It’s no secret—getting professional dental care often comes with the fear of breaking one’s bank. In fact, 92% of Americans would consider delaying dental care due to its cost.
Fortunately, dental insurance takes away the heavy lifting from insured patients by covering essential treatments, especially those “preventive ones” or routine dental procedures.
There’s a reason why we emphasized the term “preventive.”
Not all dental procedures are covered by your dental insurance, specifically those meant for cosmetic enhancements like veneers or teeth whitening.
What about dental implants?
The answer isn’t always straightforward. Unlike routine dental procedures, implant coverage depends on multiple factors, including whether the procedure is deemed medically necessary and what type of insurance plan you have.
This guide will walk you through when insurance might cover dental implants, what costs to expect, and what to do if your plan doesn’t include them. We’ll also explore alternative financing options to make implants more affordable.
When Does Insurance Cover Dental Implants?
You might have heard some say “that might be covered by medical insurance.” Medical insurance and dental insurance are different things, and understanding their difference is crucial.
With regard to dental implants, dental insurance considers implants a cosmetic procedure, thus will not cover them. There are, however, cases where your medical insurance may step in to cover your implant procedure if, and only if, it was caused by an accident, medical condition, or congenital defect.
Here are some situations where insurance might cover implants:
- Accident-Related Tooth Loss – If you lost a tooth due to a car accident or a sports injury, medical insurance might cover the cost of replacement.
- Medical Conditions – Some diseases, like oral cancer or congenital disorders, can cause tooth loss. If implants are necessary to restore function, medical insurance may provide coverage.
- Severe Periodontal Disease – If a patient requires full-mouth rehabilitation due to gum disease, certain insurance plans might cover part of the cost.
Replacing your tooth with an implant because of a medical condition is different from simply fixing a gap that has been plaguing your smile for a long time. Unless, otherwise, this gap can cause a far more serious dental-related issue that can affect your overall health.
In that case, talking to your dentist, physician, and dental insurance provider is paramount.
What Insurance Might Cover
If you look at a dental implant procedure in its entirety, including the multiple stages you have to go through, your insurance might still cover selected treatments. Here’s what it means.
Dental implant surgery involves multiple stages. Some of the procedures involved in each stage may or may not be covered by insurance:
- Tooth Extraction – If a tooth must be removed due to decay or disease, dental insurance may cover the dental extraction.
- Bone Grafting – Many patients need bone grafts before implant placement. Unfortunately, most dental plans don’t cover this step, even though it’s essential for implant success.
- Implant Placement – Some plans classify this as a major procedure and cover up to 50% of the cost.
- Crown Placement – If the crown is considered similar to a traditional dental crown, insurance may offer partial coverage.
Out-of-Pocket Expenses
Now, let’s say your insurance covers part of the implant procedure. Oftentimes there would be additional costs that catch you by surprise. We’re talking about out-of-pocket expenses that include:
- Consultation fees – Initial appointments and evaluations may not be included in your coverage.
- X-rays & CT scans – Imaging is necessary to assess bone health and implant placement but may not be covered.
- Follow-up visits & potential complications – If issues arise after your procedure, additional treatments may be required.
- Implant failure replacement costs – While uncommon, implant failure can occur, leading to additional expenses.
To minimize costs, consider scheduling procedures strategically to maximize your insurance benefits in a given year.
Alternative Financing & Payment Options
If your insurance doesn’t cover dental implants, don’t worry—there are still ways to make the procedure affordable:
- CareCredit & Third-Party Financing – These healthcare credit lines allow you to pay for implants in manageable monthly installments.
- In-House Dental Payment Plans – Many dental clinics offer payment plans that let you spread out costs over time. For instance, Upland Dental Practice offers a preventive membership plan that gives you a 15% off on dental implants and more.
- Health Savings Accounts (HSA) & Flexible Spending Accounts (FSA) – If you have one of these accounts, you can use pre-tax dollars to pay for dental implants.
Additionally, some patients negotiate payment plans directly with their dentist to ease the financial burden.
How to Appeal Insurance Denials & Maximize Coverage
Being denied your dental implant coverage doesn’t always mean you can’t challenge their decision. Sometimes, it’s just a matter of asserting your right to appeal the decision, especially if you have valid justifications.
Here’s how you can challenge the decision:
- Obtain a Medical Necessity Letter – Your dentist can provide documentation explaining why implants are essential for your health. Present it to your insurance provider. So, it’s important to collaborate and communicate well with your dental partner.
- Submit Supporting X-rays & Treatment Justifications – Providing concrete evidence may strengthen your case.
- Contact Your Insurance Provider – Sometimes, a phone call can clarify misunderstandings and lead to a better outcome. Better yet, go directly to your provider’s nearest office to talk to them personally.
- File a Formal Appeal – Once the supporting documents are in place, file for a formal appeal.
Use all available appeal levels and include supporting documents like radiographs, photos, and detailed notes. Some plans allow multiple appeals, while others require submission within six months. Request a call from the dental consultant before a final denial to discuss the case.
Ensure the appeal is clearly labeled and sent to the correct department. If needed, request plan documents or call the insurer using the number on the patient’s ID card.
FAQs
Can I switch insurance plans to get implants covered? Yes, but make sure the new plan explicitly includes implant coverage, as many do not.
Does insurance cover implant repairs or maintenance? Some plans may cover implant repairs, but routine maintenance is usually out-of-pocket.
What if I need multiple implants—does coverage differ? Some insurance plans limit the number of implants they’ll cover, so check your policy details.
Are mini implants covered under insurance? Mini implants are less expensive but may still not be covered under standard dental plans.
Next Steps: Reach Out To Upland Dental Practice
Dental implant coverage can be confusing, but understanding your insurance policy is the first step toward making an informed decision. Here’s what to remember:
- Coverage depends on medical necessity and the type of insurance you have.
- Some stages of the procedure may be covered, while others require out-of-pocket payments.
- Hidden costs can add up, so plan ahead.
- Alternative financing options exist to help manage costs.
- You can appeal insurance denials and strategize to maximize benefits.
If you plan to get implants in Upland California, we advise you to check your insurance policy, explore financing options, and book a consultation with us at Upland Dental Practice to discuss the best approach for your situation.
