Dental Insurance: How It Works & Coverage

Dental insurance, like medical insurance, is important to have. It's necessary to properly keep your mouth healthy. So understanding dental insurance helps you determine the plan that best suits your needs.

Dental insurance is designed to assist you in maintaining good mouth health while helping offset costs for dental care procedures. The insurance pays a portion of the cost of treatment procedures so that the patient isn’t left with the entire bill.

Follow these steps to make sure you’re thoroughly vetting the best dental plan for you or your family.

• Determine your needs: This is based on your dental health history and whether you have a family.
• Study the different plan types: Preferred Provider Organizations, Dental Health Maintenance Organizations, Discount Plans, and Managed Fee-for-Service Plans are the most common.
• Determine plan availability: Not every plan type will be available in your area.
• Understand what each plan covers: Your needs play a role in plan evaluation.
• Network size: This directly affects your procedure copay amounts.
• Finances:  Know what you can afford for out-of-pocket costs.

Dental insurance emphasizes preventive coverage. It also shares the costs of other procedure types. Dental insurance tends to follow the 100-80-50 coverage structure, where those numbers equate to the percentage of the procedure's cost that is covered. Broken down, that often means:

• 100%: This includes routine preventive and diagnostic care like professional cleanings and oral exams.
• 80%: This covers basic procedures and includes fillings, root canals, and tooth extractions.
• 50%: This covers major procedures like bridges, crowns, and implants.

Items not covered by dental insurance can be divided into three classifications:

• Cosmetic procedures: Teeth whitening is a typical example of a procedure not covered by insurance.
• Pre-existing conditions: Conditions a patient had prior to enrolling in a plan typically aren’t covered by dental insurance.
• Select procedures: Some plans don't cover specific procedures like orthodontia. The specifics are outlined in the plan's documents.

Yes, health insurance can cover dental care, but not always. Health insurance can provide dental coverage in a few ways:

• Through an employer-provided health plan
• As part of a self-purchased health plan
• As a stand-alone dental plan or “rider”

Knowing the different types of dental plans will help a patient choose one that works best for their specific needs, including the out-of-pocket costs, benefits, and deductibles of each plan. Here is a summary of four of the most common types of dental insurance plans.

A dental HMO focuses on preventive care while providing lower costs. Preventive care includes dental cleanings, oral evaluations, sealants, and x-rays. Dental HMO patients must use in-network dentists to qualify for coverage. The dentist network for HMO patients tends to be smaller than a PPO’s network, but the cost tends to be lower. Patients also pay a fixed monthly premium.

Also known as a Dental Discount Plan, this plan lets members choose from a group of participating dentists who bill their services at reduced rates. Participating members pay an annual fee to obtain discounted rates. This plan type usually has a lower premium than a Preferred Provider Organization (PPO) or a Managed Fee for Service Plan.

Members usually have the largest network of dentists to choose from using this plan type.

For each service type, members pay a certain percentage while the plan pays the remainder subject to the deductible and annual maximum. Out-of-pocket costs vary based on the type of service performed.

Members in this plan pay a higher out-of-pocket cost based on having a larger dentist pool to choose from than a PPO provides.

This plan type is highly popular due to its desirable benefits, as discussed below.

Preferred Provider Organizations account for more than 80% of dental insurance plans. PPO plans are so popular due to the advantages they offer, such as:

The typical insurance company develops a network of dentists. They agree to charge patients rates that tend to be lower than their usual fees. PPO dental networks offer the most significant discounts of any network.

While a PPO plan has a large network of dentists, patients can opt to visit any licensed dentist. This applies to dentists who aren’t in the PPO network.

Patients maximize their benefits and savings by seeing a PPO dentist since they will pay lower fees while minimizing out-of-pocket expenses.

A deductible is the amount members pay for covered dental services before the dental plan starts to pay. Deductibles typically reset once every 12 months, with most providers following the calendar year.

Deductibles come in two forms: individual and family. The individual deductible applies only to the sole benefit of the plan, while the family deductible is the cumulative amount from any number of family members.

A copay, also referred to as a copayment, is the payment portion of a particular dental service for which the patient is financially responsible.

Copays are typically a percentage of the dentist’s fee. They can also be the enrollee’s predetermined payment for a given service.

Coinsurance takes effect once a plan deductible has been met. When that is the case, insurance policies usually cover a percentage of the outstanding costs. The patient is financially responsible for the remainder, referred to as coinsurance. A plan’s coinsurance amount typically ranges from 20% to 80% of the total bill.

You don’t have to choose a dentist within the plan’s network depending on your plan type. However, opting for out-of-network dentists can make your payments significantly more expensive.

Consult your dentist to discuss any questions about dental insurance 101 and dental plans. Or, check out The Smile Generation Find a Dentist tool to find a dentist near you for all your mouth health needs. You can read patient reviews, peruse staff bios, and schedule an appointment online with a click of your mouse.