What Does Dental Insurance Cover?

Dental insurance is designed to help reduce the costs of dental care, helping to make routine check-ups, treatments, and even major procedures are more affordable for individuals and families. Whether you’re seeking preventative care like cleanings or more complex treatments such as crowns or root canals, understanding your dental insurance options can help you make the most of your benefits while minimizing out-of-pocket costs.

Types of dental insurance plans

There are several types of dental insurance plans available, each with different structures, coverage levels, and benefits. The two most common types are DPPO (Dental Preferred Provider Organization, also simply called PPO plans), and DHMO (Dental Health Maintenance Organization, also referred to as HMO plans). Still available but less commonly offered by employers are dental indemnity plans. Each type of dental insurance impacts how much flexibility you have when choosing providers and how much you’ll pay for services. Note that less-expensive insurance plans may only cover basic care, check plan details carefully to see what procedures are included.

PPO dental insurance

PPO plans often have higher premiums than HMO insurance plans but are popular because they offer the flexibility to see any dentist you choose. That said, you will save the most if you stay in-network. Be aware that PPO dental insurance typically has waiting periods of 6-12 months after purchasing a plan before coverage is provided for major procedures. There is also often an annual limit on coverage, typically $1000-$1,500, after which you pay for dental care out of pocket. PPO plans may not cover cosmetic treatments or dental implants.

HMO dental insurance

HMO dental plans typically have lower premiums than PPO plans, but generally require you to select a primary dentist from a specific network. You do need to stay in network, and you’ll often need referrals for specialist treatments. HMO plans typically do not have waiting periods or annual caps on coverage but may limit the frequency of services (for example, you may only be able to get dentures replaced every few years, rather than on demand). HMO plans can be a cost-effective option if you’re comfortable with the dentists within the limited network. Like PPO plans, HMO plans may not cover cosmetic treatments or dental implants.

Dental indemnity plans

With an indemnity plan, you can see any dentist you choose, and you pay the dentist in full at the time of treatment and are later reimbursed a set amount by your insurance company. These plans often have a higher annual maximum spending limit – $2,500- $3,500+, and may have a shorter than usual waiting period than DPPO plans (check plan details, as this can vary).

What types of treatments does dental insurance cover?

Dental insurance coverage is typically divided into four categories: preventative care, basic procedures, major/restorative procedures, and orthodontics.

Preventative care

Preventative care is one of the most vital components of dental insurance. Routine check-ups, cleanings, and X-rays are generally fully covered, as these services are designed to catch potential problems early and maintain overall oral health. This coverage encourages individuals to visit the dentist regularly, avoiding costly and complicated procedures down the line. Dental insurance typically covers preventive care at 100%, even if you haven’t met your annual deductible.

Basic procedures

Basic procedures include treatments such as fillings, extractions, and simple root canals. Most insurance plans cover a percentage of these procedures after the deductible is met, making them more affordable for policyholders. Basic procedures often address issues that can worsen if not treated promptly. Basic procedures are often covered at 80% – your insurance pays for 80% of the cost, you pay the remaining cost out-of-pocket.

Major procedures

Major procedures such as crowns, bridges, dentures, and complex root canals typically receive less coverage than basic procedures – insurance usually pays 50% of the cost of these treatments. This still can significantly reduce the financial burden for patients who need major procedures, but factor in the annual coverage caps that limit the amount that your insurance will pay. Its easy to exhaust your coverage quickly with a major procedure, and if that happens you need to pay the full amount for your care until your insurance plan resets.

Orthodontics

Orthodontics covers braces and other bite alignment treatments. Orthodontics coverage for children is often included in dental insurance plans as a separate benefit with a lifetime limit (example: outside of your annual cap, you might get $1000 specifically for a one-time use for orthodontics treatment for each child on the plan). Coverage for adults seeking orthodontic treatment may be limited or subject to additional fees. Understanding the extent of your orthodontic coverage is essential if you or a family member needs braces or other corrective procedures.

Cosmetic procedures

Cosmetic procedures, such as teeth whitening and veneers, are generally not covered by dental insurance as they are considered elective and not medically necessary. Dental implants are sometimes considered cosmetic care by some plan providers. Insurance may offer discounts on certain cosmetic services, or specific parts of a procedure like dental implants. It’s important to review your policy if you’re interested in cosmetic work to understand the limitations and potential out-of-pocket costs.

Common exclusions and limitations

As with any type of insurance, dental insurance has certain exclusions and limitations.

Dental procedures that insurance doesn’t often cover

Cosmetic procedures are one of the most common exclusions, as they are deemed non-essential. Similarly, new treatment technologies may not be covered until they are widely accepted within the dental community and are seen to have provable health advantages when compared to more traditional treatments. As an example, coverage for dental implants has recently been added to a few dental insurance plans, due to their ability to forestall bone loss and maintain oral functions.

Dental insurance coverage limits

Annual coverage limits are another important aspect to consider. Most dental insurance plans cap the amount they will pay for treatments each year – the average cap is $1,000-$1,500. Once this limit is reached, any additional treatments must be paid for out of pocket.

Dental insurance waiting periods

Additionally, as noted above, many PPO plans have waiting periods before coverage kicks in for certain services, particularly for more expensive procedures like orthodontics or major restorative work. Understanding these limitations can help you plan your dental care more effectively, ensuring that you don’t get hit with coverage denials and unexpected costs.

Understanding out-of-pocket dental costs

Out-of-pocket costs can vary significantly depending on the type of dental insurance plan you have and the services you require. In general, dental plans involve a combination of copayments, deductibles, and coinsurance.

• A copayment is a set amount you pay for each visit or service. It’s a very predictable way to pay for dental care.
• Coinsurance refers to the percentage of costs you’re responsible for after the deductible is met. As this is based on the total cost of a procedure, it’s somewhat less predictable. Your dentist will breakdown costs for necessary treatments in your treatment plan.
• A deductible is the amount you must pay out of pocket (typically $50 per covered person) before your insurance begins to cover services.

It’s crucial to compare different dental insurance plans and estimate potential costs before deciding. Many insurance providers offer cost estimators, which can help you get an idea of how much you’ll pay for certain procedures.

Additionally, some people opt for dental savings plans instead of traditional insurance, as these plans offer set discounts on services in exchange for an annual fee. Comparing dental insurance vs. dental savings plans can help you decide which option is best for your needs and budget.

Maximizing your dental insurance benefits

To get the most out of your dental insurance, it’s important to understand your coverage and talk to your dentist about how to maximize your savings.

Scheduling regular preventative care appointments ensures that you maintain good oral health while maximizing the benefits of full coverage for these services. Additionally, if you anticipate needing major work, it may be necessary to stagger treatments across multiple years to stay within your annual coverage limits. You could also look into dental savings plans to reduce the cost of major procedures, as these plans have no annual coverage limit. Speak to your dentist about how to maximize your benefits, and always check your insurance policy for any limitations.

Handling claims and disputes can sometimes be a challenging part of using dental insurance. Always keep records of your treatments and communication with your insurance provider to avoid issues. If a claim is denied, you have the right to appeal the decision. Familiarizing yourself with the appeals process can help ensure you don’t end up paying for services that should be covered.

Exploring Supplemental Dental Insurance for Additional Coverage

If you find that your existing dental coverage doesn’t fully meet your needs, a supplemental dental insurance plan might be worth considering. These plans can work alongside your primary dental insurance plan to help cover gaps in your current insurance plan. While standard plans typically focus on routine care and basic dental treatments, supplemental plans can help with costs related to more complex care, such as oral surgery, tooth extractions, and other specialized dental work.

Supplemental plans can be particularly useful if your current dental insurance plan has strict limits or doesn’t cover certain procedures. For instance, many plans include preventive dental care like cleanings and X-rays, but may have limited coverage for more advanced dental services, such as implants or crowns. Adding a supplemental plan can help ensure that you have more comprehensive dental benefits, giving you peace of mind for both routine and unexpected care.

Before opting for supplemental coverage, it’s important to see how it fits with your existing health insurance and dental insurance plans. This way, you can avoid paying for duplicate coverage and make sure you’re getting the most out of both plans. For those with ongoing dental work needs, such as multiple tooth extractions or oral surgery, a supplemental plan could make a significant difference in managing out-of-pocket expenses.

Understanding how these plans work and how they can complement your existing coverage can help you make smarter choices about your dental coverage. But if you’re looking for a different way to manage your dental expenses, you might also want to explore dental savings plans.

Dental savings plans versus dental insurance

For those seeking an alternative to traditional dental insurance, a dental savings plan can be a cost-effective solution. These plans can also be used to reduce the cost of procedures that your insurance policy won’t pay for or doesn’t include.

Dental savings plans provide discounts from a nationwide network of dentists who have agreed to offer reduced rates to plan members. This can result in substantial savings for a wide array of dental services, including procedures not typically covered by insurance, such as cosmetic dentistry. Plan members report saving an average of 50%* on their dental care costs.

Dental savings plans have a low annual fee and no deductibles or annual limits, making them an attractive option for anyone who wants to manage their dental care expenses more predictably. Plan members can save on virtually all dental procedures, from routine cleanings to more complex treatments, without worrying about exceeding annual caps or navigating complex dental insurance policy guidelines.

Want a quick look at how much you can save with a dental savings plan? Use the calculator below now.

Dental insurance – is it right for you?

Choosing and effectively using dental insurance or a dental savings plan is an essential part of maintaining oral health. By understanding the types of plans available, the coverage they provide, and the costs associated with different procedures, you can make informed decisions that help you get the care you need without breaking the bank. Be sure to evaluate your options, take full advantage of preventative care, and be aware of your plan’s limitations to maximize your dental insurance benefits. With careful planning and a proactive approach, dental insurance can be a valuable tool in maintaining both your smile and your budget.

*Discount Health Program consumer and provider surveys indicate average savings of 50%. Savings may vary by provider, location, and plan.