Insurance “dental services” categories – Preventive, Basic, Major –

Preventive vs. Basic vs. Major dental services.

Dental plans usually group the specific procedures they provide coverage for into one of three categories: Preventive, Basic, and Major dental services.

Which procedures fall into which group?

It’s useful to know the category into which the dental procedures you’re going to need have been assigned because it provides an indication of the level of coverage (level of benefits) that your policy provides for them. For specific details about what’s common, use the links below.

• List of Preventive dental services – Dental procedures found in this category typically include routine dental cleanings, exams, and x-rays.
• List of Basic dental services – Dental procedures like fillings, root canals, routine tooth extractions, and some kinds of periodontal (gum) treatment are usually found here.
• List of Major dental services – This group typically includes higher-priced, less-frequently-performed procedures like dental implants, crowns, bridges, and full and partial dentures.

Keep in mind that what’s considered a Preventive, Basic, or Major service will vary with each dental plan.

While the information we present on this page is typical of most dental insurance policies, yours may categorize procedures or provide benefits differently.

There’s only a few ways to find out for sure beforehand. You might look in your plan’s handbook, on their website, or call your insurer’s toll-free number. However, since it is the area of their expertise, the simplest way is probably to just ask your dentist’s front-office staff for assistance. Even if they don’t know the answer to your question, they’ll either know where to look or specifically direct you to look.

A) Preventive dental services.

You’ll probably find that your policy’s coverage and level of benefits for Preventive (and Diagnostic) dental services are comparatively generous.

Benefits level.

• It’s common for indemnity insurance and preferred provider (PPO) plans to provide coverage at around 70 to 80% of your dentist’s bill (using either a “UCR” or “Table of Allowances” calculation – see below). And in many cases, it may even run 100%.

  You’ll need to check your policy to see if its deductible must be met before you receive any benefits. With many plans, this is not a requirement.

• With an HMO plan, you can expect that you’ll have little or no copayment when Preventive procedures are performed.

What kinds of procedures are considered preventive dental care?

A plan’s Preventive Dental Services list will be composed of procedures that dentists use to diagnose, monitor, and maintain their patients’ good oral health.

Included will be measures used to identify developing gum disease, tooth decay, or other serious issues (inside your mouth, jawbones, and/or neck). Also, expect to see services that can help to arrest small dental problems before they grow into more serious ones.

List of Preventive dental services / Diagnostic dental services.

• oral examinations
• routine dental cleanings (prophylaxis)
• bitewing x-rays
• periapical x-rays
• full-mouth series or panoramic x-rays
• fluoride treatments (age limitations may apply)
• space maintainers (may be considered a Basic service, age limitations may apply)
• tooth sealants (may be considered a Basic service, age limitations may apply)
• athletic mouthguards (coverage varies widely)
• nighttime mouthguards (coverage varies widely)
• oral hygiene instructions
• oral cancer screenings

Ideally, your plan will provide these Preventive services at least at these frequencies.

• oral examinations – twice per year.
  
• bite-wing x-rays – once per year.
  
• routine teeth cleanings – twice per year.
  
• full mouth x-ray series – once every three years.

Additional preventive dental care for children and adolescents.

• topical fluoride treatments – twice per year.

While the intervals stated above are not written in stone, they are those that are typically recommended by dentists for a large percentage of the general population and therefore ideally included in one’s dental insurance plan.

B) Basic dental services.

In general, basic services are typically those types of treatments and procedures that are relatively straightforward in nature and don’t involve a significant laboratory expense for the dentist.

Benefits level.

• It’s common for indemnity and PPO insurance plans to cover Basic services at a rate of about 70 to 80%. In most cases, benefits are not paid until the member has met their deductible.
• With HMO plans, a modest copayment may be required when these services are performed.

List of Basic dental services.

• emergency care for pain relief
• amalgam fillings
• composite fillings (white fillings)
• sedative fillings
• routine tooth extractions – (Details about insurance coverage for pulling teeth.)
• root canal treatment – (may be considered a Major service) (Details about insurance coverage for root canals.)
• periodontal scaling and root planing
• periodontal surgery (may be considered a Major service)
• recementing dental crowns
• stainless steel (prefabricated) crowns
• non-routine x-rays

C) Major dental services.

The Major dental services category typically includes procedures and treatments that are relatively more complex in nature and often involve a dental laboratory expense. These services tend to be more costly than those found in the Basic category.

Benefits level.

• With indemnity and PPO insurance policies, the benefits provided for Major dental services frequently run on the order of 50% of the procedure’s cost, after the deductible has been met.
• With HMO plans a copayment is typically required.

List of Major dental services.

• dental crowns (may be a Basic service) – (Details about insurance coverage for dental crowns.)
• inlays and onlays
• bridgework
• tooth implants
• impacted wisdom teeth removal (may be considered a Basic service)
• complex oral surgery procedures
• anesthesia / sedation
• removable partial dentures
• complete dentures
• denture relines and rebases
• denture repair
• orthodontic treatment

Clarifications: Major vs. Basic procedure classifications.

There are a number of dental procedures that insurance companies frequently classify differently. While you’ll still need to refer to the definitions list stated in your specific plan, here are some general rules about how they are generally categorized.

► Is Wisdom Tooth removal considered a Basic or Major dental service?

“Simple” (routine) tooth extractions are typically classified as a Basic service while “surgical” extractions (like removing impacted teeth) are a Major one. Depending on the circumstances, having a wisdom tooth removed might fall under either classification (this page explains).

In the case where a policy doesn’t cover surgical extractions, the person’s health insurance might.

► Is Periodontal Treatment considered a Basic or Major dental service?

Gum treatments may be either surgical (periodontal surgery) or non-surgical (scaling and root planing). Non-surgical procedures are typically listed as a Basic service. Surgical ones may fall under either classification, simply depending on the policy.

► Is Root Canal Treatment considered a Basic or Major dental service?

There’s no obvious rule of thumb that seems to apply to the categorization of routine root canal therapy. It may be listed as either a Basic (most commonly) or Major (less frequently) procedure, you’ll simply need to refer to your policy for clarification.

Situations where either a Basic or Major procedure might solve your dental problem.

There can be times when more than one procedure might be deemed an appropriate method of treatment for a person’s dental condition. And in these types of situations, it’s common that an insurance plan will only provide coverage for the less costly service (such as a Basic service vs. a Major one).

If so, it may be possible for the person to opt for the more expensive treatment yet still receive some policy benefits. Under this scenario, the insurance company would provide benefits as if the covered (less expensive) dental work was performed. The patient then pays the remaining balance out of pocket.

“Waiting periods” for dental procedures.

Some dental plans impose “wait time” restrictions on some dental services. (Not all plans do. You’ll simply have to check.)

When imposed, these limitations may be implemented according to the procedure’s classification Major, Basic, or Preventive/Diagnostic.

What is a “wait” period?

• A dental plan waiting period is a time frame during which certain procedures are not covered, or else not covered as fully as they will be after an initial time period has elapsed.
• Common time frames for waiting periods are 6 or 12 months.

• You may find that during the first year of your new plan’s term only Diagnostic and Preventive dental services are covered (exams, cleanings, x-rays, etc…).
• More extensive dental work, like the Major dental services (crown and bridge placement, dentures, etc…) or even Basic services (like root canal treatment or fillings) are not.
• Then, after the waiting period has lapsed, the plan initiates/allows coverage for the previously excluded services too.

A waiting period is the insurer’s way to limit their financial exposure.

The classic explanation for a company’s need for a wait clause is simply this.

• Enroll in a plan.
• Have extensive work performed during their first few months of coverage.
• Drop the policy once their treatment has been completed.

With this scenario, the dollar amount of premiums paid likely will not come close to covering the cost of the member’s (now ex-member’s) claims. And while a company doesn’t necessarily expect to make a profit on every single member, if a large number were to take advantage of this loophole it would have difficulty staying in business.

Possible workarounds for waiting periods.

Depending upon your situation, a plan’s wait-period clause may make it unsuitable, or at the very least unaccommodating to your current needs. However, you may have some options in finding a way past this obstacle.

► If you’ve had previous dental coverage …

Some policies state that if the insured had dental coverage during the last 60 days before enrolling (you’ll need to provide documentation), the waiting period may be waived.

► If you’re a member of a group with new insurance …

Wait-period restrictions may not apply if you’re part of a group that has just joined a program (such as your employer has enrolled your company in a new dental plan). However, future hires (new employees to the company) frequently will have one imposed.

► Possibly some portion of your treatment can be delayed …

Some types of dental conditions may not require immediate attention. This might include areas of arrested decay, deteriorated but seemingly stable dental crowns or fillings, ill-fitting dentures, etc… If so:

• Their resolution may be able to be postponed until after your waiting period has expired and full benefits for your needed Basic and Major procedures become available.
• It may be possible to address more active concerns by temporizing them (likely at your own expense). Your permanent dental work can then be placed at a later date.

Important note: Under no circumstances should you make these types of treatment decisions on your own. Instead, take advantage of the diagnostic services that your policy currently makes available to you (exam, x-rays) and then discuss with your dentist which of your dental needs might be reasonably postponed.

Dental plan restrictions on which procedures are covered.

A step even more restrictive than instituting waiting periods is the issue of a plan not covering some procedures or even an entire class of dental services at all (most frequently Major services).

So, when considering a plan, you’ll need to confirm that it provides benefits for the types of dental work you require.

a) Limitations on Major dental services.

It’s certainly not unheard of for a plan not to cover Major services at all. This would typically include crowns, bridges, implants, and full and partial dentures. And for some people, this deficiency may make the plan totally unsuited for them.

b) Limitations on Basic dental services.

It’s possible that a plan may only cover certain Basic procedures. As an example, composite fillings (white fillings) may not be covered for back teeth, although amalgam (silver) ones are.

As a middle ground, a provision may exist where coverage is provided for posterior composite restorations but only at the rate provided for amalgam fillings (which usually cost less). The patient then pays the cost difference out of pocket.

c) Other possible limitations.

It’s fairly common that a plan will not cover restorations that are placed solely to repair tooth abrasion, attrition, and/or erosion. Or to restore or alter the patient’s vertical dimension. These stipulations might affect coverage for some dental crowns, bridges, or even some fillings (Major and Basic services).

d) Cosmetic procedures are seldom covered by insurance.

Most policies will exclude coverage for any Basic or Major dental services that are performed solely for cosmetic reasons. These types of procedures might include porcelain veneers, composite veneers, and potentially even some dental crowns, bridges, or white fillings.

(However, if the restoration provides other important non-cosmetic benefits, then it may be eligible for coverage.)

Limitations governing how frequently some procedures can be performed.

Some dental procedures may be limited in how often coverage is provided for them. As examples:

• It’s common that many Preventive/Diagnostic procedures are only covered at certain intervals.

  Cleanings and exams may be limited to either twice a year or else every 6 months. Bite-wing x-rays may be covered as frequently as every 6 months, or just once a year. Full-mouth x-rays may be limited to once every several years (3 to 5).

• The frequency of coverage for some types of Major dental services may be limited. Benefits for dental crown replacement are often restricted to once every 5 years. Full and partial dentures may only qualify once every 7 years.

Ask your dentist’s office staff for help in determining your benefits.

As you can tell from all of the possible policy stipulations discussed above, for dental patients, trying to calculate their dental benefits can be both very confusing and very difficult to get right. So, don’t hesitate to ask your dentist’s staff for help or clarification.

• It’s normal and routine for them to make these types of calculations. What patients wouldn’t want to know what their costs will be before having a procedure performed?
• In many cases, they may be so familiar with the plan you have (because other patients do too) that they can come up with the right figure off the top of their head.

Preauthorization

Of course, the ultimate authority on this issue is your insurance company. You do have a contract with them and certain treatment obligations are outlined in it. But with some procedures (especially Major services), the conditions under which they are covered may be open to the insurance company’s interpretation.

So, and especially in situations where larger sums are involved, your dentist’s office may feel that they should submit for pre-treatment authorization.

In this situation, your dentist will file a predetermination form that details specifics about your proposed treatment plan (they may also send x-rays, pictures, or study models). In response, the insurance company will send an itemized reply stating what your expected benefits for each procedure should be.

This is usually a free service. (Filling out the form is an extension of goodwill on the part of your dentist. Making the calculation is one of your company’s obligations to you as a plan member.) Turnaround time for the process is usually 2 to 3 weeks.