What Will Your Dental Insurance Plan Cover?

Dental insurance is designed to help people pay for routine preventive care because most people don’t need extensive dental work on a regular basis. Preventive care helps identify problems early so that they don’t become bigger and more expensive issues later. In the following article, we’ll discuss the basics of what dental insurance covers so that you can make a more informed decision about your healthcare. Dental policies cover four classes of service as described below.

  • Preventive care: Routine dental care includes semi-annual checkups and cleanings. Some plans also cover X-rays and other diagnostic testing once a year. Regular screenings are considered “class I” services, and dental carriers usually cover the full cost of these checkups.
  • Minor treatments: Minimally invasive treatments like basic fillings, normal tooth extractions and root canals qualify as “class II” services under dental insurance guidelines. Most plans will cover up to 80 percent of the cost of these treatments. The remaining 20 percent is your responsibility, which is considered “coinsurance.” Even if you’ve met your deductible for the year, you’re still responsible for coinsurance payments.
  • Intensive procedures: If you need extensive or invasive dental procedures done such as crown fittings and bridges, then you’ll probably pay about half of the cost as coinsurance. Most dental plans only cover 50 percent of “class III” services. These procedures tend to cost more than other dental work, too, so watch your annual maximum limit if you need a lot of work done. Dentures also count as a class III service.
  • Orthodontia: It’s estimated that between 50 and 70 percent of kids wear braces. Despite this high percentage, most dental insurance plans place low limits on coverage for orthodontia, which is considered a “class IV” service. Some plans don’t cover adult orthodontia, so if you need corrective care for your own teeth, then you’ll need to shop around. Each plan varies in its allotment for specialty treatments, so ask prospective carriers about their policies for orthodontic care.

Types of Dental Insurance Plans

Like medical insurance, you have options when it comes to the type of dental insurance you buy. There are three main types of dental plans: Dental PPOs, DHMOs and dental indemnity plans. Each of these plans covers similar benefits, and all dental insurance plans will cover routine care at least. A fourth type of policy exists, but it’s not considered dental insurance. Known as a dental discount card, you can use this plan to pay for dental treatments at a reduced rate with your provider. However, a dental discount card does not give you the same benefits that insurance does.

Dental PPOs are dental preferred provider organizations. As the name suggests, this plan works on the premise that you’ll visit a dentist who’s in your policy’s network of providers. Most insurance carriers work with a network of providers, and PPO plans give you a better discount and more coverage for seeing those in-network dentists. With a PPO, you’re covered under different tiers. For example:

  • In a PPO plan, seeing an in-network dentist for a semi-annual cleaning will be covered completely at 100 percent. There’s no out-of-pocket cost for routine care.
  • If you choose an out-of-network provider for your routine visits, then you may be responsible for about 20 percent of the cost because a PPO plan will only pay 80 percent when you go outside the network.

If you buy a PPO policy and go outside your network, be prepared to pay higher fees. However, a PPO plan still covers some of those costs. The opposite is true with a DHMO plan, which stands for a dental health maintenance organization. If you participate in a DHMO plan, you must use dentists from within the network. There’s no guarantee of coverage outside of the network.

Your individual carrier or provider may work out a deal for you to pay the difference in fees, but this type of policy usually limits your visits to in-network professionals. You also need to visit your primary dentist for referrals to specialists. Despite these limitations, DHMO plans offer at least one advantage: Annual maximum payouts tend to be higher, which means you may be able to get more dental work done within the year.

If your preferred provider doesn’t participate in a network, then you may be better off with a dental indemnity plan, which gives you the most flexibility in choosing your dentist. You may only find indemnity plans through your employer, however, so check with your work to see what they offer.

What Dental Insurance Doesn’t Cover

Since dental insurance is designed to help people maintain good routine habits, many dental plans don’t cover a full range of benefits. Your policy may place restrictions on the number of procedures you can receive each year and the type of treatments available to you. Most policies also include an annual maximum payout limit. This limit ranges from $1,000 to $1,500 per annual period. Once your carrier has paid out the maximum limit, you’ll be responsible for any additional costs.

If you need substantial dental work, meaning thousands or tends of thousands of dollars in work, and you’re hoping that the tooth-fairy has some kind of payment plan in place, well you’ll have no such luck. Dental insurance providers are not going to be on the hook if you want $20,000 for all new veneers either. That said, you could always finance the mouth of your dreams, just beware the interest rates that many of the companies offer. You do not want to end up ruining your credit by extending yourself too far just because you want to have a celebrity smile, and you feel like dentures are out of the question.

Discuss what it is you want with your dentist or oral surgeon and then make a decision that’s based on what is best for you personally and financially.