Why doesn't my plan cover this treatment at all?
The short answer
Every dental plan has a “we don't do that” list, officially called exclusions. Cosmetic work like whitening and veneers is a common one, and some plans also leave out implants or adult braces.
Where to find your plan's exclusions
- Look for a section called “Limitations and Exclusions” in your benefits booklet or Summary of Benefits.
- Call the member services number on your insurance card and ask about the specific treatment.
- If your plan comes through work, your HR or benefits office can send you the plan documents.
What you'll owe
If a service is excluded, the plan pays nothing and you're responsible for the cost. In most states, a dentist in your plan's network can charge their regular fee for a truly excluded service. Forty-four states have laws that stop plans from setting the dentist's fee for services the plan doesn't cover. In the other six (Delaware, Hawaii, Massachusetts, Michigan, New York, and South Carolina), the dentist's network contract usually decides what they can charge.
Excluded vs. “covered but not paid”
These are different. If the plan normally covers a service but didn't pay this time (because you hit your yearly maximum, for example), that's not an exclusion, and different pricing rules usually apply. See Can an in-network dentist charge me more?
Questions to ask
- Is this treatment excluded by my plan, or is it covered with limits?
- Is there a covered option that would also work for me?
- What's your fee for this, and can I have it in writing before we start?