have paid for a less expensive way to replace the tooth, such as a bridge or a partial denture, and you pay the difference.

Rules differ by plan and by state, and plans change their terms over time. The list of covered services, limitations and exclusions in your plan documents is what counts.

Many dental plans pay preventive care at 100 percent, basic care such as fillings at 80 percent, and major care such as crowns at 50 percent, after a deductible that is commonly $50 to $100. Implants, where covered, usually sit in the major group. All of this varies by plan.

Three numbers then shape what you pay:

• The percentage. A plan that pays 50 percent of the allowed fee leaves the other half to you, plus any amount above the allowed fee if the dentist is outside the plan's network.
• The deductible. You pay this first each benefit year before the plan pays for basic or major care.
• The annual maximum. This is the most the plan pays in a benefit year for all of your care combined. After that, you pay the rest until the next benefit year begins.

The annual maximum tends to matter most with implants. If a plan has a $1,500 maximum, it pays no more than $1,500 in that benefit year, whatever the implant fee is. Typical US fee ranges are on the dental implant cost page, and they vary widely by region, provider and case.

To see the arithmetic with your own figures, the insurance calculator works out what a plan would pay on one procedure from the percentage, deductible and maximum you enter. It is an estimate for planning, not a statement of what your plan will pay.

Implant treatment is often done in stages over several months, so charges may fall in more than one benefit year. How the stages are timed is a clinical decision for your dentist.

Beyond the percentage and the maximum, a handful of clauses decide whether a plan pays for a particular implant at all.

What most people call an implant is usually billed as several separate procedures. A plan can cover some and exclude others, so it helps to know the parts:

• Exam and imaging, which may include a three-dimensional scan
• Removal of the tooth, if it is still there (see tooth extraction)
• A bone graft, when the dentist finds there is not enough bone to hold the implant
• Placement of the implant, the post that sits in the jaw
• The abutment, the connector between the post and the crown
• The crown, the visible tooth

Not everyone needs every step. Only the dentist or surgeon who examines you can say which apply, and the dental implant procedure page describes the usual sequence. A written treatment plan lists each procedure with its code and fee, and the plan's answer may be different for each line.

Sometimes, in limited situations. Dental implants are usually treated as dental care, and medical plans generally do not pay for them. A medical plan may consider part of the treatment when tooth loss is tied to a medical problem. Examples people commonly ask about include teeth lost in an accident or injury, and reconstruction after surgery on the jaw.

Whether any of that applies is decided by the medical plan under its own rules, usually after the dental office or surgeon sends records and asks for approval in advance. If you think your situation might qualify:

• Ask the dental office or oral surgeon whether they bill medical plans.
• Ask the medical plan what documentation it needs and whether approval is required before treatment starts.
• If both plans may pay, ask how they work together. The glossary entry on coordination of benefits covers the basics.

For Medicare, Original Medicare generally does not cover routine dental care, while many Medicare Advantage plans include some dental benefits that differ from plan to plan. The article on whether Medicare covers dental goes through where to check.

This site does not name or rank insurance companies or plans, and no single plan is the right answer for everyone. A plan that pays well for one person can pay nothing for another because of a missing tooth clause or a waiting period.

What you can do is compare plans on the features that matter for implants:

• Are implants listed as a covered service, and at what percentage?
• Is there a waiting period for major care, and does prior coverage shorten it?
• Is there a missing tooth clause or an alternate benefit clause?
• What is the annual maximum, and is there a separate limit for implants?
• Is the dentist or surgeon you want to see in the plan's network?
• What does a year of premiums add up to compared with what the plan could pay?

Individual plan premiums are commonly quoted at roughly $20 to $60 a month for one person. Buying a plan shortly before implant treatment often helps less than people expect, because waiting periods and missing tooth clauses are aimed at that situation. The article on dental insurance with no waiting period explains what those plans usually trade away.

The most dependable route is a pretreatment estimate, which many plans also call a pre-authorization or predetermination. The usual steps:

• Ask the dental office for a written treatment plan with each procedure, its code and its fee.
• Ask the office to send it to your plan for a pretreatment estimate before any work starts.
• Read the plan's reply line by line. It typically shows what the plan expects to pay for each procedure and what is left for you.
• Ask the office to explain any line marked as not covered, as an alternate benefit, or as subject to a waiting period.

A pretreatment estimate is not a guarantee of payment. Plans usually pay based on your eligibility and remaining benefits on the day the work is done, so the final figure can differ.

Also ask the plan how much of your annual maximum is left this benefit year and when it resets. The visit notes tool can keep your questions in one place before you call.

Common options to raise with the dental office include:

• A payment plan. Many offices offer one. Read the terms of any financing carefully before you sign.
• Other ways to replace the tooth. A dental bridge or dentures may be covered differently. Which options are suitable for your mouth is your dentist's call.
• Dental school clinics. These exist in most states and often charge reduced fees.
• A discount plan. This is not insurance. You pay an annual fee, commonly around $100 to $200, for reduced fees at participating dentists, with no annual maximum and no waiting period. Check whether implants are on the fee list and whether your dentist takes part.

Ask for the cash fee as well.

Sorting out implant coverage can take weeks. That is a different matter from a mouth that hurts. Pain, swelling, fever, a broken tooth or bleeding means being seen by a dentist now, whatever your coverage looks like. Tell the office you are concerned about cost and ask about the cash fee and a payment plan.

Trouble breathing or swallowing, swelling spreading toward the eye or neck, fever with facial swelling, or bleeding that will not stop means calling 911 or going to the emergency room. If you are unsure how quickly you need to be seen, the ER or dentist tool walks through the warning signs, and it always points you to a professional.