Dental Insurance Guide

  • Discount Dental Issurance 101
  • How Does Dental Coverage Work
  • Is it covered under the ACA
  • Pricing Plans Costs & Features
  • HMO, PPO (confusing Terms) 101

How Do You Get Started?

Right Here
  • A Division of HealthNetwork, the fastest growing healthcare marketing company in the U.S., helping more than 15 Million Americans get coverage each year
  • We only work with Leading Dental Insurance companies
  • Pricing at lowest rates possible, as low as $10 a month
  • We are not an insurance broker or an agency, which means we have no incentive to favor one plan over another
  • Just for registering with us, you get access to all of HealthNetwork’s member benefits

Guide To Dental Insurance

Wondering How Dental Insurance Works?

For many people, the idea of buying health insurance is daunting enough without worrying about optional coverage like dental insurance. If you don’t visit the dentist regularly, then you may not even think you need this type of coverage.

But buying a plan that covers care for your teeth and gums can be a good investment in your overall health. In the following guide, we offer basic information on how dental insurance works and what you can expect when you choose a plan.

Medical vs. Dental Coverage

Medical insurance differs from dental insurance in a few important ways, but these two types of insurance share some common features. Both dental and medical coverage:

  • Require a monthly premium
  • Cover a set number of benefits and services
  • Require you to spend money out of pocket on some benefits, to different degrees

All insurance works on the premise that you’re protected “just in case.” It’s not going to cover every situation or every bill, but it can help lower what you pay out of pocket when you need care.

That said, dental insurance differs from medical insurance in a few key ways. Typically, dental insurance:

  • Has a much lower monthly premium
  • Doesn’t cover as broad of a list of services and benefits as medical coverage
  • Includes a cap on how much your insurance company will cover in a plan year
  • Dental insurers will cover preventive care and other services such as fillings, but there’s a lower annual maximum than there would be for medical claims. In other words, dental insurance doesn’t always guarantee coverage for certain procedures.
  • With medical insurance, some services are always covered without limitation. That’s not the case with dental coverage, which may place a cap on how many treatments or services of the same type that the plan will cover.

It might have more limits than comprehensive medical coverage, but dental insurance can be useful, especially if you need more extensive dental care. Dental work tends to be expensive and more immediately necessary than certain types of routine medical procedures. If you need a root canal, for example, then you can’t wait months without risking the loss of your tooth.

Like vision insurance, dental coverage is an optional add-on to your medical coverage that may help you prevent major crises later.

In the following sections, we’ll take a more detailed look at dental insurance and how this type of coverage works for the average person.

What a Dental Plan Covers

The biggest difference between medical and dental coverage is that dental coverage sets limits on the types of services it covers and how often you can access these benefits.

For instance, your medical insurance plan will cover its share of your medical bills no matter how many times you get sick in a year. If you get the flu three times, you’ll still have coverage for your care. And in fact, marketplace coverage under the Affordable Care Act guarantees that you’ll eventually pay less over time the more you need care because there’s a cap on out-of-pocket costs for comprehensive health insurance.

But dental insurance works differently. There are no out-of-pocket caps with dental coverage. Instead, plans typically cap what they’ll pay towards your care, which means you may pay more out of pocket if you need a lot of dental work in a single year.

Here are the major classes of services covered by dental insurance:

  • Class I: Preventive and diagnostic care is considered “Class I.” Most dental plans fully cover twice-annual cleanings, routine X-rays and other services that fall under the preventive category.
  • Class II: Normal restorative care, such as root canals or standard fillings, count as “Class II” services. Many plans cover 80 percent of the cost of these treatments.
  • Class III: If you need a more invasive or intensive procedure, like crowns, this treatment counts as a “Class III” service. Dentures also fall within this category. Dental plans will usually pay 50 percent of the cost for Class III services.
  • Class IV: Class IV services specifically cover orthodontic treatments, such as braces. Many dental plans place a separate coverage cap on orthodontic treatment, and some plans only offer coverage for braces for minors or younger dependents. Your plan may not cover orthodontia at all.

While most dental plans will cover at least the first three classes of service, some plans cover more services than others. For example, your plan might only include annual X-rays, full X-rays every five years or limited restorative treatments. Before you commit to a plan, check these and other limits carefully.

Three Types of Dental Plans

Like medical insurance, dental insurance offers different levels of coverage depending on plan type. For example, some medical plans may require you to use only in-network doctors when getting care. Dental plans work the same way. There are three standard types of dental plans:

1) Dental Health Maintenance Organization (DHMO)

  • In a dental health maintenance organization (DHMO) plan, you’ll only get covered benefits for visiting in-network providers.
  • The tradeoff for having a limited network is that you may not have an annual limit on coverage with this type of plan, and you’ll likely have lower out-of-pocket costs.
  • DHMO plans work well if you want to avoid high out-of-pocket costs, but there are some limitations with these types of plans. Out-of-network providers can charge full price for their services, and you may have to pay the entire cost yourself if you get care from someone outside the plan’s network.
  • Also, you’ll have to see your primary dentist to get referrals if you need other dental services from specialists, such as oral surgeons.

2) Dental Preferred Provider Organizations (DPPO)

  • In a preferred provider organization (DPPO) plan, you have greater flexibility in choosing your providers, but you’ll still gain the most benefit from seeing providers who are in network.
  • Providers who participate in PPO plans agree to charge a set amount for their services, which means that many preventive or routine services will be fully or mostly covered. If you go outside of your network, you’ll still get care at a reduced price, but you’re more likely to pay higher fees plus any additional charges not covered by insurance.
  • The upside to PPO plans is that your provider will typically handle the paperwork and claims process for you. You may also be able to avoid referrals and go straight to a specialist if you need one.

3) Dental Indemnity Plan

  • Not all dental providers operate within a network. If your dentist doesn’t participate in a larger network of providers or any particular plan, then a dental indemnity plan may work for you.
  • In this type of plan, you’ll choose your coverage based on carrier. The insurer will then cover certain services based on what you chose.
  • You’ll still have a deductible and coinsurance as with other plans.

Note: You can also buy a dental plan called a discount dental plan, but it’s not actually insurance. These plans offer a discount on dental services according to a set rate schedule agreed upon by your provider.

You can use discount dental plans on any service, cosmetic or necessary, but you’ll cover the cost entirely on your own. Your only discount will be the set price offered by your providers.

Paying for Dental Services

When you visit your doctor, you may pay a set amount up front known as a copay. This amount covers the cost of the visit unless you receive other services while you’re there.

With dental care, you may or may not have a copay when you see your dentist because payment for dental services works differently. In some cases, you may have to pay your dental office before you receive treatment. Once the work is done, your insurer will decide how much to reimburse you for the services.

But you may have a plan type that handles billing for you, meaning they’ll take care of the claims and you’ll pay the difference, like you would with medical insurance. It all comes down to your plan.

Example:

  • Marc needs a filling done, which is a class II service and covered at 80% by his insurer. Marc has a PPO plan. He can choose which dentist performs the filling, but he’ll pay more for an out-of-network provider.
  • The retail cost of the filling is $188. Marc chooses an out-of-network dentist because he’s heard good reviews about her.
  • Marc’s insurance provider pays 60% of the $188 cost because the dentist is outside of the network, which equals $112.80. Marc will have to pay the difference of $75.20 out of his own pocket for the filling.
  • Even though Marc’s out-of-pocket cost is relatively low, he’ll still have to pay the full cost of the filling before he gets the work done because that’s how his policy works. Out-of-network providers often charge the full cost beforehand.

Once Marc gets the work done, his dental office will submit the claim for reimbursement for Marc because he has a PPO plan, and most PPO plans take care of the paperwork for you. DHMO plans also usually take care of the paperwork.

However, since he chose an out-of-network provider, Marc may have to handle the claim on his own. Each dental practice has its own policies on filing claims.

Marc could have saved even more money by using an in-network provider (his out-of-pocket cost would’ve dropped to $37.60 in this scenario), but you don’t have to pick a dentist you dislike just to save money. When calculating cost, consider the providers available within your network and whether those providers have good reviews and a good reputation. The peace of mind that comes from choosing a quality dental provider can sometimes outweigh the higher price tag.

How the ACA Affected Dental Coverage

The Affordable Care Act (ACA) required all eligible American citizens to have minimum essential health coverage when it was passed in 2010. But the mandate to get health insurance is no longer in effect, and this rule only applied to medical insurance anyway.

Dental and vision coverage have always been optional under the law — for adults.

But you might still have questions about the ACA and how it impacts dental coverage. There are a few things you should know:

  • You can buy dental coverage as part of a medical insurance plan on the marketplace.
  • If the marketplace medical insurance plan you choose doesn’t include dental coverage, you can buy dental coverage as a standalone policy on the marketplace. But you can’t buy it alone. You have to buy medical coverage, too, even if it’s not through the same company.
  • Dental coverage is a required essential benefit for children ages 18 and younger, making it easier to buy on the marketplace.

As an adult over the age of 18, you can only buy dental coverage on the marketplace if you meet either of the above conditions.

But children (18 and younger) don’t have to meet these rules to qualify for dental coverage. Under the ACA, pediatric dental care is included among the 10 essential benefits provision. This means that all kids must have access to dental coverage within ACA-compliant plans.

You don’t have to purchase dental coverage for your kids, but you have to be given the option with your medical coverage.

You can choose to decline dental coverage for your kids if you want, but it’s a covered service under your medical plan thanks to the ACA.

How & Why to Buy Dental Insurance

The purpose of this dental insurance guide is to help you understand how dental insurance works. In this section, we wanted to mention briefly how to get dental coverage and why it might be a good idea for you.

Good preventive care may help you avoid costly and unnecessary problems later in life. Dental issues can be astronomically expensive. A single crown, for example, might cost $1,200 or more in some areas. And while insurance may only cover half the cost, it still saves you $600 in this scenario.

Dental plans aren’t usually expensive, either, so your upfront costs can be low as well.

If you’re ready to get insurance, then you have several options.

If your employer offers optional dental coverage, then enroll in a group plan, which may save you some money. Otherwise, take advantage of private plans available directly through your preferred carrier or a marketplace plan available on your state or federal health insurance exchange site.

Remember: dental coverage is not required.

However, you may find that investing a small amount each month for regular dental care helps keep you and your family healthier in the long run.