Dental Insurance: What’s Covered, What’s Not

If you have dental benefits, do you know what’s in the fine print and what type of plan is best for you?

Many Americans — 77% — have dental benefits, the National Association of Dental Plans says. Most people have private coverage, usually from an employer or group program. (Medicare doesn’t cover dental care, and most state Medicaid programs cover dental care only for children.)

To make the most of your benefits, you need to know these things.

Insurance or Benefits?

When shopping for insurance, you may see the term dental benefits, which is different from insurance.

An insurance plan is meant to absorb risk — the risk that you’ll need to have a tooth pulled, for instance, or to get a root canal — and covers costs accordingly.

A benefits plan covers some things in full, but other things only partially, and others not at all. It’s meant to be helpful, but it’s not a catch-all.

Types of Plans

Dental plans are similar in some ways to health insurance plans in some respects, but different in other ways. You’ll generally have the following options:

Preferred Provider Organization (PPO): As with a health insurance PPO, these plans come with a list of dentists that accept the plan. You have the option of going out of network, but your out-of-pocket costs will be higher.

Dental Health Maintenance Organization (DHMO): Like a health insurance HMO, these plans provide a network of dentists that accept the plan for a set co-pay, or no fee at all. However, you may not be able to see an out-of-network dentist.

Discount or referral dental plan: This is a plan in which you get a discount on dental services from a select group of dentists. Unlike health insurance, the discount or referral plan doesn’t pay anything for your care. Rather, the dentists who participate agree to give you a discount for the care you receive.

What They Cover

Generally, dental policies cover some portion of the cost of preventive care, fillings, crowns, root canals, and oral surgery, such as tooth extractions. They might also cover orthodontics, periodontics (the structures that support and surround the tooth) and prosthodontics, such as dentures and bridges. You’re usually covered for two preventive visits per year.

If you get an individual policy, periodontics and prosthodontics may not be available in the first year of coverage. And orthodontics often requires a rider, in which you pay an additional fee, for any kind of policy.

Most plans follow the 100-80-50 coverage structure. That means they cover preventive care at 100%, basic procedures at 80%, and major procedures at 50%, or a larger co-payment. But a dental plan may elect not to cover some procedures, such as sealants, at all.

Every plan has a cap on what it will pay during a plan year, and for many that cap is quite low. This is the annual maximum. You pay all expenses that go beyond that amount. About half of dental PPOs offer annual maximums of less than $1,500. If that’s your plan, you’d be responsible for all expenses above $1,500. If you need a crown, a root canal, or oral surgery, you can reach the maximum quickly.

Timing

Experts generally encourage adults to see their dentists twice a year. Dental benefits policies support this, although the wording varies. It may be that your policy will pay for a preventive visit every 6 months (but no closer together), or twice per calendar year, or twice in a 12-month period. Get to know your policy so you understand how it works. That will help you schedule your appointments.

There are usually time limits on other services as well, such as X-rays, fillings on the same tooth, crowns and bridges on the same tooth, or fluoride treatments for children. For instance, your policy may pay for a full series of X-rays only once every 3 years.

Pre-existing Conditions

You may not be able to find a dental plan that covers conditions that exist before you enrolled. If that’s the case, you will have to pay any ongoing treatment costs out of pocket.

What to Do Before a Procedure

Read your dental policy closely to see whether your procedure is covered. Call your insurance company if you have questions.

If you need a major procedure, you can ask your dentist to submit a pre-treatment estimate. This will help you know what you’ll likely owe after any coinsurance, deductible, and policy maximum.

It’s also smart to understand how your dental plan handles emergencies. Many have provisions for urgent care or after-hours care, but you may owe a deductible, a co-pay, or a larger percentage of costs.

What to Consider

If your employer offers dental coverage, that’s an easy choice. It tends to be cheaper than getting a policy on your own. If you’re shopping for your own plan and you already have a dentist, your dentist may be able to recommend a plan based on your dental history.

As you compare plans, try to find out the following things:

  • Whether your dentist and any specialists you may need are in network
  • Total costs for the plan each year, including premiums, co-pays, and deductibles
  • Annual maximum
  • Out-of-pocket limit, if any
  • Limitations on pre-existing conditions
  • Coverage for braces, if needed or anticipated
  • Emergency treatment coverage, including treatment if you’re away from home

With the right research, you’ll be able to choose a plan that meets all your dental needs.

We love our patients and love to help them form healthy dental life that will last them a lifetime. For more information call us today to answer all of your questions so get appointment today.