Is oral surgery covered by medical or dental insurance?

For specific kinds of oral surgery, you may be able to get coverage from both your medical and dental insurance plans. Here's what you need to know.

Going to the dentist is a lot like any other doctor visit. You'll check in and fill out paperwork. You'll talk to some providers. You'll sit in a sterile room surrounded by medical instruments. But the care you get there isn't usually covered by medical insurance.

Dental care, at least for adults, isn't an essential health benefit under the Affordable Care Act (ACA). So your trips to the dentist for cleanings and exams aren't covered by medical insurance, explains Adria Gross. She's CEO and founder of MedWise Insurance Advocacy in Monroe, New York. Instead, you'll need a separate dental insurance plan to cover that routine care. (It's worth noting that some health plans may offer dental coverage too.)

But what if your dentist tells you that you need surgery to remove a tooth or treat gum disease? Does your medical insurance cover more serious treatments for your mouth?

It's a simple question with a complicated answer. Some oral care, such as oral surgery, may be covered completely or in part by your medical insurance, says Gross. But it depends on the details of your dental plan, your health, what care you need and why you need it. Here's a closer look.

Thinking about a stand-alone dental plan? Call a licensed insurance agent at 1-800-827-9990 to talk about available supplemental plans, or browse your options online today.

What does dental insurance cover?

Dental plans can vary widely, so you'll want to check your plan details to know exactly what's covered. Dental services generally come in 3 major categories:

Preventive services. This includes routine cleanings, exams and X-rays. Most dental plans cover preventive services, and some may cover 100% of the cost.
Basic services. This includes simple treatments such as cavity fillings and removing teeth (tooth extraction). Dental plans sometimes cover these services. They'll pay a percentage of the cost.
Major services. This includes more serious treatments such as:
- Crowns
- Dentures
- Implants
- Root canals
- Some oral surgeries
- Surgical tooth extractions

These services may or may not be covered by your plan. And plans usually pay a lower percentage of the cost for major services than they pay for basic services. Some of these services may need to be done by a dental specialist. For example, root canals are often done by an endodontist. Note that many dental plans don't cover orthodontic services, such as braces, for adults.

Many plans also have yearly benefits maximums. "Dental plans usually have fairly low benefit caps," says Gross. "This means that if you need extensive dental care, you may exhaust your dental benefits before the year is over." Once you reach that maximum, you'll have to pay for dental services out of pocket for the rest of the year.

Dental care for children is different. Under the Affordable Care Act, pediatric dental coverage must be included in individual and small-group health insurance plans. There's also no yearly maximum on dental benefits for children, unless you buy a non-ACA plan. Just keep in mind that since it's part of a medical plan, you'll have to meet that deductible before your plan begins to pay for your child's dental or oral surgery services. And medical plan deductibles are often much higher than dental plan deductibles.

Ready to explore insuarance plans where you live?

Will my oral surgery be covered by my dental or medical insurance?

That will depend on the details of your plan. Oral surgery is one of those "major services" that may or may not be covered by your dental plan. If your dental plan doesn't cover major services, it may not cover any part of your oral surgery.

Dental plans can also have waiting periods or limited coverage for your first year on the plan. It's a good idea to always have dental coverage, not just when you think you might need major dental treatments.

Your medical plan may cover some or all of your surgery, depending on what kind of oral treatment you're getting and why you need it. "Medical insurance usually only covers dental work if you've sustained trauma like an accident or an injury, or you have a medical condition such as an oral cancer that affects your mouth," explains Gross.

It all comes down to whether your treatment is considered "medically necessary" for your overall health. According to Gross, some dental treatments covered by medical insurance might include:

Complex tooth removals
Tissue biopsies
Surgeries to correct facial deformities that impact your mouth
Cancer-related oral treatments
Bacterial testing
Tests conducted to find the cause of oral and myofascial pain
General anesthesia during oral surgery
Emergency treatment to drain abscesses

With children, it's less complicated. Since their dental care is covered by an individual or small-group medical plan, oral surgery and any other dental care your child needs will usually be covered.

How can I find out if a dental procedure is covered by medical insurance?

Getting to the bottom of this can be complicated. You can start by reading the summary plan description for your medical plan. This will list covered services as well as exclusions, says Gross.

Just be forewarned: "It's very common to see a wide range of exclusions related to dental care," Gross says. You can also call your insurance company to ask them directly if your specific treatment will be covered. Another option? Call a licensed insurance agent at 1-800-827-9990.

You'll also want to talk with your dentist and/or oral surgeon any time you need a major dental service. Whether something is covered by your medical insurance will depend on what billing codes your provider uses. It's best to get this treatment from a provider who's experienced with billing both dental and medical insurances.

You can also ask your provider to get a pre-treatment estimate (known as a predetermination) for any oral surgery procedure. Here's how it works:

Your provider will write up the treatment plan with all the medical and dental billing codes.
Then they'll submit that to your dental and medical plans for review before the procedure is done.
The insurance companies will then let you and your provider know what will be covered and what you can expect to pay out of pocket.

The predetermination is an estimate — your final bills may be slightly different. But it can give you a general idea of what you can expect to pay so that you can make an informed decision.

How do I submit a claim for oral care that's covered by my medical insurance?

If both medical and dental insurance cover your procedure, your provider will need to submit claims to both plans. Some medical plans may require that dental insurance is billed first.

If your provider is in network, they can submit the claim just as they would for any other medical procedure, explains Gross. But if they're out of network, you may have to pay for the service up front and then seek reimbursement from your health plan directly. Just make sure your health plan allows you to seek out-of-network care, as some don't, Gross notes.

It's also important to check with your health insurance company to make sure that no prior authorizations are required, she adds. Prior authorization means that your provider has to get approval for a treatment plan from your insurer before performing the procedure. Some medical plans may also require a referral from your primary care doctor to cover the procedure. It may take some time and effort to coordinate your medical and dental benefits, but it's worth it.

Need a supplemental dental insurance plan? Call a licensed agent at 1-800-827-9990 to talk about available plans, or browse your options online today.

49408-HM-0223

Sources:

HealthCare.gov. "Dental Coverage in the Marketplace." Retrieved from https://www.healthcare.gov/coverage/dental-coverage/ Accessed December 21, 2022

MassHealth. "Guidelines for Medical Necessity Determination for Orthognathic Surgery." October 4, 2022. Retrieved from https://www.mass.gov/doc/guidelines-for-medical-necessity-determination-for-orthognathic-surgery/download

UnitedHealthcare. "Dental insurance frequently asked questions (FAQs)." Retrieved from https://www.uhc.com/dental-vision-supplemental-plans/dental-insurance/faq January 3, 2023.