Does dental insurance cover crowns?

Will your insurance plan cover your dental crowns?

How can you figure out the coverage you have?

Your dental plan very well may provide benefits for crown placement, although not usually at 100%. To know for certain, and to understand what level of coverage to expect, you’ll simply have to check the wording of your policy or the promotional materials that you’ve been given or have access to online.

The first portion of this page explains how to do that. Then, once you’ve determined that this is in fact a covered procedure, the bottom section of this page gives sample calculations detailing how much crowns can cost with insurance. Jump ahead.

What details do you need to look for?

1) Are dental crowns mentioned as a covered item?

Insurance companies typically group dental procedures into general categories (usually Preventive, Basic and Major). The level of benefits paid for a particular procedure is then influenced by the category in which it’s been placed.

What insurance classification do dental crowns fall under?

Crowns are usually classified as a “Major” dental service Defined.. So, check this section of the materials you have to see if crowns are included in the list of provided services.

What kinds of crowns does dental insurance cover?

If crowns are a covered procedure with your plan, take notice if there are any obvious limitations in what you see mentioned, like the case where only certain types are listed.

A list that includes all kinds of crowns Types of dental crowns. would be expected to include terms similar to the following three categories: 1) Full-cast/All-metal, 2) All-ceramic/Full-porcelain/Metal-free, and 3) Porcelain-fused-to-metal/PFM. (Other possible plan limitations for crowns are outlined below.)

2) If included, what level of benefits does the plan provide?

How much coverage does dental insurance usually provide for crowns?

As a Major service, dental plans usually cover crowns at 50% of what the company considers the “usual, customary and reasonable” (UCR) fee Calculation explained. for that kind of crown. Crown costs, by type.

Do any plans cover crowns at 100%?

Well yes, there must be some. But no, that’s not the norm. The prevailing level of benefits provided by plans for dental crowns is 50%.

How a plan’s UCR fee may affect the level of benefits you received.

It’s important to understand that in some cases the benefits your insurance company pays out will be based on their UCR fee and NOT the actual fee you’ve been charged for your crown by your dentist.

This issue only becomes a factor if your dentist’s fee happens to be greater than the insurance company’s UCR fee. In a large majority of instances, this won’t be the case. (The link above explains how a UCR fee is calculated and used by dental plans to reduce insurance payouts.)

Your dentist’s office won’t know what the insurance company’s exact UCR fee for the type of crown you’re having placed is. But from experience (like filing claims for other patients, or obtaining pre-authorization for your procedure (see below)), they’ll have an idea. And if the insurance payout is expected to be lower than what you the patient might have otherwise anticipated, they can give you a heads up.

3) Are there additional plan restrictions on crown placement?

Almost all insurance policies will have additional conditions that apply to covered procedures. In regard to crown placement, here are some examples of what’s common.

• Expect that no benefits will be paid for crowns until the policy’s deductible has been met. Calculation explained.
• And realize that no benefits will be paid out that exceed the plan’s maximum benefits limitation Calculation explained., which typically runs on a per-year basis.

Beyond those issues, there can be additional policy restrictions that only apply to crown placement that limits the amount of benefits paid, if any are paid at all. (We discuss them in our next section.)

For this reason, having your dentist’s office request “preauthorization” from your insurance company for your proposed treatment plan makes a good idea when crown placement is included. We discuss doing so below.

Possible dental plan restrictions on crown placement.

A plan’s basic coverage for dental crowns may be limited by the following additional issues and conditions.

a) Only certain kinds of crowns may be allowed.

As mentioned above, a plan may have restrictions about the type of restoration that’s placed, based either on the crown’s application or construction type. As possible examples:

• Coverage may not be provided for the placement of some types of all-ceramic crowns on back teeth.
• The policy may limit the kind of metal used in the crown’s construction (i.e. gold/precious metal vs. non-precious alloys). Dental alloys explained.

FYI: While seemingly not covered, some plans may allow that a member may have a different type of crown placed than the one(s) typically allowed. The patient is then responsible for the difference in cost between the two.

b) The crown’s placement must be justified.

Your dentist may have to submit documentation (x-rays, clinical notes, study casts) explaining why a crown is needed (and demonstrating that the tooth is worthy of rebuilding) before its coverage can be determined.

This way, the insurance company has evidence that an alternative procedure or approach wouldn’t have sufficed or provided more appropriate treatment.

Does dental insurance cover “cosmetic” crowns?

Most policies will not provide coverage for dental crowns that are placed solely for cosmetic reasons.

Keep in mind, however, if the crown’s placement can be justified for any reason accepted by the plan (like the tooth needs rebuilding or strengthening), and a side benefit just happens to be that the crown will also restore the tooth’s appearance, then coverage can be expected.

c) Waiting periods.

With insurance, how long do you have to wait before getting a crown?

New policyholders may find that their plan stipulates a waiting period Explained. before their needed crowns are covered. For example, there may not be coverage during the member’s first 12 months.

d) Age restrictions for crown placement.

Dental plan benefits for crowns may be limited to persons of a certain age. The cutoff might be as low as age 12. We’ve also seen policies that limit crown placement to persons 16 years and over.

It’s common that a dentist will want to wait until the stipulated age limit anyway due to age-related growth issues.

e) How often will dental insurance pay for crowns?

1) Does dental insurance cover crown replacement?

A plan may not provide coverage for a replacement crown if that same plan had provided benefits for the previously existing one within a certain time period. 5 to possibly 7 years is a common limitation time frame.

Generally, any crown slated for replacement must have some type of demonstrable clinical deficiency, (recurrent decay, open margin, fractured porcelain, metal perforation, etc…). Crown replacement based solely on cosmetic concerns is typically not covered.

2) Does dental insurance cover replacing lost dental crowns?

Some insurance policies specifically state that they will not provide benefits for “lost, missing or stolen crowns.” This type of stipulation brings to light how important it is to manage a lost crown situation properly. What to do.

Preauthorization

Considering all of the possible conditions and restrictions on crown placement that a dental policy may impose, considering the idea of having your treatment plan “preauthorized” often makes sense. In some cases, your dentist’s office may insist on it.

Preauthorizing a procedure is the process where the dentist collects all relevant information and then submits it to the insurance company so to let them know what treatment is planned. The company then reviews the information and responds by stating what they expect they will provide as coverage (referred to as a “predetermination of benefits”).

Ask your dentist’s office if this step is needed. It isn’t always. But in situations where some question exists and a significant procedure cost is involved, doing so can help to avoid surprises.

Having difficulty figuring things out? Ask your dentist.

A very simple way to find out about your plan’s level of benefits for crowns is to simply ask your dentist’s front-office staff.

Your dentist’s office is a business, and as such, a main goal is providing billable services. And since they know that for most patients the financial assistance they get from their dental plan is an important consideration, especially for big-ticket items like crowns, their staff is usually quite cooperative in helping you understand the level of coverage you have.

How much do crowns cost with insurance?

There are several issues that may be factors in how much your new crown actually ends up costing you after your insurance pays. Here are some example calculations that explain possible outcomes, both when a dental plan is and isn’t involved.

How many crowns will dental insurance cover?

It’s unlikely that any set number is mentioned in your policy. Instead, your limit in how many crowns are covered will simply be determined by your plan’s “maximum yearly benefits” limitation, and when that money ultimately runs out.

In our discussion below, we include suggestions for how the obstacle of exceeding your policy’s yearly maximum benefits can sometimes be worked around when multiple crowns are needed.

How much does dental insurance pay for crowns? – Example calculations.

FYI: For the sake of simplification and using round numbers, in the sample calculations below we’ve set the per-unit price of crowns at $1000. This page provides a more realistic estimate of crown fees. Crown costs.

If you just need one or two crowns placed:

For 2:

• Total charges by your dentist for your work: $1000 (unit price) X 2 (number of “units”) = $2000.
• If insurance is involved: As a “Major” dental service, it’s common for insurance plans to cover 50% of the (UCR) fee of crowns, after the policy’s deductible has been met, but only up to the amount of its maximum annual benefits. (See above for an explanation of these terms.)

  For our examples on this page, we’ll set the deductible at $100 and the policy’s maximum benefits at $1000. Both of these numbers are fairly common.

  Insurance benefits: [$2000 (total charges) – $100 (policy deductible)] X 50% = $950. Note, this number is smaller than the maximum yearly benefit.

  Amount you pay: $2000 (total charges) – $950 (insurance benefits) = $1050.

For 1:

• Total charges by your dentist for your work: $1000 (unit price) X 1 (number of “units”) = $1000.
• Insurance benefits: Using the example policy values stated above, the calculation for one crown would be [$1000 (total charges) – $100 (the policy deductible)] X 50% = $450. Once again, this amount lies below the policy’s maximum benefits.

  Amount you pay: $1000 (total charges) – $450 (insurance benefits) = $550.

If you need three or four crowns placed:

For 4:

• Total charges by your dentist for your work: $1000 (unit price) X 4 (number of “units”) = $4000.
• Insurance benefits: Using the policy values above, the calculation for four crowns would be [$4000 (total charges) – $100 (the policy deductible)] X 50% = $1950. However, this number is greater than the policy’s maximum benefits, so in this example, the benefits would be limited to $1000 (see discussion below).

  Amount you pay: $4000 (total charges) – $1000 (insurance benefits) = $3000.

For 3:

• Total charges by your dentist for your work: $1000 (unit price) X 3 (number of “units”) = $3000.
• Insurance benefits: Using the policy values above, the calculation for three crowns would be [$3000 (total charges) – $100 (the policy deductible)] X 50% = $1450. Because this number is greater than the policy’s maximum benefits, the total amount paid would be limited to $1000 (see discussion below).

  Amount you pay: $3000 (total charges) – $1000 (insurance benefits) = $2000.

Working around the maximum yearly benefits limitation.

As you can see from these last two examples, when multiple crowns are needed a policy’s maximum benefits limitation can be reached very quickly.

A possible workaround.

If that’s true for your case, ask your dentist about the timing of your policy year and how your treatment can be planned with it in mind.

For example, with those that run on an annual cycle, you might have some crowns placed in late December and the remainder in early January. Doing so might satisfy the conditions of your policy, yet allow all of your work to be completed within a relatively compact time frame.

Not all treatment plans can be divided up this way. But if yours can, using this approach may be able to save you some money.

If you need five or six crowns placed:

For 6:

• Total charges by your dentist for your work: $1000 (unit price) X 6 (number of “units”) = $6000.
• Insurance benefits: Using the same policy values as above, the calculation for six crowns would be [$6000 (total charges) – $100 (the policy deductible)] X 50% = $2950. But since this number is greater than the policy’s maximum benefits, the amount paid would be limited to $1000 (see discussion below).

  Amount you pay: $6000 (total charges) – $1000 (insurance benefits) = $5000.

For 5:

• Total charges by your dentist for your work: $1000 (unit price) X 5 (number of “units”) = $5000.
• Insurance benefits: Using the policy values above, the calculation for five crowns would be [$5000 (total charges) – $100 (the policy deductible)] X 50% = $2450. But once again, the total benefits paid would be limited to $1000 (see discussion below).

  Amount you pay: $5000 (total charges) – $1000 (insurance benefits) = $4000.

Dealing with insurance limitations when a large number of crowns are needed.

As you can see, in cases where a relatively large number of restorations are planned, the benefits actually paid by your insurance company can become comparatively minor.

Possible workarounds.

As discussed above, some cases might be split up, where part of the work is performed during the very last part of one policy year and the very beginning of the next.

As yet another alternative, one might consider stretching out their crown placement over several years. However, doing so may be ill-advised. For example, teeth that need the strengthening effect that a crown can provide may suffer irreparable damage if not treated in a timely fashion.

We discuss the issue of crown alternatives and alternative approaches here. Possible options. Keep in mind however, only your dentist has the needed knowledge to make an informed decision about which ones make an appropriate choice for your situation.