Dental Insurance

Preventative care includes services that are rendered to help prevent future dental issues. Most preventative services are covered at 50% - 100% based on the dental plan you choose, and cover services such as:

- Routine dental cleanings (prophylaxis)

- Dental x-rays

- Initial / periodic / emergency examinations

- Fluoride treatment

Typically, preventative services do not apply to the annual deductible and are not subject to any waiting periods determined by the plan.

Each dental plan will determine which specific dental services are considered “basic” and which ones are considered “major” (see below), which can affect the percentages at which they are covered by the insurance company on your behalf. Most basic services are covered at 30% - 80% based on the dental plan you choose, and can cover restorative services such as:

- Tooth-colored dental fillings

- Amalgam dental fillings

- Palliative treatment to relieve pain

- Periodontal procedures such as scaling and root planing

- Oral surgery procedures such as extractions

- Endodontic procedures such as root canals

Each dental plan will determine which specific dental services are considered “major” and which ones are considered “basic” (see above), which can affect the percentages at which they are covered by the insurance company on your behalf. Most basic services are covered at 0% - 50% based on the dental plan you choose, and can cover dental services such as:

- Periodontal procedures such as scaling and root planing

- Oral surgery procedures such as extractions

- Endodontic procedures such as root canals

- Dental crowns and bridges

- Dental implant procedures such as implant placement and implant crowns

- Removable prosthetics such as full dentures and partial dentures

Much like health, accident, critical illness, vision, medicare supplemental, and life insurance, dental insurance also has a monthly premium. A monthly premium is an amount that you agree to pay each month to your insurance carrier. 

The amount of premium paid will determine the amount of benefits allowed, annual maximum, annual deductible, and coverage percentages for all services. So, the more you pay per month, the more benefits you likely will have. 

Dental insurance typically has an annual deductible, which must be paid out of pocket before your benefits will kick in. 

Deductibles range from $0 - $100 per year per household member, and once met, will allow for your insurance company to pay out on claims based on the coverage percentages and maximums determined by the plan.

Dental coinsurance represents the patient’s out of pocket expense for many dental related services, and can apply to preventative, basic, and major services. It’s essentially the difference between the dental office fee for a particular service and insurance plan payment for that service. 

The coinsurance is often collected at the time the services are rendered, subject to the deductible, terms, percentages, and annual maximum of your plan.

Dental copay represents the patient’s out of pocket expense for many dental related services, and can apply to preventative, basic, and major services. It’s essentially a flat fee for a particular service, which has been agreed upon between the dental office and insurance carrier. 

The copay is often collected at the time the services are rendered, not typically subject to the deductible, terms, percentages, and annual maximum of your plan.

Much like health insurance, dental insurance has an annual maximum that the insurance carrier will pay out on your behalf during the term of your policy. 

The annual max is the total amount of money the plan will compensate you or your dentist for dental expenses, and often ranges from $250 - $1000 per plan or calendar year. 

Many times, dental plans include waiting periods for certain, specific dental services. Waiting periods are the number of days or months one must wait before insurance will cover those specified services.

Waiting periods prevent a patient from maxing out his / her / their benefits without paying in enough to the insurance policy, and generally apply to basic and major services for a duration of 3-6 months.  

You’ve likely heard the term “in-network” regarding your medical insurance, but it also applies to dentists as well. A PPO dentist is one who has agreed to discount their fees to gain greater access to patients of a particular carrier or plan.

You may have experienced the difference between “in-network” and “out-of-network” doctors before, often resulting in paying more to an out-of-network provider. This is because many plans also have different benefits based on the status of the provider, in or out. Seeing an in-network dentist will allow you to fully maximize your dental benefits, saving you the most money. 

More common and traditional in nature, indemnity plans will allow you to see a wide variety of dentists, in-network and out-of-network, and insurance payments are based on a specific percentage specified in your plan. 

If you see an in-network dentist, you may have more benefits available or receive discounted fees for treatment. If you choose an out-of-network dentist, the plan will typically pay out based on the percentage of a “usual, customary, and reasonable” fee for that city, zip code, etc. 

You can find your area's UCR fees by visiting https://www.fairhealthconsumer.org/dental/zip. 

DHMOs are very strict as to what providers you can see to utilize your dental benefits. DHMO dentists are not paid per service, instead, they are paid a monthly amount per person by the carrier. 

With these plans, patients are typically not paying anything out of pocket, or a dramatically reduced fee. In turn, the services that the dentist is permitted to provide is generally more restrictive.  

A discount dental plan allows you to receive a nice discount for all dental services from an in-network. Discount plans are not considered insurance, so there are no claims to file, no annual maximums, no deductibles, etc. You pay 100% of the discounted fee up front to the dentist directly.