Understanding Dental Insurance - Part 3 (Major Services)

by Jeremy Granger May 30, 2020

The majority of the time, major dental services deal with procedures that require an artificial, man-made material to be placed inside the mouth. For most insurance plans, major services are covered at 50%, are subject to the plan's annual deductible and can easily max out a yearly dental plan limit. These include, but are not limited to the following:

Crowns, often called caps, are made from various materials. These materials include porcelain, porcelain fused to metal, gold, zirconia and several others options. When a tooth reaches a point that a filling will no longer support it under normal biting forces, a crown is necessary to protect it. A dental crown requires the dentist to remove a significant portion of the original tooth for the crown to sit on. If the decay or damage is significant, a foundation called a build-up is necessary to create a proper margin and area for retention.
Inlays and onlays can be made of porcelain or gold, and can be used in place of fillings. The downside to inlays and onlays is that they are expensive. Insurance usually does not cover them. If an insurance plan does cover them, it is usually only at 50%. Also, they do not fully cover the tooth. If the tooth develops another cavity, the inlay or onlay might need to be removed and another one, or a crown, might need to be made. Many dentists would agree that they potentially can have have the following benefits:

Less post-operative sensitivity
Feel the same as natural tooth structure. Resin white fillings can feel less smooth in texture, especially at first, and over time with brushing can eventually feel like enamel.
They can be custom color matched.
Porcelain is very strong and can last longer than traditional fillings. Gold is the material of choice due to its non-abrasiveness and biocompatibility
Better contacts between teeth. Traditional resin material used to fill cavities between teeth cannot be polished but can be smoothed with a sanding strip. This can lead to a noticeable difference when flossing, and possibly a food packing area.

Implants are used to replace missing teeth or to support dentures. Implants are anchors placed in the jaw bone that are used to support a dental appliance. The appliance can be either a single tooth, a bridge of teeth or even a full upper or lower denture. Implants are very expensive, often ranging from $3,000 - $6,000 per implant. They are highly desired because of their successful use in restoring a patient's missing teeth, however, their price exceeds insurance annual maximums significantly. Many insurance plans cover implants at 50%, but it will easily max out the remaining benefits for the year.
Dentures and Partial Dentures are removable appliances that are almost always made by a dental lab. Previous generations of dentists would often have an in-house lab where they would make the appliance themselves. In modern times, this is seldom done, and practitioners typically send impressions to a dental laboratory for fabrication. This process often takes two - three weeks to make a denture or partial denture. Full arch dentures are replacements for all the teeth missing in either the mandibular (lower) or maxillary (upper) jaw. For patients who still have some remaining healthy teeth, a partial denture can be constructed to fill in the gaps and provide a full set of usable teeth.

Implant supported denture

Why Are Major Services So Expensive?

As the name implies, major dental services restore teeth that have more extensive treatment needs and require significantly more time, often two or more visits. These procedures can require either a lab to fabricate the dental appliance or the dental office to do so in house. To fabricate crowns, bridges, inlays and onlays in the dental office, the office would have to purchase a scanner and milling machine that cost upwards of $100,000. Even for dental offices that have a scanner and milling machine such as a Cerec, monthly costs to maintain, run and purchase supplies for the units is in the thousands of dollars. Unlike basic procedures, major dental treatments take more chair time, doctor and staff involvement, material costs and multiple visits. All these factors create a significant jump in price when going from fillings to crowns.

How Do You Know If A Service Is Covered Under Major?

Most dental offices can easily retrieve a breakdown of benefits from an insurance company within a matter of minutes. This summary will give the dental office and patient an idea of whether a procedure is covered and may or may not include any limitations and exclusions such as waiting periods. The information retrieved from the insurance company may or may not include benefits used to date that affect the plan’s maximum yearly allowance. Although it takes longer, a pre-treatment estimate is the most effective and accurate way of determining a plan’s willingness to pay for services and will take into account benefits already used.

Can Major Services Be Prevented?

In most cases, dental problems that lead to major services can be prevented by regular cleanings and checkups. By taking such preventative measures, patients can work with their dental team to prevent decay or stop it before it becomes a major problem. Decay, if left untreated, can lead to serious problems: teeth that are painful and need root canals, build ups and crowns; fractures in teeth requiring crowns to restore; tooth loss requiring extractions and implants or a removable prosthesis. Most major dental procedures could have been prevented. Regardless of care, there is always potential for an accident which could result in the need for major dental services.

Cancer And Chemotherapy That Lead To Major Services

Oral cancer can cause tooth loss and severe facial disfigurement. The earlier it can be detected, the better the chance of a successful outcome is. Treatment of oral cancer often involves surgery and chemotherapy. Any type of chemotherapy has the potential to destroy or damage the salivary glands. Once the salivary glands are compromised, the mouth can no longer effectively buffer against acids. This leads to accelerated tooth decay and loss. Unfortunately, many prescription medications inhibit the flow of saliva, triggering similar problems in noncancer patients. Luckily, there are special mouth rinses that can help restore proper pH and are tailored to patients who are suffering from such conditions. Additionally, prescription strength fluoride can be a powerful tool at minimizing new carious lesions in a cavity-prone mouth.

What Happens When An Insurance Plan Maximum Has Been Reached?

A typical side effect of major services is that they gobble up an insurance plan’s annual maximum which often range from $1,000 to $2,000. Once a dental plan’s limit has been met, the insurance company will no longer pay for any services, even those that fall under preventative services and are covered at 100%. One of the most commonly misunderstood areas of a dental plan is about cleanings. Patients might assume that routine cleanings and checkups are free because they are normally covered at 100% and not subject to the plans deductible. Unfortunately many patients are shocked after they have maxed out their plan and discover their insurance company does not pay for one or more of their annual cleanings, x-rays and exams because the annual maximum has been met.

To learn more about our practice visit Biltmore Avenue Family Dentistry's Home Page or Contact US for questions. If you enjoyed this article, we invite you to peruse our other Blogs and check out our last article “UNDERSTANDING DENTAL INSURANCE - PART 2 (BASIC SERVICES)”.