If you’re considering undergoing major oral surgery, one of your first questions might be whether your medical or dental insurance will cover the costs. In our blog, “Is Oral Surgery Covered by Medical Insurance?” we thoroughly explore if oral surgery is included under medical insurance and help you discover what types of procedures might be covered by your health or dental plan. Keep reading to clear up all your doubts!
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Is Oral Surgery Covered by Medical or Dental Insurance?
Whether oral surgery is covered by medical or dental insurance depends on the type of procedure and its cause. Generally, medical insurance covers oral surgeries deemed necessary for health reasons, while dental insurance usually focuses on issues related to the teeth and gums.
For example, if oral surgery is tied to a serious medical condition, such as treating a facial injury, an infection that has spread beyond the mouth, or the removal of cysts or tumors in the jaw, medical insurance is likely to cover the costs. These types of procedures are often seen as part of the patient’s overall health care.
On the other hand, dental insurance tends to cover more common procedures, such as wisdom tooth extractions, dental implants, surgeries to treat chronic dental issues like periodontal disease, and restorative procedures like crowns or bridges. These plans often have limitations, especially for cosmetic procedures like implants or veneers.
It’s recommended to check with both your medical and dental insurance providers before undergoing any procedure, as each has different criteria, and you might find overlap or exceptions that could benefit you.
What Does Dental Insurance Cover?
Dental insurance generally provides a mix of preventive, restorative, and in some cases, orthodontic coverage. Coverage levels can vary depending on your plan.
Preventive Care
This is the foundation of most dental plans. Routine exams, cleanings, fluoride treatments, and X-rays are typically covered 100%. Some plans limit the number of services you can access per year (e.g., two cleanings and one set of X-rays annually). Preventive care aims to reduce the risk of more serious and costly dental issues in the future.
Basic Procedures
These include fillings, simple extractions, and treatments for periodontal disease, like deep gum cleanings. Insurance often covers 70% to 80% of these costs. Though these are considered “basic,” some procedures, like root canals, can still be expensive, making it essential to check what portion of the cost your insurance will cover.
Major Procedures
More complex treatments, such as crowns, bridges, dentures, and dental implants, generally have more limited coverage, around 50%. Many plans also impose an annual limit on the total amount they’ll cover for major procedures, meaning you could reach the cap quickly and have to pay the remainder.
Be aware of waiting periods associated with certain treatments. Some plans may require you to be a member for a set period before they cover major procedures.
What Dental Insurance Covers
Dental insurance groups services into preventive, basic, and major categories. Understanding how your plan classifies each procedure is key to managing costs.
Preventive Coverage
This includes routine check-ups, cleanings, and X-rays, usually covered at 100%. These services are essential for maintaining oral health and preventing more significant problems. They are typically available without a waiting period, allowing new members immediate access.
Basic Coverage
Common treatments like fillings, caries treatments, and deep cleanings for gingivitis fall into this category. Some endodontic procedures, like root canals, may also be included. Typically, the patient pays part of the cost, with insurance covering 70% to 80%.
Major Coverage
Complex treatments like crowns, bridges, implants, and dentures fall here. Insurance generally covers about 50%, but the exact amount depends on your plan. These procedures often have a waiting period of six months to a year, and many insurance plans set an annual limit on coverage for these treatments, meaning once you hit a certain amount, you’re responsible for the rest.
It’s also worth noting that cosmetic procedures, such as teeth whitening or veneers, are often not covered since they are considered elective.
When Medical Insurance Covers Oral Surgery
Medical insurance covers oral surgery when it’s directly related to a medical condition affecting overall health. Examples include:
Cancer-Related Treatments
If a patient needs oral surgery to treat a tumor or cyst in the jaw or face, or to prepare for cancer treatments like radiation or chemotherapy, medical insurance will typically cover the procedure.
Traumatic Injuries
Surgeries for jaw fractures or facial injuries that require intervention are usually covered by medical insurance as they are considered essential for physical health.
Serious Illnesses
In cases where severe infections have spread beyond the mouth or life-threatening complications arise (such as sinus or airway issues), medical insurance can cover the necessary oral surgery.
Reconstructive Surgery
If facial or jaw reconstruction is needed due to congenital malformations or injuries, medical insurance may also cover these surgeries.
Patients should consult their medical insurance provider before undergoing oral surgery to determine if it will be covered and under what conditions. Depending on the treatment, a medical diagnosis may be needed to justify the necessity of the procedure for overall health.
How to Check if a Dental Procedure is Covered by Medical Insurance
Determining whether a dental procedure is covered by medical insurance can be confusing, especially for complex treatments like implants or oral surgeries. Here’s how to get clarity:
Review Your Insurance Policy
Start by reading through your medical insurance policy. Medical insurance often covers procedures considered necessary from a health perspective, like surgeries related to trauma, cancer treatments, or severe infections. Dental procedures like fillings or implants usually fall under dental insurance.
Contact Your Insurance Company
A quick way to verify if a procedure is covered is by contacting your insurance provider directly. When calling, ask specific questions, such as whether they cover oral surgeries or dental implants, to get clear answers.
Consult Your Dentist
Many dental offices are familiar with the insurance verification process. The staff can help check if the procedure is covered, especially if they’ve dealt with a variety of insurance plans. Some clinics may even offer to submit a pre-treatment plan to your insurance provider to confirm coverage and the amount they’ll cover.
Request Pre-Authorization
For major procedures, it’s a good idea to request pre-authorization. This involves submitting a treatment plan to your insurance provider to confirm coverage before you undergo the procedure. This can help you avoid unexpected costs and clarify what portion will be covered.
Check with Your Employer
If your insurance is through your job, speak with the benefits or HR department. Group insurance plans may include additional benefits or limitations that aren’t immediately clear in the general policy. They can help clarify coverage or connect you with the insurance provider for more details.
Know the Limits of Medical Insurance
Many medical insurance plans don’t cover treatments considered purely cosmetic. Procedures like teeth whitening, veneers, or closing gaps between teeth are often classified as elective and aren’t covered. If there’s a medical reason for the procedure, such as trauma or a congenital defect, insurance may cover part of the cost.
Conclusion
Before undergoing oral surgery, it’s essential to verify if your medical insurance will cover the procedure and what percentage of the costs they’ll cover. Coverage can vary based on the type of treatment, so it’s wise to confirm in advance what’s included and what portion you’ll need to pay. Understanding this will help you prepare financially and avoid any surprises. Some procedures may be fully covered for medical reasons, while others, like implants or cosmetic interventions, may not be or could only be partially covered. Stay informed, consult your dentist, and communicate with your insurance provider to ensure you have a complete understanding of what to expect regarding coverage.