Dental insurance covers dental care and preventative work that directly concerns the health of one’s teeth and gums. The amount of out-of-pocket expenses you may incur for dental care is greatly influenced by factors such as the insurance company you work with, the type of insurance plan you choose, the dental provider you select, and your geographic location. We’ve put together some basic information to help you navigate the dental insurance system, but you should always check with your insurance provider for information about your specific plan.
Terms to Know
Most people rely on their dental insurance to help offset the cost of dental care. Therefore, it is important to familiarize yourself with your policy so that you know what to expect from it. The definitions below will help you better understand the basic terminology used by insurance agencies and dental providers.
Annual Maximum: This refers to the maximum amount that the insurance company will pay for an individual enrollee’s dental care in a certain time period–usually a calendar year. Once you reach your annual maximum, you must pay for additional services needed out of pocket without reimbursement until the end of that year. The average yearly allowance for any type of dental plan is often around $1,000 to $1,500.
Deductible: Your dental insurance plan might require you to pay a certain amount, called a deductible, each year before your benefits start. This means that until you reach your deductive, all fees are out of pocket and non-reimbursable. It is important when comparing plans that you know your deductible amount and are aware of the costs of routine dental care in a one-year period. The higher your deductible, the less likely you are to receive insurance benefits.
Coinsurance: Coinsurance is a percentage of a medical charge that you pay and the rest is paid by your health insurance plan, which typically applies after your deductible has been met. For example, if you have a 20% coinsurance, you pay 20% of each medical bill, and your health insurance will cover 80%.
Copay: This is a single, predetermined amount that you pay at the time of each service. You pay this fee directly to the provider, but the insurance company sets the amount. Your copay for a routine visit will likely be somewhere between $15 and $50.
Premium: A monthly payment you make to have insurance. Like a gym membership, you pay the premium each month–even if you don’t use it–or else lose coverage. If your dental insurance is through your employer, the company typically pays a portion or all of the premium.
Pre-Treatment Estimate: For particularly expensive or extensive dental work, you might need an estimate from your insurance company about the portion of the treatment you will be responsible for. In most cases, the insurance company will not give you an estimate over the phone. To receive the most accurate estimate, you will need to ask your dentist’s office to submit documentation to the insurer along with the appropriate procedure codes.
Exclusions and Limitations: Many dental plans do not cover all available services. For example, plans frequently exclude orthodontic work. Most plans also limit the number of services you can receive in one year. For example, you might be limited to two cleanings a year, in which case you would pay out of pocket for additional cleanings.
Preauthorization: Some insurance plans will require approval of any procedure before it happens. Your provider will need to submit a request to the insurance company and explain why she believes the treatment is necessary. The insurance will then either agree to extend coverage for it or deny coverage. If you do not wait for the insurance company to authorize the procedure it won’t be covered.
In-Network: If your provider is “in-network” with your insurance, then she has agreed to bill the insurance at pre-negotiated rates. In nearly all cases, a discrepancy exists between what the provider would charge for a service and the maximum amount the insurance company has agreed to pay. For example, if the office fee for a cleaning is $100, the insurance company might say that its “allowable amount” is $80. If your provider is in-network with that insurance company, then he agrees to accept the $80 payment and write off the rest. Therefore, your out-of-pocket costs will not be affected.
Out-Of-Network: If your provider is “out-of-network” with your insurance, you might still be able to see him based on your plan, but you will have to pay the full amount at the time of your visit. If you choose to see an out-of-network provider and your dental plan reimburses you for some of these costs, then you typically will be eligible to receive a percentage of what the insurance company would pay an in-network provider. For example, let’s say your policy will pay you 50% of the allowed amount. If you receive a procedure that the dentist charged $100 for, and the allowed amount from the insurance company was $80, then you would receive a $40 reimbursement.
Reimbursement Level: This is the percentage of the allowable amount per service that the insurance company is willing to reimburse you for out-of-network services.
Waiting Period: This is the amount of time that must pass after you become insured before your benefits become active.
What Are Types of Dental Care?
Dental plans usually group the types of services they cover into three categories: preventative, basic services, and major services. Preventative services are the routine care performed in order to prevent or diagnose a dental problem. These services usually receive the highest level of insurance coverage. Typically, preventative services include:
- Examinations (covered twice per year)
- Cleanings (covered twice per year)
- X-rays (bitewing X-rays once per year; full mouth X-rays once every three years)
- Fluoride treatments (twice per year)
Basic dental services are ones that are straightforward and typically can be completed in a single office visit. Insurance policies usually cover a substantial amount of work at this level. Basic services include:
- Emergency care for pain relief
- Crown repairs
- Routine tooth extractions
- Non-routine dental X-rays
Major dental services are ones that most often cannot be completed in a single office visit. The patient is likely to pay a more significant percentage out of pocket for these services, which include:
- Root canals
- Tooth implants
- Oral surgery (may be covered by medical insurance)
Cosmetic Dental Care
Cosmetic dentistry is the use of dental treatments and procedures to improve the appearance of the teeth and mouth.
Dental insurance usually will not cover cosmetic dental work that doesn’t have significant medical necessity. Dental insurance usually deems medical necessity to include treatment or prevention of decay and disease, treatment to correct damage caused by an accident or injury, and treatment that alters the mechanics of a patient’s bite to allow for functionality.
There is a lot of gray area between what insurance companies consider medical versus cosmetic. An example of this is composite (tooth-colored) fillings. Often, coverage will only be provided for amalgam (silver) fillings, and policyholders will be responsible for paying the difference if they prefer composite fillings.
Another gray area is orthodontic treatment. Braces are usually never covered if they are desired to correct the alignment of the teeth for personal appearance preferences. However, certain types of braces may be covered if they are needed to correct medical problems. For example, some types of bite misalignments can cause significant chronic pain, limit the utility of the jaw or place the person at risk of disease or infection. But even in these circumstances, the insurance company is likely to limit the options for the type of orthodontic work it will cover. For example, in a medically necessary situation, your plan might cover traditional metal brackets but not clear, removable aligners.
Dental Insurance Plans
In some cases, you might need to choose between two or more types of dental plans. Most often, the least restrictive plans will cost more in premiums, while plans that restrict access will have lower premiums. Whether you are choosing among options your employer offers or shopping on your own, you will need to consider your needs versus what the plan offers in order to make the choice that will be most cost effective while allowing you the access to care that is best suited for you.
Preferred Provider Organization (PPO)
PPO dental insurance plans offer the best services and least restrictions compared with other types of policies. However, this insurance option is usually the most expensive. A dental PPO casts a much broader network of dentists than other types of insurance plans and allows patients to seek specialty care without approved referrals. If enrollees choose to receive services or care outside of the network, the insurance company will typically reimburse them for a portion of their out-of-pocket expenses. However, this flexibility also comes with the added work of completing claim forms and waiting to receive reimbursement. Those insured through a PPO typically have co-payments they must fulfill at the time of service, and many PPO plans require the insured to meet an annual deductible before benefits activate.
Dental Health Maintenance Organization (DHMO)
DHMO policies are usually much cheaper than PPO plans, but offer greater restriction in terms of available providers and services. HMO dental plans have networks of dentists under contract with the insurance company that offer dental services to insured members at predetermined rates, so there are no out-of-pocket fees or premiums for those insured. DHMO plans will not provide any reimbursement for out-of-network costs. If you choose to visit a provider or receive a service that the insurance company does not approve, you will not receive any insurance benefits. Like medical HMOs, people with HMO dental insurance plans must select a primary care provider from a pre-approved list. All referrals to dental specialists must be provided by the primary dentist.
Point Of Service Plan (POS)
POS dental plans are a hybrid of the PPO and DHMO plans. Like DHMO plans, members usually need to declare a primary dental provider and receive referrals for specialists. However, like PPO policies, POS plans typically allow members to visit out-of-network providers and receive some reimbursement. Also like PPO plans, they typically include annual deductibles and require copayments.
Direct Reimbursement Plans
A direct reimbursement plan is usually entirely funded by your employer, meaning you will not pay premiums to keep your insurance. This type of plan allows you to choose any dentist without the hassle of networks. Direct reimbursement plans also do not limit you to specific treatments or exclude others. Some employers may choose to reimburse you after you have paid for your dental work, and some may choose to pay the dentist directly for you. A common direct reimbursement plan would pay for 100% of the first $100 spent on dental services, 80% of the next $500 and 50% of the next $1,000.
Questions to Consider When Selecting A Plan
- Does the plan give you freedom to choose your dentist and/or dental specialist?
- Who controls treatment decisions–you and your dentist or the dental plan? Some plans may require dentists choose a similar (but sometimes suboptimal) treatment that is less expensive.
- Does the plan cover preventative care and/or basic and major services?
- How soon after enrolling in the plan are you eligible to access benefits?
- Are there annual restrictions such as deductibles and/or maximums?
- What will the copayments, if any, be?
- What are the plan’s limitations (a limit to the benefits for a procedure or the number of times a procedure will be covered) and exclusions (denied coverage for certain procedures)?
- Can you see the dentist when you need to and schedule appointment times convenient for you?
Purchasing Dental Insurance
If you do not have dental insurance through an employer, then you may want to consider purchasing an insurance policy on your own. Whether you want to invest in dental insurance and what plan you choose will likely depend on your dental needs.
In order to determine whether purchasing private dental insurance is worth the investment, you’ll want to consider the costs you anticipate incurring on an annual basis. If you have generally excellent dental health, you might research the amount you would spend on cleanings, X-rays and other routine care. You might also want to consider the cost of a filling or two just in case you develop cavities.
If you have a history of dental problems, it will probably be worth it to spend the money on coverage.
One alternative to traditional dental insurance you may consider is a dental savings plan.
Dental savings plans require a low annual membership fee for access to an extensive network of participating dentists and dental specialists who often provide discounts on dental care at the time of service. These discounts typically range between 10% and 60% depending on the service and your location.
Since they are not insurance plans, dental savings plans do not require you to meet a deductible, pay copayments, or submit claims. They also do not have annual limits. In addition, some plans offer discounts on dental specialties that are rarely covered by insurance, including cosmetic dentistry services.