Understanding insurance coverage for wisdom tooth removal can be challenging.
Is it a dental issue, or does it fall under medical insurance?
The answer is often unclear, but knowing the details can save you money and stress.
In this guide, we will explain insurance policies. You will learn if medical or dental insurance covers your wisdom tooth extraction.
With this knowledge, you can make better decisions and save money. Read on to discover how to maximize your benefits and minimize out-of-pocket costs!
Medical Insurance Coverage
Health insurance covers wisdom teeth removal when medically necessary. Bone-impacted extractions meet the criteria. Soft-tissue embedded extractions do not.
Your plan will be the primary payer for covered treatment, with no annual dollar limit. Out-of-pocket costs are lowest when choosing an oral surgeon in-network with your plan.
Bone-Impacted
Medical insurance typically covers the extraction of bone-impacted wisdom teeth. Removing third molars embedded in the jaw is necessary because there is no space for them to erupt.
Health insurance covers dental work that treats injuries, diseases, or symptoms. Bone-impacted wisdom teeth can cause pain, swelling, infection, decay, and cysts.
Oral surgeons frequently bill medical insurance for their services. Their staff should know all the documents needed to file claims, like procedure codes and diagnostic information.
Primary Payer
Health insurance is the primary payer for the medically necessary extraction of bone-impacted wisdom teeth. The primary plan pays first, covering costs as if no other insurance exists.
Your health insurance cost-sharing features determine how much it will cover as the primary payer. Consider these typical factors.
- Annual deductible: expenses paid by the member before benefits begin
- Coinsurance: percentage of the allowed amount paid by the member
- Copayment: fixed amount paid by the member for each service date
No Annual Limit
Medical insurance does not have annual benefit maximums. The Affordable Care Act bans annual and lifetime dollar limits on claim payments.
Most dental plans include annual maximums. So, using health insurance as the primary payer for wisdom teeth extraction significantly cuts out-of-pocket costs.
In-Network Charges
Choose an oral surgeon that is in-network with your health insurance. Visit the online doctor directory to find a participating provider.
Your wisdom teeth out-of-pocket costs will be much higher with out-of-network oral surgeons. In contrast, in-network providers save money in two ways.
- In-network oral surgeons agree to accept the lower allowed amount as full payment, whereas out-of-network providers can charge more.
- Medical plans often have separate, higher deductibles and coinsurance for patients using out-of-network oral surgeons.
Dental Insurance Coverage
Many dental plans cover wisdom teeth removal after health insurance processes your provider’s claims. Dental insurance is the primary payer for gum-impacted extractions and secondary for medically necessary services.
Soft-Tissue Impacted
Dental insurance typically covers removing soft-tissue-impacted wisdom teeth as the primary payer. Health insurance plans usually deny these claims because the treatment is not medically necessary.
Payment plans with financing can help since leftover costs are higher with gum-impacted removals. Your dental plan will be the only payer, covering a lower percentage of the charges.
- The yearly benefit limit might cap the plan’s pay if the dentist removes all four wisdom teeth in one year. Spreading the treatment over two years can save money.
- Dental plan members often pay a higher coinsurance, sometimes 50% or more. Most medical plans have a coinsurance of 20% or less.
Secondary Payer
Dental plans often cover bone-impacted wisdom teeth removal as the secondary payer. The secondary insurance pays the remaining eligible costs.
The coordination process will follow these steps.
- The oral surgeon first submits the claim to the primary health insurance company.
- The primary insurance company processes the claim according to its policy terms and issues an Explanation of Benefits (EOB).
- The provider sends the EOB and the original claim form to the secondary insurer.
- The secondary dental insurer reviews the benefits to determine what the patient still owes.
- The secondary payer checks the remaining balance to see what the dental policy covers.
- The secondary insurer pays the dental provider and sends a separate EOB detailing the coverage.
