Are Crowns Covered by Insurance: Coverage Insights

Dental crowns are a common and often necessary procedure to restore the function and appearance of damaged teeth. Whether it’s due to severe decay, a root canal, or a fractured tooth, crowns can play a vital role in maintaining oral health. However, as with many dental procedures, the cost can be significant.

Understanding whether your insurance will cover the expense of a dental crown is crucial for planning both your health care and your budget. In this blog post, we’ll delve into the details of dental crown coverage, exploring when and how insurance might help, and share tips to help you maximize your savings. But first, let’s look at some basic information on this popular tooth restoration procedure.

What are dental crowns?

A dental crown is essentially a cap that is placed over a damaged or decayed tooth to restore its shape, size, strength, and/or appearance.

There are several types of dental crowns, each with distinct characteristics and price points:

• Porcelain-Fused-to-Metal (PFM) Crowns: These crowns combine the strength of metal with the aesthetic appeal of porcelain.
• All-Ceramic or All-Porcelain Crowns: An all ceramic crown or porcelain crown can provide the best natural color match and are ideal for front teeth.
• Gold Crowns: Known for their durability and biocompatibility, making them suitable for molars.
• Zirconia Crowns: Offer a balance of strength and aesthetics, often used for both front and back teeth.

Additionally, the actual dental crown placement process typically involves two stages. During the first visit, the dentist shapes the tooth, making it look like a smaller version of itself, takes an impression, and creates a temporary crown. The permanent crown is custom-made and placed during the second visit. The dental crown cost varies depending on the material used and the complexity of the procedure. For example, metal crowns are often used for back teeth due to their durability, while porcelain crowns are more suited for visible front teeth because of their natural appearance.

Cost comparison of each type of dental crown

• PFM crowns: $800 – $1,500
• All-ceramic or all-porcelain crowns: $1,000 – $2,500
• Gold crowns: $1,200 – $3,000
• Zirconia crowns: $1,000 – $2,500

When considering dental crown costs, patients should also account for potential additional fees related to crown placement or future crown replacement, particularly if the crown becomes damaged or dislodged.

Common reasons for needing a crown

There are several situations where a dental crown might be necessary. One of the most common reasons is extensive tooth decay that weakens the structure of the tooth to the point where a filling is insufficient. After a root canal treatment, where the tooth’s pulp is removed, a crown is often needed to protect the remaining tooth structure.

Crowns are also used to repair broken or severely worn-down teeth, cover dental implants, and anchor a dental bridge. In some cases, crowns are used for cosmetic dental treatments, such as covering discolored or misshapen teeth. In the case of sudden damage, an emergency dentist may place a temporary crown until the permanent crown is ready.

Types of dental plans that may cover crowns

Dental insurance

Dental insurance plans typically fall into two main categories: Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs).

HMO vs. PPO and how they work

HMO plans may require you to select a primary dentist and get referrals for specialists. These plans often have lower premiums, but you do need to see an in-network dentist.

PPO plans offer more flexibility, allowing you to see any dentist, but you may pay more out-of-pocket if you go out of the network. Both types of plans generally cover preventive, basic, and major procedures, though the extent of coverage can vary significantly. Review your dental plan to confirm the level of dental coverage provided for major procedures such as dental crown placement, as out-of-network treatments may result in higher costs.

Does dental insurance always cover dental crowns?

Insurance is most likely to cover a dental crown when it is deemed medically necessary. This means the procedure is required to restore the function of a damaged tooth, prevent further dental problems, or address severe decay. For example, if a tooth is severely cracked and at risk of breaking, a crown would be considered necessary to preserve the tooth.

Dental insurance typically does not cover cosmetic care, which often includes dental implants. (Patients may need to explore additional dental coverage options or dental savings plans for cosmetic treatments. Dental savings plans, an alternative to dental insurance, often do include discounts on cosmetic dental care and dental implants.)

Preventive, basic, or major procedures: Where crowns fit in

Dental insurance typically categorizes procedures into preventive, basic, and major. Crowns, like most restorative care treatments, are usually classified as a major procedure, which means you may face higher out-of-pocket costs (typically, insurance will pay 50% of the dental crowns cost) compared to preventive or basic services like cleanings (covered at 100%) or fillings (usually insurance will pay 80% of the cost of fillings). You may need to meet an annual deductible before the insurance begins to pay.

Health insurance: rare instances where health insurance might cover crowns

If your dental issue is tied to a medical condition, such as reconstructive surgery following an accident or disease, your health insurance policy may cover part or all of the dental crown cost. Note that this is not typical, and you need to check with your health insurance provider – or your benefits specialist if your dental insurance is provided by your employer – to see if your health plan includes dental work in your particular situation.

Medicare and Medicaid: Coverage possibilities under government insurance programs

Medicare, the federal health insurance program primarily for people aged 65 and older, generally does not cover dental procedures like crowns unless they are part of a medically necessary treatment following an injury. Medicare Advantage plans may include dental insurance, which would function in the same way as employer-provided or self-purchased dental insurance.

Medicaid, a state and federal program providing health coverage for low-income individuals, may offer some dental benefits, including crowns, depending on the state.

However, coverage can be limited and is often restricted to specific cases or types of crowns. Some insurance is most likely to cover a dental crown when it is deemed medically necessary. This means the procedure is required to restore the function of a damaged tooth, prevent further dental problems, or address severe decay. For example, if a tooth is severely cracked and at risk of breaking, a crown would be considered necessary to preserve the tooth.

Factors that affect coverage for crowns

Dental health issues you had prior to purchasing insurance

Restrictions based on past dental conditions can impact your insurance coverage for any type of restorative dental care, including crowns. It’s important to review your policy to understand how pre-existing conditions are handled.

Annual maximum benefits

Most dental insurance plans have an annual maximum benefit, typically between $1,000-$1,5000, which is the maximum amount the insurance company will pay for dental procedures each year. If the cost of your crown exceeds this amount, you will need to pay the difference out of pocket.

This cap can significantly affect your coverage, especially if you need multiple dental services/procedures in a single year. If you check the “cost comparison” section above, you can easily see that one crown can wipe out all or a significant part of your annual maximum benefit.

Waiting Periods

If you just joined a PPO dental insurance plan, it’s likely the plan will not cover major procedures like crowns for 6-12 months. If you need a crown before your coverage becomes available, you may need to delay the procedure or pay for it out of pocket until the waiting period is over.

Tips for maximizing your insurance benefits

Timing procedures around insurance benefits

One strategy for maximizing your insurance coverage is to time your dental procedures around your insurance benefits. For example, if you’re close to reaching your annual maximum, you might consider scheduling part of your treatment at the end of one benefit year and the rest at the beginning of the next. This can help you avoid paying out-of-pocket for procedures that exceed your annual maximum.

Using Flexible Spending Accounts (FSA) or Health Savings Accounts (HSA) for crowns

FSAs and HSAs are valuable tools for managing the cost of dental procedures like crowns. These accounts allow you to set aside pre-tax dollars for healthcare expenses, including dental work. By using funds from an FSA or HSA, you can reduce your taxable income and lower the effective cost of your crown.

Dental savings plans

Unlike traditional insurance, dental savings plans don’t have annual spending limits or restrictions on when and how often you can get dental care. Dental savings plans offer discounts on many procedures, and plan members report saving an average of 50%* on the cost of their dental care, including crown replacement or permanent crown treatments.

The quickest way to find a plan that fits your needs is by using the calculator at the bottom of this article. You’ll be shown the plans in your area, and see how much each can save you on crowns and more.

Summing it up: Dental crowns costs and savings options

Dental crowns are an important investment in your oral health, but they can come with a significant cost. Understanding your insurance coverage is key to managing this expense effectively. By knowing when crowns are covered, what factors can affect your coverage, and how to navigate your insurance policy, you can make informed decisions about your dental care.

Looking into dental savings plans is also an excellent option and may be a better fit for your needs than traditional dental insurance. With the right planning, you can maximize your dental health and minimize your out-of-pocket costs.

All cost averages obtained from the DentalPlans.com procedure search tool, and independent research.

*Discount health program consumer and provider surveys indicate average savings of 50%. savings may vary by provider, location, and plan.