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What Is Covered, What Isn’t Covered with Dental Insurance?

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dental insurance

Dental insurance helps to cover the costs of routine dental care and reduces the out-of-pocket expenses associated with dental care, but it doesn’t cover everything. It can also help you and your dentist detect signs of disease in the oral cavity before they become severe or painful.

Here’s a look at what dental insurance covers and doesn’t.

What is Dental Insurance, and How Does It Work?

Dental insurance is a type of health insurance that helps offset the cost of routine dental care. It usually works by reimbursing you for a percentage of your dental costs either after you’ve paid them out-of-pocket or as part of a pre-determined annual maximum.

Types of Dental Plans

There are four main types of dental plans:

  • Dental indemnity plans
  • Dental preferred provider organization (PPO)
  • Dental health maintenance organization (DHMO)
  • Dental discount plans

Dental Indemnity Plans

Indemnity plans, aka fee-for-service plans, are the most traditional type of dental insurance. With these plans, you can visit any dentist, and your insurer will pay a percentage of the costs based on a fee schedule (a list of retail prices for common procedures).

An indemnity policy can include deductibles, waiting periods, and yearly coverage maximums.

Dental Preferred Provider Organization Plans

PPO coverage is similar to indemnity coverage in that you’re free to visit any dentist. However, it is different from indemnity coverage in that there are lower out-of-pocket costs if you choose a provider within the PPO network.

A preferred provider organization (PPO) is a network of healthcare providers that have agreed to provide their services at discounted rates. If you visit an in-network provider, your insurer will often cover more of the costs, and you’ll pay less out-of-pocket.

Dental Health Maintenance Organization Plans

DHMOs only cover services provided by dentists who have contracted with your insurer. Your DHMO will likely provide you with a list of in-network dentists, or you can call your insurer’s member services department to ask for a referral.

A DHMO is like an HMO (health maintenance organization) but only covers dental care. Your dentist will typically be able to provide all the services you need within their office so that there are no out-of-network claims.

Dental Discount Plans

Discount plans are not insurance, but they can serve as a substitute for dental insurance in some cases. With discount plans, you pay an annual fee to access reduced rates on certain procedures from an established network of providers who have agreed to provide services at discounted rates. Unlike traditional dental insurance, there is no reimbursement.

What Does Dental Insurance Cover?

The types of procedures covered by dental insurance can vary significantly depending on the type of plan you have purchased. Your plan will specify which dental services are covered and how much your insurance provider will pay for each one. Overall, most dental insurance cover part or all of the costs of preventative care, restorative procedures, and orthodontic treatment.

The services covered are typically divided into three categories, namely:

Preventive care

Basic services

Major procedures

Many insurance firms utilize the “100-80-50” plan, which provides coverage for:

1. 100% of regular preventative care, such as tooth cleanings, dental examinations, fluoride treatment, X-Rays, and sealants

2. 80% of basic operations, including dental fillings, extractions, and root canals

3. 50% of all major surgeries such as bridges, implants, crowns, dentures, and oral surgery

What Isn’t Included in a Dental Insurance Plan?

The particular services covered in a dental insurance plan differ depending on the policy. For example, you may select a preventative-only plan that covers preventive care and not significant operations. However, most dental plans do not cover aesthetic procedures such as tooth whitening or veneers, and many do not cover orthodontics.

Frequently Asked Questions (FAQs)

Is there a deductible on dental insurance?

Yes, most dental plans require a co-payment for specific covered procedures. Many policies, however, do not need a deductible for preventative or diagnostic care, such as annual dental cleaning.

Will my dental insurance cover the therapy that my dentist has recommended?

Dental insurance policies cover a specific range of operations that vary depending on the plan. To avoid paying for the suggested treatment out of cash, check with your dental plan administrator and ensure that the operation is covered.

Is it possible to purchase dental insurance through the Health Insurance Marketplace?

Yes, both stand-alone dental policies and health insurance plans that include dental care are available on the Health Insurance Marketplace. You may, however, only get dental insurance through the Marketplace if you also purchase a health insurance plan.

Limitations of Dental Insurance Plans

Though dental insurance can be a helpful way to cover some costs associated with dental care, there are limitations to what these policies will and will not cover. It is also crucial to remember that dental insurance is not health insurance and will not cover any medical expenses incurred after an accident or illness.

Additionally, most dental insurance plans have annual caps on the total amount they will pay for procedures within a given year. Once you reach this cap, you will be responsible for any additional costs incurred. Finally, many dentists do not belong to a network, leading to out-of-pocket expenses if you choose to visit one who is not in-network.

Despite these limitations, dental insurance can be a helpful way to cover some costs associated with dental care. When considering purchasing a dental insurance policy, you should understand what is and isn’t covered, as well as the annual cap on benefits. Doing so can help you make an informed decision about whether dental insurance is right for you.

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