Dental crowns are a common treatment for restoring damaged or decayed teeth. Many people are curious about how often dental insurance covers crowns. If you have dental insurance, it’s important to understand the coverage for crowns. In this article, we’ll explore when dental insurance typically covers crowns, the types of insurance plans available, and factors that can affect your coverage.
What Are Dental Crowns?
Dental crowns are caps that are placed over a damaged or decayed tooth. They help restore the tooth’s function, shape, and appearance. Crowns are made from a variety of materials, including porcelain, metal, and ceramic. They are used to cover teeth that are cracked, severely decayed, or weakened from root canal treatment.
Types of Dental Insurance
Understanding how often dental insurance covers crowns starts with knowing the different types of dental insurance plans.
PPO Dental Insurance
A Preferred Provider Organization (PPO) plan allows you to see any dentist, but you’ll save more money if you visit an in-network dentist. PPO plans often provide coverage for crowns, but the amount covered may depend on whether the dentist is in-network or out-of-network.
HMO Dental Insurance
Health Maintenance Organization (HMO) plans typically have a smaller network of dentists. To receive coverage, you must see a dentist within this network. These plans usually cover crowns, but you may be required to get a referral from your primary care dentist before seeing a specialist.
Indemnity Dental Insurance
Indemnity plans are more flexible and allow you to visit any dentist. They are less common than PPO and HMO plans. With indemnity insurance, crowns are typically covered, but you will likely pay a larger portion of the cost compared to other types of plans.
Discount or Dental Savings Plans
Dental savings plans are not insurance, but they offer discounts on dental procedures, including crowns. You pay an annual fee to join the plan, and in return, you receive reduced rates on services. Crowns are usually covered under these plans at a discounted price.
How Often Does Insurance Cover Crowns?
Dental insurance coverage for crowns can vary depending on several factors. Let’s take a look at some of the common scenarios where insurance may cover crowns.
Coverage Frequency
In most cases, dental insurance plans will cover a crown every 5 to 7 years. This is because crowns are designed to be long-lasting, but over time, they can wear down or become damaged. If your crown needs to be replaced before the 5-7 year mark, you may be responsible for the additional cost, unless there’s a clear reason for replacement, such as damage or wear.
Major Dental Benefits
Crowns are usually classified as major dental procedures, which means they fall under the major dental benefits section of your insurance plan. Insurance typically covers 50% to 80% of the cost for major procedures, including crowns, after you meet your deductible. The percentage of coverage can vary depending on your specific plan.
Waiting Periods
Many dental insurance plans have a waiting period before coverage kicks in for major procedures like crowns. This waiting period can range from 6 to 12 months. If you need a crown before the waiting period is over, you may have to pay for the entire procedure out-of-pocket.
Pre-existing Conditions
If you have a pre-existing condition, such as a tooth that has already been treated for decay or damage before you obtain dental insurance, your coverage for crowns may be limited. Some insurance plans do not cover crowns for pre-existing conditions, so it’s important to review your policy for any exclusions.
Factors That Affect Crown Coverage
Several factors can influence how much your dental insurance will cover for crowns. These include your policy’s annual maximum, the material of the crown, and whether the crown is medically necessary.
Annual Maximum
Most dental insurance plans have an annual maximum, which is the maximum amount the insurance will pay for dental care in a year. If you’ve already used up your annual maximum on other dental procedures, you may be responsible for the full cost of the crown.
Material of the Crown
The type of crown you need may also affect the coverage. Porcelain or ceramic crowns are often more expensive than metal crowns, and some insurance plans may only cover a portion of the cost if you choose a more expensive material. If you select a material that is not covered under your plan, you may need to pay the difference.
Medically Necessary Crowns
In some cases, crowns are considered medically necessary if they are needed to restore a tooth’s function or prevent further damage. If your dentist can demonstrate that the crown is medically necessary, your insurance is more likely to cover the procedure. However, if the crown is purely for cosmetic reasons, your insurance may not cover it at all.
How to Maximize Your Crown Coverage
If you want to make sure you get the most out of your dental insurance when it comes to crowns, here are some tips:
Check Your Policy
Before scheduling a procedure, review your dental insurance policy to understand what is covered and any limitations on crown coverage. Pay close attention to the waiting periods, annual maximums, and exclusions.
Visit an In-Network Dentist
If you have a PPO or HMO plan, visiting an in-network dentist can help you save money on crowns. In-network dentists have agreed to accept the insurance company’s payment rates, which are usually lower than the fees charged by out-of-network dentists.
Consider Timing
If you are nearing the end of the year and have already used a significant portion of your annual maximum, it might be wise to wait until the next year to get your crown. However, if you need a crown immediately, check to see if your plan covers a higher percentage of the cost early in the year.
Ask for a Pre-authorization
Some dental insurance plans require pre-authorization for major procedures like crowns. This means your dentist will submit a request to the insurance company for approval before starting the procedure. Pre-authorization can help clarify what will be covered and reduce any surprises when the bill arrives.
Look for Financing Options
If your dental insurance doesn’t cover the full cost of a crown, ask your dentist about financing options. Many dental offices offer payment plans or financing through third-party companies that allow you to pay for the crown over time.
Conclusion
Dental insurance typically covers crowns, but the coverage depends on your specific plan, the type of crown, and other factors like waiting periods and annual maximums. Understanding the details of your dental insurance policy can help you plan for the cost of crowns and ensure that you get the most coverage possible.
If you need a crown, be sure to consult with your dentist and review your insurance policy to understand your coverage. By knowing what to expect, you can avoid unexpected expenses and ensure that your dental care is both effective and affordable.
Related topics:
