Does dental insurance cover implants?

The short answer

Sometimes. Some dental plans pay part of the cost of an implant. Many plans pay nothing for the implant itself, and almost none pay all of it.

The reason is simple. Implants are expensive, and most dental plans have a low yearly limit. So even a plan that covers implants may only cover a small slice of the bill. The best way to know is to ask your plan before you plan treatment. This article shows you how.

Why plans treat implants differently

Dental plans sort treatments into groups. Cleanings and exams are "preventive." Fillings are usually "basic." Crowns, bridges, dentures and surgery are usually "major." Humana explains that a common setup pays 100% for preventive care, 80% for basic care and 50% for major care, after you meet your deductible. Consumer Reports describes the same 100, 80 and 50 pattern.

Implants often fall in the major group. Some plans leave implants out completely. They may pay for a bridge or a denture instead. Others cover part of the implant surgery or part of the crown on top, and they treat each piece as a separate line.

Some plans also use what is called a "least expensive alternative treatment" rule. The American Dental Association lists this in its guide to insurance statements. In plain words, the plan may pay what it would pay for the cheaper option, like a bridge. You then pay the difference if you choose the implant.

The yearly maximum is the real limit

Almost every dental plan has a yearly maximum. That is the most the plan will pay in one year, no matter how big the bill is.

Consumer Reports, citing the National Association of Dental Plans, says the middle yearly maximum is about $1,500. Individual plans it describes often fall between $1,000 and $2,000. The same article lists typical 2018 prices for an adult implant at $1,200 to $2,500. Those numbers are older, and prices have gone up since. But the point holds. One implant can use up an entire year of benefits.

The good news is that the limits are slowly rising. An executive of the dental plans association told Becker's Dental Review that plans with a maximum of $1,000 or less used to be about 53% of the market, and they have dropped to about 34%. Still, a higher limit does not mean the plan pays for implants. You need to check both things.

Here is a simple example, with made-up numbers. Say your plan pays 50% of major work, your yearly maximum is $1,500 and the bill for the implant and crown is $4,000. Half of $4,000 is $2,000, but the plan stops at $1,500. You would pay the other $2,500. Your real numbers will differ, which is why a written estimate matters.

Waiting periods and other fine print

Many plans make you wait before they pay for bigger work. Humana lists a common pattern: no wait for preventive care, six months for basic care and 12 months for major care. Some plans waive the wait if you had similar coverage for the past 12 months. Others do not.

Other rules can also change what you pay:

• Deductible: an amount you pay first. Humana gives $50 per person as one example, and preventive care is often exempt.
• Missing tooth clause: some plans will not pay to replace a tooth that was lost before your coverage started.
• Frequency limits: some plans only pay for one replacement of a tooth in five to ten years.
• In-network or out-of-network: you usually pay less when the dentist is in your plan's network.

What about Medicare and Medicare Advantage?

Original Medicare does not cover routine dental care, including implants. Medicare.gov says you pay all costs for most dental services.

Many Medicare Advantage plans add dental. The Kaiser Family Foundation (KFF) found that in 2021, 94% of people in individual Medicare Advantage plans could get some dental coverage. Of those, 86% had more than just preventive care. But these plans also have limits. For plans with broader coverage, the average yearly cap was about $1,300, and 59% of people were in plans capped at $1,000 or less. That is not much for an implant.

Some people have a Medicare supplemental plan instead. Those usually help with medical costs, and dental help depends on the plan. Read your benefits book or call the number on your card.

Seven questions to ask your plan

Before you book anything, call the number on your insurance card, or ask the dental office to send a request to the plan. Ask these questions:

• Does my plan cover implants, and which parts: the surgery, the connector piece (abutment) or the crown?
• What percent does it pay, and does that come after a deductible?
• What is my yearly maximum, and how much have I already used this year?
• Is there a waiting period for major work, and when does it end?
• Does the plan only pay the amount of a cheaper option, like a bridge?
• How many years must pass before it pays to replace the same tooth?
• Is my dentist in my network, and does that change the price?

Other ways to pay for an implant

If your plan pays little or nothing, you still have options. Many offices offer monthly payment plans through outside lenders. Read the terms with care, because some cards charge back interest if you do not pay the full balance on time. If you have a health savings account (HSA) or flexible spending account (FSA), ask your plan administrator whether implants qualify.

You can also split care across two plan years. Your plan resets its yearly maximum each year, so some people do the surgery in one year and the crown in the next. Ask your dentist if that fits your case. Never delay care that you need for pain or infection just to save on benefits. See a dentist soon if you have swelling, pain or a loose tooth.

Getting a clear number at KDA

At Kendall Dental Associates (KDA), we plan implants with a 3D scan taken in our office, then explain each step before you decide. We accept most dental insurance plans, and financing is available. We can look at your plan with you so you know what to expect before treatment starts.

Call 305-271-1421 or visit us at 8833 SW 107th Ave, Miami, in the Kendall Mall. We are open Monday to Friday, 8:00 AM to 5:00 PM. Have your insurance card handy, and we will help you get answers.

If you are not sure an implant is right for you, ask about the other choices too. Bridges and dentures cost less up front, and some plans pay more for them. Our team will explain the pros and cons of each, so you can pick what fits your health, your budget and your life.

Common questions

This article is general information, not medical advice. Your dentist will confirm what is right for you at your exam. General information checked against: consumerreports.org, humana.com, kff.org, beckersdental.com, ada.org.