On average, delta dental will cover 80% of the cost of a night guard with an estimated copay of about $100 out of pocket expense. However, every insurance plan is different and the contracted rates are based on what your employer negotiated for you. In other words, you could potentially have even more or less coverage than that.
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How much does delta dental cover?
Most commonly, we've personally seen 80% night guard coverage with our delta dental patients. Below is a eligibility and benefits breakdown for one of our patients who has eighty percent coverage.
The image above shows that the patient is responsible for paying 20% of the entire procedure. That means delta will cover the other 80% of the procedure.
The dental billing code for a night guard is D9944.
Can they cover more?
If you're fortunate enough to have very good insurance, we have seen delta dental cover 100% of the night guard cost. Here is an example of one of our patients who had zero out of pocket costs because their plan covered the entire procedure.
That just goes to show you as to what is possible. Usually if you see this level of coverage, it means that your employer and HR must really care about you! However the opposite can also be true which we'll demonstrate below.
Can they cover less?
If you're unfortunate, your insurance could potentially cover less than the average. Here is an example of a delta dental plan which covers the night guard at only 50% which is about half.
If this is your plan then you'll be expected to pay more for this oral appliance. There is no other way around it.
What can I expect to pay?
On average if you have 80% coverage, you can expect to pay about $100 for a night guard if you have delta dental as your insurance. Although it can be more or less depending on the amount of coverage that you have. These are all estimated amounts.
What it would cost with different coverage:
For 50% coverage you can expect to pay more.
For 100% coverage you wouldn't have any copay at all for the night guard since delta would cover the entire amount.
Frequency limitation
Despite having coverage for a night guard, delta dental can deny the insurance claim if there is a frequency limitation. For most procedures, insurances will limit you to getting it every couple of years. This is to prevent you from taking advantage of the system and getting a night guard every year.
In our experience, we often see a 5 year frequency limitation for night guards with delta dental insurance. That means they will approve the oral appliance only if it's been 5 years or more since your last one.
We've provided evidence of one of our patients who we made a nightguard for. If you look at the last section which is labeled "Limitations", you can see it specifically states: "1 visit every 60 months".
What if I had a different insura
nce before?
If your previous night guard was on a different insurance plan, the frequency limitation would not apply to you. You'd be in the clear to proceed with getting a new one.
However you should be wary if your previous employer also used delta dental. If they did, despite changing plans you may potentially get it denied. For this cases it would be best to ask your dentist to send a pre-determination to see if it would be covered.
Other factors that may influence cost
Aside from the frequency limitation, which may deny you all benefits, there are other factors which may affect your copay.
Factors influencing cost:
Deductible. Most insurance plans including delta do have an annual deductible which needs to be met prior to benefits being disbursed. On average this is about $50 which would be added to the cost of your mouth guard.
Annual maximum. The night guard will use up some of your annual benefits. If you had a lot of fillings and other dental work done, you should check to make sure you haven't maxed out. If you've maxed out your benefits, despite having coverage for it, you may have to pay for the mouth guard out of pocket.
Network status. All of the numbers and statistics which we've provided above are only valid if you're seeing an in-network dentist. If your dentist is not participating with delta, the copay could be significantly higher.
Takeaway
The average cost of a night guard with delta dental is approximately $100 if you have 80% coverage. Depending on your plan's exact coverage you may need to pay more or even less. If you ever want to know for certain you could always ask your dentist to send a pre-approval. Delta will get back to you within 2 weeks and let you know exactly how much you are expected to pay.
