Mutual dental insurance: what reimbursements does it cover?

Mutual dental insurance: what reimbursements does it cover?

Scaling, extraction, prostheses, implants, or even orthodontics… Dental care is essential but also often generates very high health costs. To counter this, having mutual insurance covering your teeth sufficiently is therefore essential.

Reimbursement of conventional dental care by dental insurance 

There are two main families of dental care :

  • conservative care (for example, devitalization of a tooth, treatment of a cavity or scaling);
  • surgical care (extraction).

Health insurance covers them up to 70 % of a basic rate set by Social Security, which sometimes varies according to the age of the insured (more or less than 13 years). The dental mutual then completes this reimbursement.

> Example: the price for devitalization of a premolar for a child under 13 is set at € 55.77. Health insurance reimburses 70% of this, ie €39.04. The remainder payable by the insured is, therefore, €16.73. A 100 % dental health mutual, ie providing reimbursement up to the basic Social Security rate, will pay the remaining €16.73. 

Many dentists, however, practice fee overruns: they apply higher rates than those set by Social Security. These overruns are then not taken into account in the reimbursement of health insurance but may be covered by a dental mutual whose level of guarantee is greater than 100 %.

> Example: if a dentist carries out a dental devitalization at the price of €75 (always in the case of an insured person under 13 years old), the reimbursement of the health insurance will always be €39.04. A 100% dental mutual will continue to cover your costs only up to the basic Social Security rate, ie up to €55.77 in total, maximum. But a 200% mutual, for example, guarantees you a refund of up to 2 times this basic rate (up to €111.54 therefore). If necessary, the cost of €75 for extraction may be fully covered. 

Reimbursement of orthodontics by dental insurance 

Orthodontic care is very partially reimbursed by health insurance for children under 16 years old. The basis applied depends on the acts carried out:

  • One semester of orthodontic treatment is paid at 100% based on a maximum rate set at €193.50;
  • Surveillance consultations are funded at 70% of a basic rate of €10.75;
  • Restraint care is 100% covered the 1st year for a price of €161.25, and the 2nd year up to 70% of the price of €107.50.

But beware: the vast majority of orthodontists apply far higher rates than those set by Social Security, often 3 to 6 times higher. Reimbursements from health insurance are then often derisory compared to the costs incurred. A dental mutual covering them at more than 100% is therefore necessary.

Good to know: before starting a care protocol, your orthodontist must give you an estimate, so that you can send it to your dental insurance company and know the exact amount of its coverage.

For insured persons over the age of 16, orthodontic care is simply not covered by health insurance, except by prior exceptional agreement. 

If you are an adult and you need dental equipment, remember to take out dental insurance which reimburses you at actual costs or a flat rate, for this treatment not covered by Social Security. A refund of 300% on a refund basis of €0 would indeed be of no use to you! 

Reimbursement of dental prostheses by dental insurance 

Many French people have long had to give up dental prostheses because of their very expensive price. This is why, since the 100% health reform, certain devices are now fully funded. Especially: 

  • Tooth-supported dental crowns in monolithic ceramic (other than zircon) on visible teeth;
  • Metal dental bridges.

Since January 1, 2021, around fifty other removable (dentures) or fixed (crowns and bridges) prostheses have been added to the 100% health basket. The full cost of these devices is borne jointly by the Health Insurance and by the dental insurance companies. To benefit from the remainder at zero charges, you must therefore benefit from complementary health insurance. 

Reimbursement of aesthetic dental services by the health insurance fund 

To find a beautiful smile, do you need veneers or dental implants? Considered as dental aesthetic services, they are not fully reimbursed by health insurance, even though they are very expensive. Count on average between 500 and 1,000 € for a ceramic veneer and between 1,400 and 2,500 € for an implant. But a specific dental mutual can cover this expense, most often based on a fixed annual fee.

How to choose your dental mutual? 

The coverage of care by dental mutuals, therefore, depends on the level of cover chosen. Reimbursement can thus be made based on: 

  • A percentage ranging from 100 % to 800 % of the basic Social Security rate, for the most protective contracts. The higher this percentage, the more expensive the dental insurance;
  • An annual lump sum in euros, which allows you to know in advance the maximum amount of reimbursement and to anticipate your remaining charge;
  • At actual costs . 

To find the best dental insurance, also consider:

  • The frequency of fee overruns admitted each year;
  • Reimbursement of unlisted and aesthetic treatments;
  • Reimbursement deadlines;
  • The length of the waiting period is sometimes imposed for certain treatments.

Services such as membership in a dedicated care network can also promote better coverage of your expenses by dental insurance. Think about it!

By Master James

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