Dental insurance covers a portion of the costs of certain procedures. Depending on the policy, there may be a deductible, coinsurance or annual benefit maximum.
Most dental policies have three types of coverage — preventive, basic and major. There may also be waiting periods (typically six months to a year) for some services, such as crowns, root canals and oral surgery.
Preventive Care
Dental insurance is meant to help cover the cost of necessary procedures that can save patients money and time in the long run. Without a plan, patients may not visit the dentist regularly and can develop serious problems that result in more expensive treatments. Preventive services can include things like cleanings, X-rays and fluoride applications to prevent cavities. These types of routine services are typically covered 100% by dental insurance.
In order to minimize the amount of money that patients have to pay out of pocket for basic and major restorative care, most dental plans are set up with a deductible and maximums that are applied to each service. These deductibles and maximums will vary from plan to plan. Some plans, such as those offered by Ameritas, offer a coinsurance rate on basic and major services, which means that after the patient reaches their deductible, the plan will start to pay for some of the costs.
Other plans are set up with a Usual, Customary and Reasonable program which pays a determined fee for the treatment regardless of what the dentist charges. The remaining amount is then paid by the patient. In many cases, these type of plans have limited coverage for non-network providers. This can be problematic because many dentists have agreed to lower fees in exchange for being part of a network.
Basic Care
Most dental insurance plans cover at least some of the cost for basic services like cleanings and checkups. This includes some or all of the cost for fillings and extractions after you’ve met your deductible, and it may also pay for a portion of more extensive procedures like root canals, crowns, bridges, or dentures. In addition, some dental plans allow enrollees to see dentists outside of their preferred provider network (PPO) but at a reduced coverage rate.
Most basic care is covered at a percentage of the standard fee set by your plan administrator. This fee is often called the “usual, customary, and reasonable” (UCR) fee limit. This fee is negotiated with dentists to obtain discounts on their overall fees, which in turn reduces the amount the insurance company pays for services.
Most dental plans have a deductible that you must meet before they begin to pay for basic care, and most of these are pretty low. For example, a common deductible is $50 for an individual or $150 per family each year. In addition, many dental plans have annual maximums on how much they’ll pay for major restorative care in a given year.
Major Care
Dental insurance works similarly to health care plans, with a deductible (the amount you must pay annually before your plan begins paying for covered services) and copayments (fixed amounts that apply to certain types of treatment). A monthly premium is also usually required. Dental insurance can be purchased as an add-on to a health or life insurance policy, or as a separate plan. In some cases, it is available on the health exchanges or through private companies.
Most dental plans cover Basic and Major procedures at a rate of 70 to 80%, after the annual deductible is met. However, the specifics of how a particular plan classifies procedures vary from plan to plan. For example, wisdom tooth removal may be classified as a Major procedure or a Basic one, depending on the extent of the work involved and whether it involves anesthesia or a laboratory expense.
Unlike medical insurance, where your coverage is based on a contract between you and your insurer, a dental plan is a contract between you and your provider. Some plans require you to visit a dentist within the plan’s network in order to receive the highest benefits. Others, like Preferred Provider Organization (PPO) and Dental Health Maintenance Organization (DHMO) plans, allow you to visit any licensed dentist. However, if you go to an out-of-network dentist, your benefits may be less.
Out-of-Pocket Costs
Dental insurance often covers some or all of the cost of cleanings, x-rays, and routine exams with low (or even $0) out-of-pocket costs, depending on your plan. But more extensive procedures like fillings and root canals may require a co-pay or a higher percentage of the total cost paid by you.
The most common type of dental insurance has a monthly premium and a deductible. Dental HMOs tend to have the lowest out-of-pocket costs, as their deductibles are published and fixed dollar amounts. DPPOs typically have higher deductibles, but they also usually have lower monthly premiums than indemnity products.
Most marketplace and employer-sponsored dental plans have maximum out-of-pocket limits on the amount you pay for covered services in a year, which is known as a coverage maximum. Dental deductibles and coinsurance are other out-of-pocket costs that can impact your overall cost.
Some marketplace dental plans require you to choose a dentist in your plan’s network, which is called an in-network provider. Others allow you to visit any dentist, including out-of-network providers. However, out-of-network dentists generally charge more for procedures. Ask your potential dental insurer for a schedule of procedures, and compare procedure costs between different plans to find one that fits your budget. In addition, you can look up fees for specific procedures in your area through the ADA’s Survey of Dental Fees or FAIR Health’s Dental Cost Lookup.