Dental Insurance, Oral Health and Money

Good dental care is about more than brushing your teeth and keeping an attractive smile. Teenager Dominique Allen of Petaluma, Calif., was rushed to the hospital in 2010 with a life-threatening infection. The cause? Bacteria from four rotting molars that had caused crippling pain for months had spread into her jaw and neck, triggering so much swelling she could barely breathe.

Allen's case is not unique. Between 2000 and 2008, more than 60,000 Americans were hospitalized with abscessed teeth — a preventable problem — and 66 of them died. Researchers have also linked gum disease to heart disease and other serious illnesses. This guide will help you figure out how to get dental care for you and your family — and how you can keep your mouth healthier on your own. Plus, a special section on flouridation.

Finding affordable dental care is a challenge for Americans in every income bracket, but especially for poor and middle-class adults on a tight budget. Even if they could afford dental insurance, they might have trouble finding a plan. Private insurers, Medicaid, Medicare and the Affordable Care Act Marketplace, for example, don't have to even offer dental care to adults. Employer health insurance policies may or may not include dental insurance. Here's where to look for it.

• The Marketplace
  Your Affordable Care Act plan doesn't have to offer you dental insurance, but some ACA plans do. You can look for and buy a stand-alone dental plan, but you need to purchase your ACA medical coverage first.

• FAIRHealth
  This consumer website can help you find and compare medical costs - and help you understand an insurance policy. Visit the website or call for help at 1-855-566-5871. Be aware: navigating some of these subsidized options can be confusing and time consuming. Most have a phone number to call for help.

• Medicaid
  If your income is low or you have a disability, you may qualify for Medicaid, a state-run health plan that might include dental care. States are required to offer dental benefits to children covered by Medicaid, but fewer than half of the states provide comprehensive dental care for adults. Most states do provide at least emergency dental services, but options for preventive and basic care (such as cleaning and fillings) vary by state. Check your eligibility and state's benefits on the Medicaid website. Click on "Learn How to Apply for Coverage" or contact your state Medicaid program.

Even if you earn too much to qualify for Medicaid, you may be able to enroll your children in CHIP (the Children's Insurance Health Program), which covers dental care.

Employer Health Plans
If you're a full-time or even part-time employee, you may be eligible for dental insurance through your employer. According to the National Association of Dental Plans, 96 percent of large employers offer some sort of dental coverage (either through the company or the union). The larger the group insured, the better the benefits tend to be.

Because dental benefits vary so widely, it's important to read the information carefully, especially if you have a choice of provider. Take the time to balance the offered benefits against your needs. You may be able to adjust your choice during certain enrollment periods, usually once a year.

These dental plans, which are also carried by some employers, include Delta Dental, Guardian, Humana, MetLife, Cigna Dental and Aetna. If you are planning to buy individual dental insurance, consider this:

Can you keep your dentist?
You probably won't be able to: most programs force you to select from a pool of their approved dentists.

Check exclusions:
Many major and expensive treatments, including root canals, are excluded from some policies. Implants, orthodontics, bridges, extractions and even porcelain crowns.

How soon can you be treated?
Many programs have a six month waiting period or exclude pre-existing conditions.

What is the annual limit on treatment?

Consider your needs.
If you don't want metal crowns, for example, put away some money for porcelain crowns.

You'll save big money on dental care if you don't put off seeing the dentist when you have swollen gums or a tiny cavity. Left unchecked, gum disease could cause you to lose a tooth. And if that cavity leads to an abscess down the road, it could be costly (not to mention dangerous). Besides getting routine dental exams, dental experts advise that you do the following:

1. Brush your teeth at least twice a day with a soft-bristled brush.
2. Floss your teeth once a day (before you brush).
3. After brushing, use a mouthwash to rinse your mouth.
4. Have your teeth cleaned every six months.
5. Ask your dentist about dental sealants, which help protect your teeth against decay.
6. Rinse your mouth after eating crackers or other food that sticks to your teeth.
7. Eat a balanced diet with plenty of fruits, vegetables and protein.
8. Avoid sodas and too many sugary foods.
9. If you smoke, stop.
10. If you have any tooth pain or a small crack or hole in a tooth, see your dentist right away. A filling can cost less than $50 in some places, while an untreated cavity can turn into an abscess costing hundreds of dollars or more.
11. Never give your baby soda, and give your toddlers and children water rather than soda and sugary drinks.
12. Don't let your baby go to sleep with a baby bottle in his mouth (this can cause serious tooth decay).

A healthy mouth is an important part of a healthy body. So why isn't everyone seeing the dentist?

One word: Money. Dental care is expensive. The 2014 ADA Health Policy Institute report Oral Health & Well-Being in the United States found that among all income and age groups surveyed, everyone — even people with the highest incomes — cited cost as a main reason for not seeking dental care.

That lack of care has consequences. The report found that:

• One in five low-income American adults say their mouth and teeth are in poor condition.
• Nearly 30% of young Americans say the condition of their mouth and teeth hampers their ability to interview for a job.
• One in four Americans are afraid to smile due to problems with their mouth and teeth.
• More than one in four Americans are plagued by tooth pain.
• 23% feel embarrassed about their mouth and teeth.
• One in five experience anxiety due to dental conditions.

One problem is that dental care "is excluded from most insurance plans for a bizarre and antiquated reason," according to an article in The Atlantic: As a profession, dentistry and surgery grew out of hairdressing — barbers used to pull teeth, drain abscesses and even take care of wounds. Surgery and medicine were considered two very different fields, a bias that some experts say drove policymakers planning Medicaid in the 1960s to pay little attention to dental problems.

As Columbia University professor of dental medicine Burton Edelstein told the magazine, the division between medicine and dentistry has long been a "medically, morally, and ethically inappropriate separation."

Indeed, when cost is taken care of, studies show dental care goes up dramatically. Researchers have seen improved dental health in children who are covered by Medicaid and the Children's Health Insurance Program (CHIP), which together cover 40 percent of children in the United States.

Wasn't the Affordable Care Act supposed to guarantee our right to health care? Children have definitely benefited from its expansion of dental coverage. But according to some experts, dental insurance for adults fell through the cracks.

The Affordable Care Act of 2010 (ACA), sometimes called Obamacare, made dental care for children one of the ten essential health benefits. It's credited with major improvements in childhood dental health. (See "If You Have Children Who Need Dental insurance or Dental Care.") But it didn't do much for adult dental care.

Even though ACA marketplace plans don't have to offer dental coverage for adults, some do. If you decide you want dental coverage and your plan doesn't offer it, you can buy and enroll in a separate, stand-alone dental plan. There are many reputable sites out there that provide some good information about how the ACA works, who is eligible and how much subsidy support you may get.

The bottom line: Check whether dental coverage for adults through ACA programs are cost effective for you. The government Marketplace website has programs that allow you to check the costs and benefits, along with premiums and co-pays of stand-alone dental plans.

These vary state by state. Choose your state at Healthcare.gov to check plans available to you. Or call 800-318-2596 to speak to someone at the Marketplace. Note that many commercial organizations also have "marketplace" websites offering insurance. Be sure to check your options.

The American Dental Association and the National Association of Dental Plans disagree on our current dental insurance's cost-effectiveness.

"For the vast majority of adults with private dental insurance, more is spent on premiums, copays and coinsurance than the actual cost of the procedures," said Marko Vujicic, PhD, chief economist and vice-president of the Health Policy Institute of the American Dental Association.

The Health Policy Institute just put out a comprehensive research brief on dental insurance, including employer supported plans. It examined more than 24 million dental claims across 5.9 million adults enrolled in a dental benefits plan for 365 continuous days.

First, the HPI found a third of people with private dental insurance didn't use the all benefits they paid for: More than one in three adults ages 19 through 64 with private dental benefits did not have a single dental claim within the year.

Second, the report found the fees paid to dentists were "significantly lower" than market rates for dental care.

The HPI also found that for 69 percent of adults with private dental insurance, their total spending including premiums was actually more than the "market" value of their dental care.

In many health insurance policies, the coverage kicks in to pay the costs after you've paid a certain amount — about $2,927 under the Affordable Care Act. Dental insurance is exactly the opposite: It cuts off when your costs hit the cap — usually $1,500 or less. "And for me to get a $1,500 benefit, I have to pay out almost that amount," Vujicic said.

And for adults without private or employer-sponsored insurance, the landscape is bleak. The Health Policy Institute has also released a comprehensive state-by-state report that "for the first time, shows how seriously oral health issues are impacting the lives of adults." At the national level, HPI reports, more than two out of five low-income adults have trouble biting and chewing due to the condition of their mouth and teeth. In addition, 29% of low-income Americans said the condition of their teeth interfered with their ability to look for a job.

The NADP reports that most employer-sponsored plans offering dental insurance pay for employees' premiums, but according to Vujicic, "Premiums are never free to beneficiaries. There is convincing empirical evidence by health economists that shows that employees pay for premiums either directly through contributions or indirectly through lower wages."

The National Association of Dental Plans, which represents dental insurers, insists dental insurance is absolutely worth the consumer out-of-pocket cost.

The association charges that the ADA's study on dental claims used inflated dental costs and premiums and understated the cost of services funded by dental plans to reached "incorrect and misleading" conclusions.

The premium costs the ADA chose don't reflect the out-of-pocket costs of the majority of those insured, according to Evelyn Ireland, executive director of the NADP.

"In dental policies coverage kicks in after a deductible that averages only $50, unlike a medical policy where you spend almost $3000 out of pocket before getting coverage," says Ireland. "And consumers do not spend $1,500 to get $1,500 of coverage. Preventive services are usually covered at 100% and basic services like fillings are paid at 70% to 80% by the insurer. Only major procedures like crowns are covered at 50%."

Group plans, such as those offered through employers, cover 93 percent of those with [dental] insurance, and 77 percent of them have most or all of their premiums paid for by their employer, according to Ireland.

"If you adjust the premiums in the ADA study for group coverage, employer contributions and pre-tax payment of any premium the employer does not cover, the conclusion about the value of dental benefits is the polar opposite of that asserted by the ADA," said Ireland. "Only those consumers who don't go to the dentist will pay more for dental insurance than the market value of services used."

Just having dental insurance may be a benefit - it can prompt better preventive dental care, Ireland said. "There's clear research -cited by the surgeon general- that finds people with insurance coverage are two times more likely to go to the dentist than those without coverage," she said.

The insured "are also more likely to have the additional services needed to maintain dental health," Ireland said. "Without dental benefits, we would see a significant reduction in visits to the dentist and a surge in dental disease in the United States."

In terms of limits on coverage cited by the ADA, 95% of those with dental insurance stay within the limits on the amount of treatment paid by the insurer. "The dental industry offers higher limits but with only 5% of consumers reaching the limit, employers choose limits that keep dental premiums low and serve the needs of most of their employees," Ireland said.

In a 2015 report, the Pew Charitable Trust called dental care "the greatest unmet health need among U.S. children." in 2015 approximately a quarter of U.S. children did not have dental insurance, either private or public, the report said. Left untreated, dental disease can lead to emergency room visits, hospitalizations and even death: In 2008, children went to the emergency room more than 215,000 times for preventable dental issues, at a cost of more than $104 million.

Here are some resources to help you find affordable dental care for your children.

The ACA has done more for children's oral health than adults. By helping lower dental insurance costs and encouraging use with subsidies, it's credited with major improvement in childhood dental health.

Despite the passage of the ACA, buying dental insurance and/or paying for care is a struggle for many families, according to the CDC. See what's available in your state.

The good news: States are required to provide dental benefits to children covered by Medicaid and/or the Children's Health Insurance Program (CHIP). Together, these programs cover benefits for 40 percent of children in the United States, including — in some states — medically necessary orthodontia.

Medicaid dental care for children covers regular screenings and treatment for any discoverable dental condition, whether or not the services are included in that state's Medicaid plan. Dental services include pain and infection relief, restoration (or fillings) and basic dental health.

These benefits are based on family income and size, and the two programs complement each other: All children enrolled Medicaid are eligible for dental care; and families who earn too much to qualify for Medicaid but can't afford private insurance can find free dental care through CHIP.

Much of this assistance goes unused. In 2013, however, more than 16 million children who were enrolled in Medicaid and eligible — almost 50 percent — got no dental care.

For eligibility in CHIP, some 46 States and the District of Columbia cover children up to or above 200 percent of the federal poverty level, which is $51,500 for a family of four in 2019. Some states allow 250- 300 percent of the federal poverty level. You can check the levels here on the website. States are required to post a listing of all participating Medicaid and CHIP dental providers and benefit packages. To find children's dental care programs in your state, visit Insure Kids Now or call 877-543-7669.

If your work-related health policy has dental coverage, it may cover your dependent children — perhaps up to age 26. There may be an extra premium or copay, however. Check your policy and contact your company's human resources office for more information.

Credit: GKAS Facebook page

This program has helped 5 million underserved children receive free dental services, which are provided by about 10,000 dentists and 30,000 dental team members. Visit the program's Facebook page to find out about upcoming events. The ADA also has a resource page for parents to help them find the closest clinic offering free or low-cost dental care.

The clinics tend to appear in schools with a higher percentage of children eligible for federal free or reduced-cost lunch programs. Funding comes from a variety of sources, including Medicaid.

One initiative is the school-based sealant program, which has been successful in reducing cavities by more than 70 percent, according to a Surgeon General's Report.

Dental sealants are special tooth coatings that prevent tooth decay and also stop cavities from growing. These are typically run by dental hygienists using portable equipment, a mobile dental van or clinic. Depending on the state and how a particular program works, students are checked for early signs of tooth decay. Some programs also provide cleanings, topical fluoride, oral health education, and screenings, according to Pew Charitable Trust.

Check with your school and state public health department about these other school-based programs and edibility requirements.

For information on CareCredit no-interest loans for your children's dental care, working out a payment plan with your dentist and checking into resources offered by United Way, community health centers, dental fairs and other programs, please see "How to Find Low-Cost Dental Care Outside Insurance."

Older adults are one of the fastest growing segments of the American population — and can be most at risk when it comes to dental and oral issues.

Aging brings a series of special dental needs. Seniors are often more susceptible to dry mouth, gum disease, tooth loss, jaw issues due to tooth loss, mouth fungus (thrush) and oral cancers. Yet only 2 percent of retirees have dental coverage through a prior employer, according to Oral Health America, a Chicago-based nonprofit.

Medicare is a federal health insurance program for people 65 and older and for people under 65 with specific disabilities.

Although most seniors 65 or older have Medicare, it doesn't cover dental care except in situations where the dental problem is related to certain other medical issues. It doesn't cover any routine care. Medigap — a private insurance plan that supplements Medicare — also fails to offer dental coverage. Some private Medigap Medicare Advantage managed care plans such as Kaiser's Senior Advantage do offer dental benefits, for a fee. (See Medicare Advantage Plans, next).

For more information about Medicare coverage, visit Medicare Dental Services or call 1-800-MEDICARE (1-800-633-4227). Have your Medicare number handy when you call.

These Medicare health plans are offered by private companies that contract with Medicare to provide Part A and Part B benefits. Several different kinds of organizations offer Medicare Advantage plans, including Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans and Medicare Medical Savings Account Plans.

These organizations offer prescription drug coverage, and for another fee may be able to supplement your basic coverage with dental care. However, these plans often have co-pays, do not allow preexisting conditions (such as lost teeth) and may be capped at a certain amount

Medicaid is a state-run program that offers subsidized health coverage, which can include dental care, for those who qualify. Most states do provide at least emergency dental services, but check your state's benefits: Coverage for preventive and basic care (such as cleaning and fillings) vary by state.

If you think you could be eligible for Medicaid, Visit the Medicaid website and click on "Learn How to Apply for Coverage." You can also contact your state Medicaid program.

If the Marketplace in your state is run by the federal government, there's a Catch-22: You won't be able buy a stand-alone dental plan unless you're also buying a health plan - and if you have Medicare, you already have a health plan.

If your state is running its own Marketplace, you may be able to purchase a stand-alone dental plan.

This national nonprofit supports an informative website called Tooth Wisdom that can direct you to some affordable resources in your state.

An online reference tool of the nonprofit Medicare Rights Center, this website lists some options for finding affordable dental care for seniors.

Veterans Health Administration

If you're a vet, you have health benefits through the federal Veterans Administration, but dental care is limited. To be eligible for VA dental benefits, a veteran must have a service-related dental disability, be a former prisoner of war or be totally disabled from a service-related injury. Check with the VA to see what benefits there are for you or your dependents.

Under the national VA Dental Insurance Program (VADIP), some veterans and dependents can buy private dental insurance at a reduced cost. But the benefits have the same drawbacks as other private dental insurance: payments are limited to $1,500 a year, with a copay of 50 percent for most procedures such as fillings and crowns, and some procedures aren't covered at all. (see "Buying Private Dental Insurance").

Volunteer dental professionals and organizations are proving some free services for veterans. Dental groups, individuals and organizations across the country volunteer to offer free dental care to veterans under programs such as "Veterans' Smile Day" or "Give Vets A Smile." In 2015, more than 300 dentists from nearly all the 50 states provided more than $300,000 in free dental services to an estimated 2,000 veterans, according to the ADA. This year, dental teams from Aspen Dental, a national chain of dental offices, treated more than 4,000 veterans in mobile units across the country to $2.1 million in free dentistry on its annual "Day of Service" June 25.

To learn about free programs for veterans in your area, contact your state's Dental Society. You can find a link to dental societies by state on the ADA site.

For more on free or low-cost options, see "Alternatives to Dental Insurance," above.

More than 29 million people in the U.S. have diabetes — either Type 1 or Type 2, with almost 2 million new cases diagnosed each year, according to the American Diabetes Association. This disease can cause special dental problems. People with diabetes are more vulnerable to gum disease and mouth infections, dry mouth, changes in the taste of foods and slower healing. Periodontal (gum) disease is the most common dental problem, and it can exacerbate symptoms of diabetes.

The potential savings from preventive dental care, however, is enormous. One research paper found that treating gum disease in 60 percent of Americans with diabetes could save $39 billion in health care costs.

Another study, led by dental scientist Majorie Jeffcoat, DMD, professor and dean emeritus of the University of Pennsylvania, found that that treating people with diabetes for gum disease resulted in "an average of $2,840 savings per patient per year, with drug costs decreasing by $1,477." Looking at a different sample in the same study, researchers also found that hospitalizations dropped by 39.4 percent among those who were treated for gum disease.

The American Dental Association recommends a five-point action plan to help lower the risk of dental problems for people with diabetes.

Control blood sugar levels with medication and a healthy diet to help your body fight any bacterial or fungal infections in your mouth and help relieve the dry mouth caused by diabetes. Avoid smoking. If you wear any type of denture or removal bridge, clean it each day. Make sure to brush twice a day with a soft brush and floss correctly daily. See your dentist for regular checkups.

The American Diabetes Association also has some good advice for taking care of your teeth.

The benefits and safety of fluoride for dental health have been debated and documented for nearly 70 years. Back in the 1940s and 50s, conspiracy theories about fluoride in community drinking water flourished. While science was heralding it as a public health boom, others were calling it a communist plot and public health hazard.

Over time, scientists triumphed, with community water fluoridation recommended by nearly all public health, medical and dental organizations because of its contribution to the dramatic decline in tooth decay in the United States since the 1960s. Numerous scientific studies from organizations around the world, including the World Health Organization, have found it safe and effective.

Researchers say drinking fluoridated water has reduced tooth decay by approximately 25 percent in children and adults, saving money and teeth. In fact, the Centers for Disease Control and Prevention (CDC) named community water fluoridation one of 10 great public health achievements of the 20th century. Fluoride is also available in toothpaste and mouthwashes.

"It's a very good practice," says Alice Boghosian, DDS, a spokesperson for the American Dental Association and a clinical instructor in restorative dentistry at the University of Illinois College of Dentistry. "Think back about why dentures were so prevalent in the past. People lost teeth at a relatively early age due to extensive decay, and in fact expected to lose teeth as they aged. Today, that has dramatically changed, with those who grew up with fluoridation keeping most of their teeth life long."

"Fluoridation helps prevents cavities, making teeth and the protective enamel harder," she added.

There's still some controversy, with organizations such as the Fluoride Action Network opposing adding fluoride to community water sources. If you are wondering about the benefits and purported risks of the practice, check out the FAQ on the CDC website.

Marko Vujicic , PhD, is the chief economist & vice president of the Health Policy Institute, part of the American Dental Association.