Dental insurance can provide you with much-needed peace of mind, particularly given the hefty expense of dental work. You may get coverage for everything from routine exams and cleanings to more difficult operations like root canals and extractions with a good dental insurance policy. Dental coverage should be precisely that: coverage for you and your family. While you do not need dental insurance to receive treatment, having it can help you save money on some procedures. Employer-sponsored plans, self-purchased plans, and riders connected to medical insurance policies are the three most common types of dental plans.
The National Association of Dental Plans reports that dental coverage is available to 77 percent of the population in the United States. Approximately 155 million people with dental benefits have private insurance, while 50 million receive coverage through a government program like Medicaid, CHIP, or TriCare. The majority of people have private insurance, usually through employment or a group plan. Dental benefits are more likely to be offered by large employers than by small firms, and they are more likely to be received by high-wage workers than by low-wage workers. Medicare does not cover dental treatment, and most state Medicaid programs only cover it for children. If you wish to receive the maximum benefit from your dental insurance plan, you need to understand what’s in the fine print and which plan is best for you.
Whether you already have coverage or are considering adding dental benefits, it is essential to grasp the basics of dental insurance.
Table of Contents
- 1 What are dental insurance plans?
- 2 How does dental insurance work?
- 3 Dental insurance plan categories
- 4 Types of dental insurance plans
- 5 What is a full coverage dental insurance plan?
- 6 How to apply for dental insurance plans?
- 7 What does dental insurance cover?
- 8 What is not covered by dental insurance?
- 9 Benefits of dental insurance plans
- 10 Limitations of dental insurance plans
- 11 What to do before a dental procedure?
- 12 Is dental care covered in health insurance?
- 13 Should I buy a dental insurance plan?
- 14 Costs of dental insurance plans
- 15 Orthodontic dental plans
- 16 Conclusion
What are dental insurance plans?
Dental insurance plans are the type of insurance that pays for dental work. Although businesses frequently offer a benefits package that includes medical and dental insurance, dental insurance plans have historically been separate from medical insurance. Dental and vision insurance are commonly sold together, with both forms of care covered under a single policy.
Dental insurance covers a variety of dental operations, including preventive care and more complicated procedures such as fillings, crowns, and root canals. Dental insurance plans, like other types of insurance plans, require you to pay a monthly premium, as well as an annual or lifetime deductible and copayments when you visit a dentist for treatment.
In terms of coverage, dental insurance plans are different from health insurance plans. While the Affordable Care Act (ACA) made it such that yearly restrictions on healthcare coverage are no longer applicable, dental insurance policies frequently have annual limits as low as $750 or $1,000 per person. You are supposed to pay for your dental care out of pocket after your yearly maximum benefit amount has been reached. Also, keep in mind that dental insurance often has waiting periods that vary based on the sort of treatment you require.
Pediatric dental care is one of the core health benefits included in the Affordable Care Act, but it can be included in a medical insurance plan (as it is in some states that have mandated it) or sold as a separate, stand-alone policy. The ACA does not require adults to get dental insurance. The majority of dental insurance policies include deductibles that must be met before treatment may be delivered. They also have benefit caps, limiting how much the insurance plan will pay for adult dental care, and there is no cap on how much you will have to pay out of pocket for adult dental care. In the case of kids’ dental care, however, the situation is reversed: out-of-pocket payments are limited, while insurance benefits (the amount paid by the insurer) are unlimited.
Make sure to distinguish between dental insurance plans and dental discount plans. Dental discount plans only apply to treatments provided by dentists who are part of a specified network. We will also discuss dental discount plans in the latter part of this article.
How does dental insurance work?
Most of the dental insurance plans work in the following manner:
This is usually a monthly payment for getting dental insurance. Dental coverage provided by your employer may be withheld from your wages. If you purchase a plan on your own, you pay the monthly premium to the insurer directly.
In a normal dental insurance plan, you may have to wait up to 6 months before you’re covered for dental care other than routine oral checkups. A waiting period is not required for all dental insurance. A waiting period is a time between the start of your plan and the beginning of your coverage for dental care. Basic care may require a longer wait than significant restorative care. This means you might be able to receive a filling sooner and still be insured, but you’ll have to wait longer if you need a crown or bridge. If you had previous coverage with them, certain policies might waive waiting periods.
Some dental insurance plans may limit you from selecting a primary care dentist. This is the dentist you’ll see if you have any issues, and they’ll coordinate any specialized dental care you might require.
In-network or out-network dentists
Whether you are allowed to visit the out-network dentist or not depends on the type of dental insurance plan you are enrolled in. Some plans may bind you only to visit the in-network dentists, whereas others may allow you to see any dentist you want.
Frequency of dental visits
The importance of frequency and restrictions cannot be overstated. These dental coverage words explain what you’re covered for and what you’re not. Once every six months, for example, you can get a free dental exam and cleaning. Furthermore, you may only be covered for a restricted range of dental services and treatments, ranging from basic to major.
One or more deductibles may be included in your dental insurance policy. A deductible is an amount you must pay out of pocket for dental care before your insurance plan begins to share the costs. For example, if your yearly deductible is $2,000, you’ll have to pay the first $2,000 of your total qualified medical bills before your insurance kicks in.
Individual coverage and family coverage have varying deductibles. Even if your plan covers out-of-network benefits, using in-network doctors and hospitals will often result in a smaller deductible. A plan with a larger deductible and lower premium may be an intelligent choice for you if you’re healthy and don’t expect to need expensive medical services during the year.
On the other hand, let’s imagine you’re aware that you have a medical problem that will necessitate treatment. Alternatively, you may be part of an active family with children who participate in sports. You might be better off with a plan with a smaller deductible and a higher premium that covers a more considerable percentage of your medical costs.
Coinsurance and copay
There may be some additional charges associated with your plan. Once you’ve met your dental deductible, you and your plan will start splitting the cost of your dental care. This is referred to as coinsurance. After your deductible has been reached, coinsurance is a percentage of the medical costs you pay. Coinsurance means that you and your insurance provider each pay a portion of the total amount of qualified expenditures. There may be an annual maximum on your dental insurance. This is the maximum amount of money your plan will pay for dental care in a given plan year. Above that amount, you will be financially responsible for any further care expenditures. Some plans also require you to pay a small fee when you go to the dentist. This is referred to as a copay.
Preventive dental care
Preventive dental care is frequently provided at no cost. This means you’ll get an oral exam and some types of standard X-rays every six months. As part of their preventive care, children may receive more routine attention. When you opt for a plan with no-cost preventive care, this is included in your dental insurance without charging any cost to you.
Preventive, restorative, orthodontic, and other types of dental care are all covered under dental insurance. You may get more or less coverage for specific types of dental care depending on the type of dental plan you purchase. This is why it’s critical to prepare ahead for the dental care that you and your family may require. If you just expect to need preventative dental treatment, a basic dental plan that only covers preventive dental care may be sufficient. A dental plan that covers more specialized dental care and procedures, such as crowns, root canals, bridges, implants, and so on, maybe a better fit for you if you anticipate needing crowns, root canals, bridges, implants, and so on. Full coverage dental insurance may have higher monthly premiums, but it will help you keep your out-of-pocket costs for expensive dental operations under control.
Dental insurance plan categories
Despite the fact that plan features vary, the most typical designs can be divided into the following categories:
Direct reimbursement programs
Regardless of the treatment category, direct reimbursement programs pay patients a predetermined proportion of their total spending on dental care. This strategy usually does not limit coverage based on the type of treatment required, allows patients to choose their own dentist, and encourages them to collaborate with the dentist to find healthy and cost-effective alternatives.
Table or schedule of allowance programs
A list of covered services with an allocated monetary amount is determined by a table or schedule of allowance programs. Regardless of the dentist’s price, that sum shows how much the plan will pay for those covered services. The patient is charged the difference between the acceptable price and the dentist’s fee.
Usual, customary, and reasonable (UCR) programs
Patients who participate in usual, customary, and reasonable (UCR) programs can generally visit any dentist they like. These plans pay a predetermined proportion of the dentist’s fee or the plan administrator’s ‘reasonable’ or ‘customary’ fee limit, whichever is lower. An agreement between the plan purchaser and the third-party payer established these constraints. Despite the fact that these limits are referred to as ‘customary,’ they may or may not accurately represent the rates charged by local dentists. The method by which a plan calculates the ‘customary’ fee level is subject to significant variation and lacks government oversight.
Capitation plans pay contracted dentists a certain sum per enrolled family or patient, typically every month. In exchange, the dentists agree to provide certain sorts of therapy at no cost to the patients. There may be a patient co-payment for some procedures. The amount of the capitation premium paid may range significantly from the amount provided by the plan for the patient’s actual dental care.
Types of dental insurance plans
There are numerous types of dental insurance available. Understanding the key distinctions between the various types of dental insurance can assist you in selecting the best plan for you. When you start looking for dental insurance and deciding on a plan, keep the following in mind:
- Are deductible and coinsurance required?
- Is it necessary for you to select a primary care dentist?
- Are you obliged to see dentists who are part of a specific network in order to be covered?
Dental Preferred Provider Organization (DPPO)
Dental PPOs are one of the most common and popular dental plans. These plans have a provider network from which you are supposed to pick your dentist. You can go to a dentist who isn’t in the network, but the charges will be higher. It is not necessary for you to select a primary care dentist. Annual deductibles and coinsurance are typical in DPPOs. Once you’ve met your deductible, your dental plan will begin contributing costs as part of coinsurance, up to the yearly maximum. The majority of in-network preventative dental treatment, such as cleanings, examinations, and X-rays, is fully covered. For any care that goes beyond preventive, you will have to pay a copay at the time of your visit to the dentist and share costs with your plan. If you’re willing to see dentists in the network, a DPPO can help you save money.
Dental Health Maintenance Organization (DHMO)
Dental HMO or DHMO plans are among the most cost-effective dental plans. For non-preventive dental services, there is usually no deductible and merely a flat charge. The majority of preventive dental care, including cleanings, exams, and routine X-rays, is usually fully covered.
Because you must choose a primary care dentist from the network, costs are usually lower. These plans typically don’t cover you if you go to a dentist who isn’t in the network, except for some emergency services. Smaller and more localized networks are offered in DHMO plans. Dentists in a network have agreed to cut their fees. As part of the plan’s coverage, these cost savings are passed on to patients.
There is usually no annual maximum for covered services in dental HMO plans. This means you won’t have to worry about running out of benefits at the end of the year, no matter how many covered dental procedures you require. If you require the services of a specialist, your primary care dentist will refer you to one of the network’s providers.
Dental indemnity is a sort of dental insurance that allows you a great deal of flexibility. It’s also known as a conventional or fee-for-service dental plan. There is no network for doctors, so you can go to any dentist you wish. You don’t have to pick a primary care dentist, and depending on the plan, you may not need referrals to specialists or emergency dental care.
An annual deductible and coinsurance are generally included in a dental indemnity plan. You will have to pay for services out of pocket until your deductible is met. Then you and your dental plan will split the cost of covered services up to your plan’s UCR (usual, customary, and reasonable). These dental plans are usually more expensive. A dental indemnity plan may be suitable for you if you enjoy a lot of options and few requirements.
Dental Exclusive Provider Organization (DEPO)
These sorts of dental insurance policies allow you to pick between ordinary and specialist dentists. You are not required to select a primary care dentist, nor do you require referrals to see specialists. To be covered under a DEPO plan, you must visit dentists in the network. Some sorts of dental emergencies may be covered by out-of-network coverage. A deductible and coinsurance are generally included in these plans.
Dental Point of Service (DPOS)
DHMOs and DPPOs are combined in these dental plans. You have the same freedom as a DPPO to visit dentists outside the network, but your charges will be lower if you stay in-network. Like a DHMO, you must select a primary care dentist who will make any necessary referrals to specialists, either inside or outside the network. This flexibility may come with a higher deductible, plan cost, and copays depending on the plan. If you don’t plan on seeing dentists outside of your network, a DHMO may be a better option.
Discount Dental Programs
Discount dental plans, often known as dental savings plans, are fee-based annual plans that you purchase altogether. Several insurers, as well as independent merchants, offer them. They aren’t the same as dental insurance. These discount plans work in the same way as a membership program in that they provide you with discounts and savings on a variety of dental services. They may also include additional benefits, and depending on your needs and those of your family, they may be able to help you save money on dental care. A discount dental program operates in the following manner:
- You can select from a number of dental savings plans. They can differ in terms of price and the types of discounted dental treatments available. Some programs focus on a single person rather than a family.
- You can immediately arrange dental care after purchasing a discount deal. There is no need to wait.
- Many programs will provide you with a list of dentists from which to choose.
- You will show your ID card to the dentist if your program gives you one.
- You pay a discounted fee for each service you receive, based on the program you purchased. For example, you may be responsible for a portion of the cost of your oral exams, teeth cleanings, routine X-rays, cavity fillings, and other dental procedures.
- Claims are frequently processed for you, saving you the time and effort of filling out paperwork.
- The program will terminate itself at the end of the year.
Medicaid and CHIP
Adult dental benefits vary significantly by state, whereas all states cover Medicaid and CHIP children under the age of 21. The state usually manages Medicaid and CHIP together, and there are two fundamental models:
- Managed Care: The dental benefits administration is handled by managed care firms contracted by each state. They are usually fee-for-service; however, they occasionally pay dentists on a negotiated price plan rather than the state fee schedule. The managed care provider network requires dentists to be accredited.
- Fee-for-Service: Dentists are paid based on a defined fee schedule by the state, either directly or through a third-party administrator. To be part of the Medicaid provider network, dentists must be accredited.
This program, which is for active-duty military personnel and their families, has the appearance and feel of a commercial PPO. All of these benefits have been managed by United Concordia since 2017.
What is a full coverage dental insurance plan?
Dental insurance plans come in a variety of configurations and sizes. Some provide the essentials, while others provide more comprehensive care and treatments, referred to as full coverage. Full-coverage dental insurance covers plans that include preventative care, basic and major restorative therapy, and orthodontic treatment in some situations. The term full coverage refers to the fact that you’ll be covered for a wide range of dental treatments and procedures. For example, you may be covered for more expensive procedures such as root canals, bridges, and implants, as well as preventive dental treatment. However, full coverage does not imply that your plan will pay 100% of your expenses.
Dental PPOs (DPPOs), Dental HMOs (DHMOs), Dental EPOs (DEPOs), and Dental POSs (DPOSs) may all cover a variety of dental procedures and treatments.
How to apply for dental insurance plans?
Here are a number of options for dental coverage:
- As part of your work perks, your employer may provide dental care. In this case, you can apply for it during the annual open enrollment period. You may be able to choose from a variety of dental plans to assist cover the type of dental care you anticipate needing.
- You can purchase a dental plan on your own if your company does not provide dental insurance or if you lose your job or work for yourself. This can be done through a state health exchange or a health insurance company directly.
What does dental insurance cover?
Dental insurance plans vary significantly in terms of what they will and will not cover. As a result, you should carefully study the terms and conditions of any plan you’re considering to ensure that basic dental treatment such as fillings and major services such as crowns and bridges are covered. The extent to which your dental insurance covers you is determined by the plan you select. When looking for a dental plan, consider the following categories of coverage:
Preventive dental care
Most dental insurance includes certain preventive services at no cost to you. Every six months, this usually includes a dental exam and cleaning, as well as specific types of mouth X-rays. Sealants, fluoride, and other treatments for children may be covered.
Th is includes procedures such as cavity fillings and tooth extractions, as well as root canals, crowns, bridges, dentures, and more. These types of treatments might range from minor to major. Your dental care may be more expensive if it is more intricate and specialized. If you anticipate needing dental care beyond your preventive dental exams, you may want to look into dental plans that provide extra coverage for restorative services such as these.
Correcting teeth and bite alignment is the emphasis of this dentistry specialty. Look for dental insurance that covers orthodontic procedures if you or a family member expects to require this type of treatment.
Periodontics and prosthodontics may not be provided in the first year of coverage if you purchase an individual policy. For any type of policy, orthodontics frequently requires a rider, for which you must pay an additional premium. The most common coverage structure is 100-80-50. That implies they cover 100 percent preventative care, 80 percent of basic operations, and 50 percent of big procedures, or a higher co-payment. However, other procedures, including tooth sealants, may not be covered at all by a dental plan.
What is not covered by dental insurance?
This is dependent on the dental insurance plan you select. Bridges, crowns, dentures, and root canals, for example, may not be covered if you merely get a preventive dental plan. Your dental insurance plan will not cover aesthetic procedures like teeth whitening, veneers, or orthodontic products, including braces, removable teeth aligners, and retainers.
Ensure reading and understanding the terms of any plan you’re considering for dental insurance with orthodontic benefits. There could be discrepancies in coverage for orthodontist services vs. coverage for orthodontic appliances like braces or retainers. Planning ahead for the dental care you and your family expect to require is the key to ensuring that your dental plan covers specific types of treatment. Check your dental insurance coverage to see what it covers and what it doesn’t.
Benefits of dental insurance plans
Dental insurance plans come bearing a huge set of benefits for you. Non-preventive dental care has lower out-of-pocket costs. You will be paying the whole cost of dental treatments and procedures if you do not have dental insurance. Your insurance provider works out a deal with the dentists in its network to get you a better deal. A dental plan protects you from the high cost of dental care in this way. Preventive dental care is free with dental insurance plans. Most dental insurance pay for routine, preventive dental care in full. Every six months, these plans include a dental exam, cleaning, and X-rays. Fluoride and other pediatric preventative dental care may be included for children.
Dental health has an impact on other aspects of one’s health. Dental health can assist you in detecting health issues before they become serious. Your dentist cleans and polishes your teeth, but they also inspect your mouth, throat, and tongue for cancer and other potentially serious concerns during your regular oral exam. Taking care of your teeth and gums might also help you avoid significant health issues like heart disease. Poor dental health can exacerbate existing health issues such as diabetes and coronary heart disease.
Limitations of dental insurance plans
Every plan has a limit on how much it will pay out in a given year, and many of them are pretty low. That monetary limit is the maximum amount of money you can utilize as insurance coverage in a year. You are responsible for any dental expenses that exceed that amount. Annual maximums of less than $1,500 are available in around half of dental PPOs. If that’s your strategy, you’ll be accountable for any costs over $1,500. You can get to the limit rapidly if you need a crown, a root canal, or oral surgery. Orthodontic costs usually have a distinct lifetime maximum. To save money, some plans may completely exclude certain services or treatments. Learn exactly what services the package includes and excludes.
However, most dental insurance plans have specific limitations and exclusions in place to keep the expense of dentistry from rising without penalizing the consumer. Experimental procedures and services not conducted by or under the supervision of a dentist are excluded from all plans, but there may be some less evident exclusions as well. Dental insurance and medical health insurance might sometimes overlap. Read and understand your dental insurance policy’s terms and conditions. Your medical insurance may cover exclusions in your dental plan.
What to do before a dental procedure?
Check your dental insurance coverage to verify if your surgery is covered. If you have any questions, contact your insurance company. If you require a major procedure, you can request a pre-treatment estimate from your dentist. This can help you figure out how much you’ll owe after any coinsurance, deductible, and policy limit have been applied.
It will also come in handy to know how your dental plan handles emergencies. Many plans include urgent care or after-hours care, but you may be responsible for a deductible, a copay, or a higher proportion of the bill.
Is dental care covered in health insurance?
All health plans do not cover dental benefits, and their availability varies based on where you live. Adult dental benefits are not considered an essential health benefit under the healthcare law. This means that if you’re over the age of 18, health insurance companies aren’t compelled to provide dental care.
While insurance companies are not obligated to offer adult dental insurance, children’s dental benefits are considered critical health benefits. If your health plan covers dependents aged 18 and under, the plan must either include dental benefits as part of its health coverage or provide these benefits as an individual dental plan, as required by law. Dental benefits are only required to be supplied to children under the age of 18; you are not forced to purchase them.
Your monthly premium should cover both your health and dental coverage if your health plan includes dental services. If you want dental coverage to your health plan as a supplemental benefit, you’ll pay a separate premium for your dental plan in addition to your health plan’s premium.
Should I buy a dental insurance plan?
If you are wondering about getting a dental insurance plan, you might be confused about if it’s worth it to get it or not. Because everyone’s financial circumstances and oral health demands are different, there is no general answer.
In general, you should compare the expenses of a dental plan to the costs of your regular annual dental treatment. Examine the expenses of twice-yearly cleanings, X-rays, fillings, and other standard dental care at your dentist’s office. Then, compare these prices to the rates for other dental insurance. Remember that you may be eligible to deduct your insurance costs when filing your taxes.
When selecting whether or not to purchase your own policy, you should also evaluate your general oral health. With a history of dental problems, it will almost certainly be worth the money to get the comfort and monetary relaxation that comes with coverage. If you have Medicare, keep in mind that dental work is only covered if it is medically required.
Things to consider before buying a dental insurance plan
It is a no-brainer if your job provides dental coverage. It is usually less expensive than purchasing a policy on your own. If you’re looking for a plan on your own and already have a dentist, he or she may be able to recommend one based on your dental history.
When comparing plans, look for the following details:
- Whether or not your dentist and any specialists you might require are part of the plan’s network
- Premiums, co-pays, and deductibles are all included in the plan’s annual costs.
- If there is one, there is an annual maximum out-of-pocket limit.
- Pre-existing condition restrictions
- If braces are required or expected, coverage is provided.
- Coverage for merged treatment, including therapy while you’re away from home
- Whether you have the option of choosing your own dentist
- Who has the final say on treatment: you and your dentist or the dental plan?
- Is the plan comprehensive in terms of diagnostic, preventive, and emergency care, and how much does it cost?
- What types of standard treatments are covered?
- What types of critical dental services are covered?
- Whether you will be able to see the dentist when you need to and set up appointment times that are convenient for you
- Who is eligible for the plan’s coverage, and when will coverage begin?
Last but not least, don’t put off shopping for dental insurance. As previously stated, most plans have a waiting period of up to a few months before coverage begins, so the sooner you get a policy, the sooner you may begin enjoying your dental benefits.
Costs of dental insurance plans
When looking for insurance that is perfect for you and matches your budget, there are a few things to think about:
- The cost of dental insurance varies. Dental charges typically range from $20 to $60 per month; however, this varies a lot depending on your plan and even where you reside.
- Benefits may be covered at various levels of coverage. Routine cleanings, for example, are frequently covered with no out-of-pocket charges. Following that, some plans may cover 80% of the expenses for specified procedures, such as dental fillings, leaving the policyholder responsible for the remaining 20% when the yearly deductible is met. Other policies may only cover 50% of major operations, such as implants, leaving you to foot the expense for the other half. Uncovered operations, such as orthodontics will be charged in full.
- Annual coverage limits may apply to dental policies. If your plan’s maximum coverage is reached, you’ll be responsible for any additional dental charges above that amount. If your plan’s coverage maximum is $2,000, for example, you’ll be responsible for the rest of the year’s charges after your plan has paid $2,000 in dental benefits.
- There may be time limits in place. Some dental plans only cover particular procedures, such as fillings or X-rays, once a year or every few years. So, if you need a lot of dental treatment done upfront, you might not get all of your benefits right away. If you need the operations right away and can’t wait, you may have to pay out of pocket.
Orthodontic dental plans
Orthodontic treatment, such as braces and other teeth-straightening procedures, can be costly, and not all dental insurance policies cover braces. Consider the following while looking into different types of dental insurance for orthodontic treatment:
- Is orthodontic treatment covered? The plan’s details should specify which services are covered and which are not. Some dental plans have a cap on how much they will pay out in a given year. Examine any plan limitations and how they can affect your expenditures if you expect to need expensive orthodontic services.
- Is there a network of providers that you must use as part of the plan? If you have a preferred orthodontist, check to see if they take your plan; otherwise, their treatments may not be covered.
- Are there any age restrictions in the plan? Some insurance policies only cover orthodontic treatment until you reach a particular age.
As you’re shopping for a dental insurance policy, ensure that your current dentist accepts the plan you’re considering (unless you’re willing to switch dentists). Licensed insurance brokers like eHealth make it easy to search for plans that have your current dentist in-network. You can start browsing dental insurance plans using eHealth’s plan finder tool or find individual and family plans that include dental coverage.
Before enrolling in any dental coverage, be sure to read the fine print to make sure you understand what you’ll be responsible for paying out of pocket, what’s covered versus what’s not, and what your deductible will be. You can save money by only buying what you need; stand-alone policies these days are very customizable to suit your needs and budget. If you like, eHealth’s team of knowledgeable licensed insurance agents can walk you through your options. Just give us a call during business hours to get personalized help.
On a final note, don’t put off shopping for a dental insurance plan. As mentioned, most plans have a ‘waiting period’ of up to a few months before coverage will officially kick in, so the sooner you purchase a policy, the sooner you can start using your dental benefits.