What is Considered Major Restorative Dental Work?

What is Considered Major Restorative Dental Work?


You haven’t been to the dentist in a while, but you’ve been feeling something going on with a couple of your teeth. Once you finally schedule a checkup, your dentist — much to no surprise — says you need a few of your teeth fixed. As the treatment coordinator goes over your care plan, she starts using terms like “basic” and “major” to describe the treatment being recommended. While it may not sound important, these phrases directly impact the total cost of your dental bill.

How Much Does Dental Insurance Cover on Major Treatment?

Major dental work is usually covered under the lowest “tier” of reimbursement. While preventive treatments are generally covered at nearly 100% and basic treatments closer to 75-80%, major treatments are may only be covered up to 50%, leaving the other 50% up to the patient (you) to cover out of your own pocket. 

Differentiating Minor/Basic from Major Dental Work

A “basic” dental procedure is something beyond preventive treatment (checkups and cleanings) yet not “major.” It usually involves routine fillings and such. A “major” dental treatment is something that could have usually been treated earlier on in a more affordable manner, or something that requires multiple phases of therapy to correct. Some examples of major restorative work include dental bridges, crowns, inlays and onlays, and dentures.

If your major treatment involves replacing a missing tooth or correcting decay that has been ignored for quite some time, there’s a good chance that it may be classified as a major procedure. That’s why it’s always best to see a dentist on a routine basis and treat problems early. 

Calculating Coverage on Your Major Restorative Dental Work

Now comes the tricky part: crunching the numbers. This is where your dentist’s treatment plan coordinator comes in. He or she will get a benefit breakdown from your insurance company, so that you can get an estimate of how much they cover for your major treatments coming up. Once all the math has been done, your coordinator will show you what your estimated coverage is, and what you can plan on paying for out of pocket.

Depending on your insurance carrier, some types of major dental treatments need to have a pre-approval before you can have the procedure completed. Your dentist will need to send off a description of which tooth needs a specific procedure, and possibly even an x-ray to support their diagnosis. Once you hear back from the insurance company (which may be as long as 30 days later,) you can find out whether or not they approve the treatment to be performed. 

Other Things to Keep in Mind

Being that dental insurance covers different types of procedures at different levels of reimbursement, it can be confusing to navigate what gets paid for by whom. One of the most important things to keep in mind from planning out your care are waiting periods, maximum allowable, and of course your deductible.

Some dental insurance plans have a waiting period on major treatments. That means you have to be enrolled in the plan for a set timeframe (typically six to 12 months) before the coverage will pay for major dental work. This prevents people from signing up for insurance, using the benefits immediately, and then dropping the plan.

Maximum allowable expenditures (also called “annual cap”) are the dollar amount that your insurance plan will pay up to – usually $1000-$1500 annually. After you reach your annual cap, you pay out of your own pocket for dental care for the rest of the year (your policy’s 12 months of coverage, not necessarily the date on the calendar). So, if you have two or three major treatments that need to be done in one year, your insurance may only cover one treatment. 

Finding Ways to Save on Your Major Dental Treatments

When dental needs turn complex, it may seem like your dental insurance doesn’t pay for nearly as much as you think it should. In cases like these, some people turn to a dental savings or discount plan to get a flat reduced fee on all of their treatment.

After you’ve crunched the numbers (comparing how much you’re paying out of pocket for dental insurance vs. how much you’re getting back,) some people find that they spend less on the total cost of their oral health care by using a discount plan.

Contact the experts at CalDentalPlans.com to find an insurance or dental discount plan that saves your family money every year!

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