Are Dentures Covered by Insurance? How to Use Your Insurance for Dentures
October 10, 2023
Dentures are often covered by dental insurance plans, but the level and type of coverage can vary significantly between different policies. Many dental insurance plans categorize dentures under "major" dental services, which typically means that they might cover a portion of the cost after deductibles are met.
The most essential criteria for insurance to cover dentures is usually medical necessity. If dentures are deemed medically necessary, meaning they’re not just a cosmetic choice, then most dental insurance plans will cover them. We’ll elaborate on this as well as several other confusing aspects of whether insurance covers dentures below.
When are dentures covered by insurance?
The specific conditions under which dentures are covered by insurance can vary based on your dental insurance policy. However, there are some general conditions and criteria that many insurance providers consider:
- Medical Necessity:
- For insurance to cover dentures, it's often required that the dentures be deemed medically necessary and not just for cosmetic purposes. This means there's a genuine need for them to maintain oral health, chewing function, or speech.
- Frequency Limitations:
- Many insurance plans won't pay for denture replacement unless a certain period has passed since the last time they provided coverage for a set. For example, an insurance company might cover the cost of new dentures only once every 5 or 7 years.
- Type of Denture:
- Some insurance policies might differentiate between full dentures (replacing all teeth) and partial dentures (replacing some teeth). The level of coverage may vary based on the type.
- Waiting Periods:
- Some dental insurance plans have waiting periods for certain procedures. This means you need to be a policyholder for a specific duration (e.g., 6 months or a year) before the insurance will cover major restorative work, which often includes dentures.
- Previous Dental Work:
- If you have recently received other major dental work (like extractions) under the insurance, there may be stipulations on when you can then get dentures for those extracted teeth. The aim is to ensure that the mouth has healed adequately.
- Pre-existing Conditions:
- Some dental insurance plans won't cover conditions that were present before you got the policy. If you already needed dentures before the policy started, they might refuse to cover them. However, this is becoming less common, and many modern policies do offer some level of coverage for pre-existing conditions.
- Coverage Level:
- Even if dentures are covered, insurance may not cover the full cost. It's common for insurance to cover a percentage (like 50% or 70%) of the "usual, customary, and reasonable" cost of dentures, leaving the remainder for the policyholder to pay out-of-pocket.
- Alternative Treatments:
- Insurance might evaluate the necessity of dentures based on the feasibility of alternative treatments. If a less costly option (like bridges) is viable, they might cover dentures at a reduced rate or might recommend the alternative.
- Maximum Annual Limits:
- Dental insurance policies often have an annual maximum amount they'll pay for all dental treatments combined. If you've used up this amount in a given year, the insurance might not cover dentures until the next benefit year.
- In-network vs. Out-of-network:
- The extent of coverage might depend on whether the dentist or prosthetist is within the insurance's network. In-network providers often have negotiated rates, leading to more significant insurance coverage and lower out-of-pocket costs.
When considering getting dentures and exploring insurance coverage, it's crucial to communicate directly with your insurance provider or consult the policy documents. This will give you the most accurate understanding of when and how dentures are covered by your specific plan.
Are out-of-network dentures covered by insurance?
Whether out-of-network dentures are covered by insurance depends on the type of plan you have. HMO (Health Maintenance Organization) plans often do not provide coverage for out-of-network services unless it's an emergency. PPO (Preferred Provider Organization) plans, on the other hand, usually cover out-of-network services, but the coverage might be at a lower rate than in-network services.
For more information about the difference between HMO and PPO plans, read the linked article.
If you decide to see an out-of-network dentist for dentures, SuperBill for insurance can help! We file out-of-network claims on patients’ behalfs, and we follow up with insurers to make sure you or your patient gets the best reimbursement possible.
Does health insurance cover dentures differently depending on your plan?
Absolutely. The extent of coverage, deductibles, co-payments, and other specifics can vary greatly between plans. Some might offer generous coverage for dentures, while others might provide minimal assistance. It's essential to thoroughly read and understand the terms of your specific plan or consult with a representative to determine your exact coverage.
How to find dentures covered by insurance
Finding out whether dentures are covered by insurance involves understanding your dental insurance policy and communicating with various parties involved in the process. Here's a step-by-step guide to help you navigate this:
Review Your Policy's Summary of Benefits:
- Most insurance providers give their policyholders a "Summary of Benefits," which is a document detailing what treatments and procedures are covered, to what extent, and under what conditions.
- Check for any mentions of "prosthetics," "restorative services," or "major services." Dentures typically fall into one of these categories.
Call Your Insurance Provider:
- The most direct way to find out about your coverage is to call your insurance provider's customer service line. The number is usually found on the back of your insurance card.
- Have your policy number handy and ask specifically about coverage for dentures. Inquire about any waiting periods, coverage percentages, frequency limits, and annual maximums.
Visit Your Insurance Provider's Online Portal:
- Many insurance companies offer online portals for their members. Once logged in, you can access information about your coverage, including specifics about denture coverage. Some portals even have tools that allow you to estimate the cost of specific procedures.
Consult with Your Dentist:
- Your dentist's office is familiar with a variety of insurance plans, as they process claims regularly. After an examination, they can help determine the type and style of denture you need and can provide an estimate of the costs.
- They might also be able to submit a "pre-treatment estimate" to your insurance. This is where the insurance company will outline what they'll cover before the treatment begins.
Check for In-network vs. Out-of-network Providers:
- Insurance plans often have a list of in-network providers. If you choose an in-network dentist, the coverage is typically higher, and the out-of-pocket cost is less. If your preferred dentist or prosthetist is out-of-network, the insurance might cover less, or you might need to pay a higher co-payment.
Read the Fine Print:
- Some insurance policies might have stipulations, such as only covering the cheapest type of denture even if a more expensive type is recommended. They might also cover replacements only after a certain number of years. Ensure you're fully informed about these details to avoid surprises.
Ask About Alternative Coverage Options:
- If dentures are not adequately covered under your plan, inquire if related procedures (like dental implants or bridges) have different coverage rates. Sometimes, alternative treatments might be more economically feasible after insurance contributions.
- Friends, family, or colleagues who've undergone similar procedures can provide insights into their experiences with insurance coverage and denture providers.
By methodically going through these steps, you'll have a clearer picture of how dentures are covered under your insurance plan and can make informed decisions about your oral healthcare.
What to do if you can’t afford dentures
If you find that you cannot afford dentures, consider the following options:
Payment Plans: Some dental offices offer financing or payment plans to spread the cost over time.
Dental Schools: Some dental schools offer reduced rates for procedures, including dentures, as a part of their training programs.
Charitable Clinics: Some organizations or clinics provide dental care, including dentures, at reduced rates or even free for those who qualify based on income.
Government Assistance: Depending on your location, there might be governmental programs designed to help cover the cost of dental care for those in need.
Comparison Shop: Prices can vary widely, so consider getting multiple quotes.
Discount Dental Plans: These are not insurance, but they can provide reduced rates at specific dentists.
Remember, your oral health is crucial for your overall well-being. If you're in need of dentures but are facing financial constraints, it's essential to explore all available options and find a solution that aligns with your needs and budget.
How SuperBill helps with denture reimbursement
Whether you’re a patient with out-of-network benefits or a dental practice or specialized dental biller, SuperBill may be able to help! SuperBill verifies patients’ dental benefits, then files and tracks their out-of-network claims. We will provide updates on the status of claims at every interval, and do everything in our power to get them reimbursed. We even help with bill negotiation!
You can jump through all the hoops to make sure you get your dentures covered by insurance, OR you can let SuperBill for insurance handle it. We have worked with countless dental patients, practices, and billers to take the reimbursement burden off their plates.