Can You Claim for Dental Treatment on a Private Health Insurance Plan?

Millions of Americans suffer preventable dental problems. In fact, one-third of Americans have untreated tooth decay, and 25 percent of people over the age of 65 have lost their teeth. Many people avoid a visit to the dentist to save money, but private health insurance is an increasingly popular way to manage the costs of dentistry.

Learn about the regulations governing dentistry and private health insurance, and find out about the steps you may need to take to claim the cost of treatment on your plan.

The Affordable Care Act and dentistry

The Patient Protection and Affordable Act (ACA) came into effect on March 23, 2010. Since then, sweeping reforms have changed the private health insurance market in the United States, with broad implications for patients and healthcare providers alike. The ACA affects almost every area of healthcare, including dentistry, and millions of Americans now have better insurance provision as a result of this legislation.

Most of the changes that the ACA introduced affected people who relied on government-funded Medicaid benefits. Nonetheless, experts also estimate that around 800,000 adults gained dental benefits through changes to private health insurance plans. Notably, people with health insurance plans can now shop around for the best deal via specially regulated exchange programs. As part of this change, these adults can now find a plan with better dental benefits.

For children, private health insurance plans must now also include dental benefits. Unfortunately, the ACA does not extend this change to adults, but that doesn't mean you cannot use your private health insurance for dentistry.

What private insurance offers

In an increasingly competitive marketplace, private health insurers are now more likely to offer dental coverage. As such, before you visit your dentist, check the terms and conditions of your plan to find out what coverage you have. If you're in a group plan, you can contact the administrator for more advice.

Insurers will generally offer one or both of the following benefits:

  • Routine dental, which covers regular check-ups and other preventive dentistry, as well as simple procedures like fillings
  • Emergency dental, which covers more complex treatments, but only if you have an accident or sudden illness

The ACA requires all private insurers to offer essential benefits on every plan. These benefits include emergency services, preventive care and outpatient treatment. Unfortunately, the benefits list does not yet include dentistry for adults, so it's important to shop around for the right deal.

Things to note about your health insurance coverage

Your insurance plan may impose certain restrictions on the coverage you can use.

First, there's no limit to the out-of-pocket an insurer may charge. The ACA imposes a maximum out-of-pocket limit for individual plans, but this limit only applies to essential benefits. As dentistry is not one of these benefits, your insurer can ask you to pay any amount toward the cost of your treatment.

Your plan will almost certainly have an annual limit, too. This means that you can only claim a certain amount toward the cost of dentistry. Some plans have relatively low limits, so it's important to carefully consider the value of your insurance before you switch to another insurer.

Your plan may also insist that you use a certain dentist in your area. Insurers contain costs by working with specific dentists, who agree to carry out work at a reduced cost. Your insurance plan won't necessarily pay for treatment through your current family dentist, so you need to decide if you're willing to switch to a new provider to get coverage.

How to make the most of your private health insurance

If you don't follow the terms and conditions of your health insurance, your insurer may decline your claim. As such, before you have treatment, it's a good idea to take certain steps.

Always pre-authorize treatment with your insurer or group administrator. Phone ahead to discuss the treatment you want to have, and ask for confirmation of the exact amount you can claim. Where possible, get a reference number, which you can quote throughout the process.

Ask your dentist if he or she is 'in-network' with your insurance plan. In-network dentists can often carry out work without billing you directly and will claim the cost back from the insurance company. This means you only need to pay for your out-of-pocket expenses. If you pay in full, it can take some time before the insurance company processes your claim.

Talk to your dentist about a treatment plan. He or she can tailor the work you need according to the benefits your plan offers. For example, it's often possible to carry out work in several stages. Your dentist may give you the chance to stagger your appointment across two insurance periods, effectively doubling your benefit for the work you need. What's more, even if you don't have full coverage, your dentist may still offer you a discounted rate because you have insurance.

If you have an overall limit, consider ways you can balance your contribution with the costs your insurer will cover. For example, it's often better to pay for a check-up or a basic clean, so your insurance plan covers the cost of more complex work. That aside, it's also important to take full advantage of your coverage. If you don't use your benefit during the year, your insurer won't let you carry the coverage over to the next period.

Your private health insurance may allow you to claim the cost of routine or emergency dental treatment. For more advice, visit resources like about the options he or she can suggest.