Insurance "dental services" - Preventive, Basic, Major -

A listing of  1) Classification definitions  2) Examples of covered procedures  3) Coverage levels. | How wisdom teeth, root canal and periodontal procedures may be categorized.

Dental plans usually group the procedures they cover into three categories: a) Preventive , b) Basic and c) Major dental services.

The category to which a procedure has been assigned typically indicates the amount of coverage (level of benefits) that the policy provides for that service.

Note: What's listed as Preventive, Basic or Major will vary by policy.

While the information we present on this page is typical of most plans, yours may categorize procedures or provide benefits differently.

To find out, you might read your plan's handbook or call your insurer's toll-free number. Probably the best way is to simply ask your dentist's front-office staff for help.


A) Preventive dental services.

You'll probably find that your policy's coverage and provided benefits for Preventive (and Diagnostic) dental services are comparatively generous.

Benefits level.
  • It's common for indemnity insurance and preferred-provider (PPO's) plans to provide coverage at around 70 to 80% of your dentist's bill (using either a "UCR" or "Table of Allowances" calculation - see below). And in many cases it may even run 100%.

    You'll need to check your policy to see if its deductible must be met before you receive any benefits. With many plans this is not a requirement.

  • With an HMO plan, you can expect that you'll have little or no copayment when Preventive procedures are performed.

List of Preventive / Diagnostic dental services.

  • examinations
  • cleanings (prophylaxis)
  • bitewing x-rays
  • periapical x-rays
  • full-mouth, panorex x-rays
  • fluoride treatments (age limitations may apply)
  • space maintainers (may be a Basic service, age limitations may apply)
  • tooth sealants (may be a Basic service, age limitations may apply)

Ideally your plan will provide these services at least at these frequencies.

  • Examinations - twice per year.
  • Bite-wing x-rays - once per year.
  • Teeth cleanings - twice per year.
  • Full mouth x-ray series - once every three years.

Additional preventive dental care for children and adolescents.

  • Topical fluoride treatments - twice per year.
Takeaways from this section.

Unlike with medical insurance where its primary purpose is protection against catastrophic financial loss, the primary goal of having dental coverage is the prevention of problems and diagnosing those that do occur as early as possible.

That's why benefits for Preventive and Diagnostic services are characteristically the most generous of the policy.


B) Basic dental services.

In general, basic services are typically those types of treatments and procedures that are relatively straightforward in nature and don't involve a significant laboratory expense for the dentist.

Benefits level.
  • It's common for indemnity and PPO insurance plans to cover Basic services at a rate of about 70 to 80%. In most cases, benefits are not paid until the member has met their deductible.
  • With HMO plans, a modest copayment may be required when these services are performed.

List of Basic dental services.

  • emergency care for pain relief
  • amalgam fillings
  • composite fillings (white fillings)
  • sedative fillings
  • routine tooth extractions - (Details about insurance coverage for pulling teeth.)
  • root canal treatment - (may be Major service) (Details about insurance coverage for root canals.)
  • periodontal scaling and root planing
  • periodontal surgery (may be Major service)
  • recementing dental crowns
  • stainless steel (prefabricated) crowns
  • non-routine x-rays
Takeaways from this section.

Just as prevention and early diagnosis are so important, so is correcting any problems that do develop as soon as possible.

A policy's coverage for Basic services must be generous enough that when they're needed they lie well within the member's financial reach. If not, they may not be utilized in a timely fashion.

Very few dental problems will resolve on their own. With most conditions, delaying treatment means that a more involved procedure will be required later on. That means that both the insured and insurer's ultimate costs will be greater.


C) Major dental services.

The Major dental services category typically includes procedures and treatments that are relatively more complex in nature and often involve a dental laboratory expense. These services tend to be more costly than those found in the Basic category.

Benefits level.
  • With indemnity and PPO insurance policies, the benefits provided for Major dental services frequently run on the order of 50% of the procedure's cost, after the deductible has been met.
  • With HMO plans a copayment is typically required.

List of Major dental services.

  • dental crowns (may be a Basic service) - (Details about insurance coverage for dental crowns.)
  • inlays and onlays
  • bridgework
  • tooth implants
  • impacted wisdom teeth removal (may be Basic)
  • complex oral surgery procedures
  • anesthesia / sedation
  • removable partial dentures
  • complete dentures
  • denture relines and rebases
  • denture repair
  • orthodontic treatment
Takeaways from this section.

With some insurance policies, when it comes to providing coverage for Major services, you'll find that their emphasis seems more geared toward preserving the status quo rather than providing for significant dental reconstruction.

It's often the policy's maximum benefits limitation that becomes the problem. It's level is frequently high enough that one or two teeth can be rebuilt (root canals and crowns). But when major reconstruction is planned, this limitation is easily exceeded.

As a work around, see our "Creative treatment planning" section.


Clarifications: Major vs. Basic procedure classifications.

There are a number of dental procedures that insurance companies frequently classify differently. While you'll still need to refer to the definitions list stated in your specific plan, here are some general rules about how they are generally categorized.

► Is Wisdom Tooth removal considered a Basic or Major dental service?

"Simple" (routine) tooth extractions are typically classified as a Basic service while "surgical" extractions (like removing impacted teeth) a Major one. Depending on it's circumstances, having a wisdom tooth removed might fall under either classification (this page explains).

In the case where a policy doesn't cover surgical extractions, the person's health insurance might.

► Is Periodontal Treatment considered a Basic or Major dental service?

Gum treatments may be either surgical (periodontal surgery) or non-surgical (scaling and root planing). Non-surgical procedures are typically listed as a Basic service. Surgical ones may fall under either classification, simply depending on the policy.

► Is Root Canal Treatment considered a Basic or Major dental service?

There's no obvious rule of thumb that seems to apply to the categorization of routine root canal therapy. It may be listed as either a Basic (most commonly) or Major (less frequently) procedure, you'll simply need to refer to your policy for clarification.


Situations where either a Basic or Major procedure might be chosen.

There can be times when more than one procedure might be deemed an appropriate method of treatment for a person's condition. And in these types of situations it's common that an insurance plan will only provide coverage for the less costly service (such as a Basic service vs. a Major one).

If so, it may be possible for the person to opt for the more expensive treatment yet still receive some policy benefits. Under this scenario the insurance company would provide benefits as if the covered (less expensive) dental work was performed. The patient then pays the outstanding balance.


How to calculate what your actual coverage/benefits will be.

A) Policies whose benefits are calculated using UCR fees.

Note: These calculations aren't quite as straightforward as you might expect. If this is the type of policy that you have, you'll probably gain more insight from reading through these sample calculations.

Benefits that are based on procedure "UCR" fees ("Usual, customary, reasonable") are calculated on a percentage basis.

As stated above:

  • Preventive and Diagnostic dental services (cleaning, x-rays) are often covered at a very high percentage (80 to 100%) of the UCR fee.
  • Basic services (routine dental procedures) are usually covered as a slightly lower percentage (typically 50 to 80%).
  • Major dental services, such as dentures and crown and bridge treatment, if covered, will typically be provided for at an even lower rate (possibly 50% or less).

The dollar amount of benefits paid will be limited by your policy's stated deductible and maximum benefits. You're responsible for paying your dentist the difference between what your insurance has paid and the actual cost of your treatment.

B) Policies that base benefits on a Table of Allowances.

Some insurance policies calculate their benefits using a fixed fee schedule termed a "Table of Allowances."

This table is simply a listing of all covered dental procedures and the dollar amount that the insurance company will provide as a benefit when they are performed. Keep in mind, the amount paid will be limited by the policy's deductible and plan maximum benefits.

If you are considering a plan that uses a Table of Allowances, you should inquire as to whether the payments it specifies will be accepted by the treating dentist as payment in full, or you will be expected to make up the difference by way of making a copayment (the more likely arrangement). There can be a very significant out-of-pocket difference between the two.

Ask your dentist's office staff for help in determining your benefits.

For the dental patient, trying to calculate policy benefits can be both very confusing and very difficult to get right. So, don't hesitate to ask your dentist's staff for help or clarification.

  • It's normal and routine for them to make these types of calculations. What patient wouldn't want to know what their costs will be before having a procedure performed?
  • In many cases, they may be so familiar with the plan you have (because other patients do too) that they can come up with the right figure off the top of their head.

Preauthorization

Of course, the ultimate authority on this issue is your insurance company. You do have a contract with them and certain treatment obligations are outlined in it. But with some procedures (especially Major services), the conditions under which they are covered may be open to the insurance company's interpretation.

So, and especially in situations where larger sums are involved, your dentist's office may feel that they should submit for pre-treatment authorization.

In this situation, your dentist will file a predetermination form that details specifics about your proposed treatment plan (they may also send x-rays, pictures or study models). In response, the insurance company will send an itemized reply stating what your expected benefits for each procedure should be.

This is usually a free service. (Filling out the form is an extension of goodwill on the part of your dentist. Making the calculation is one of your company's obligations to you as a plan member.) Turnaround time for the process is usually 2 to 3 weeks.

 

 
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