First, here is some good news.
Your medical insurance might cover all dental implant costs. Benefits start right away, with no exclusions for preexisting conditions. There are no additional premiums, as most people already have this coverage.
In comparison, the best dental insurance covers 50% of costs. Only federal employees can get this plan. Patients in the private sector face long waits, missing tooth exclusions, and yearly benefit limits.
Now, here is the bad news.
Few patients will get medical insurance to cover tooth implants because the rules are strict. But saving $10,000 or more makes it worth exploring.
When Medical Insurance Covers 100%
Medical insurance rarely covers dental implants, but it can cover 100% when it does. Dental plans usually cover up to 50%. Check if you qualify and understand cost-sharing features.
Medical Qualifications
Getting medical insurance to cover all dental implant charges is worth it. Dental plans cover 50% or less. You could save $10,000 or more on a full-mouth restoration!
Getting health insurance to cover dental implants will not be easy, and few will qualify. However, the payoff is enormous if you succeed.
You must prove the procedure is medically necessary. It must treat an illness, injury, condition, disease, or symptoms. Two types of patients might qualify.
- Those who lose teeth after an accidental injury, like a broken jaw.
- Patients who need teeth extracted before neck cancer radiation therapy.
Max Out-Of-Pocket
If your medical insurance covers dental implants, it will pay 100% of claims after you reach the annual maximum for out-of-pocket expenses (MOOP).
For example, the current marketplace MOOP limit is $9,450 for an individual and $18,900 for a family. You might reach the MOOP through a combination of cost-sharing features, which vary by plan.
- Annual deductible: the amount paid out-of-pocket before benefits begin
- Copayment: a fixed amount paid for each service received
- Coinsurance: a percentage of the allowed amount paid by the patient
Patients dealing with a broken jaw or cancer treatment can easily reach the MOOP in a given year. If they can get their medical insurance to pay for implants, the benefits will cover all costs for the remainder of the year.
When Medical Insurance Covers Immediately
If medical insurance covers dental implants, benefits start right away. You don’t have to worry about preexisting condition clauses like missing tooth exclusions.
However, the timing affects how cost-sharing features determine the percentage of expenses the plan covers.
No Preexisting Conditions
The Affordable Care Act requires medical insurance to cover preexisting conditions immediately. Your plan cannot deny benefits through a missing tooth exclusion, require you to satisfy a waiting period, or limit the benefits paid in one year.
- Many dental plans have missing tooth exclusions, meaning they cover implants only for teeth extracted in the future. This feature eliminates benefits for most people seeking treatment.
- Many dental plans include long waiting periods, meaning they cover implants after collecting premiums for twelve or twenty-four months first. This feature raises costs considerably.
- Many dental plans contain annual benefit maximums, meaning the plan will stop paying claims once you exceed the specified amount in one year.
Missing tooth exclusions and waiting periods in most dental plans provide another reason for accident and cancer victims to pursue benefits from their medical insurance, which does not have these limitations.
Cost-Share Timing
If your medical insurance covers tooth implants, timing affects the percentage of the allowed amount your plan will cover.
Imagine you begin dental implant treatment at the beginning of the plan year before reaching the MOOP. You might have to meet a deductible, make copayments, or pay coinsurance initially.
Even before reaching the MOOP, many patients will find that their medical insurance pays a higher overall percentage than their dental plan. For example, the BCBS Federal Employee Program (FEP) dental plan covers implants and has the richest benefits.
Compare the projected out-of-pocket costs for the BCBS dental plan versus the medical insurance for my family.
Single-Tooth @ $3,500
| Medical | BCBS Dental | |
|---|---|---|
| Deductible | $1,500 | $0 |
| Coinsurance | $400 @ 20% | $1,750 @50% |
| Total Costs | $1,900 | $1,750 |
As you can see, the BCBS dental plan holds a slight cost advantage for a single-tooth replacement when all implant costs go to satisfying the medical deductible.
Double-Tooth @ $7,000
| Medical | BCBS Dental | |
|---|---|---|
| Deductible | $1,500 | $0 |
| Coinsurance | $800 @ 20% | $3,500 @ 50% |
| Total Costs | $2,300 | $3,500 |
As you can see, the BCBS dental plan loses the cost advantage once the patient satisfies the deductible, which can happen when dental treatment doubles for two teeth or when the person incurs other medical expenses.
Full-Mouth @ $35,000
| Medical | BCBS Dental | |
|---|---|---|
| Deductible | $1,500 | $0 |
| Coinsurance | $7,000 @ 20% | $17,500 @ 50% |
| Total Costs | $7,000 | $17,500 |
As you can see, the BCBS plan loses the cost advantage by over $10,000, but yours might fall short by more. The BCBS plan has unlimited annual benefits, whereas most other dental insurance has yearly limits of $2,500 or less.
