How does dental insurance work?


Dental insurance policies help many people effectively budget for the cost of maintaining a beautiful smile. Compared to medical insurance, understanding dental insurance policies is a snap. Most policies are simple and specific regarding the procedures covered and the exact amount you have to pay out of pocket. Dental insurance is available as part of medical insurance plans or as a stand-alone policy.

Key points to remember

  • Dental insurance covers problems with teeth and gums, as well as preventative care such as annual cleanings.
  • Not all procedures are covered; for example, cosmetic procedures, such as crowns or bleaching, are not.
  • Deductibles, co-payments and coinsurance will apply, and many policies have relatively low annual coverage limits, ranging from $ 750 to $ 2,000 in many cases.

System overview

First, here’s a breakdown of how private dental insurance works. You select a plan based on which providers (dentists) you want to be able to choose from and what you can afford to pay.

  • If you already have a dentist you like and they are part of the insurance company‘s network, you may be able to go for one of the cheaper plans.
  • If you don’t have a dentist at all, you can choose from the dentists in the network and again have the option of a cheaper plan.
  • If your current dentist is not in the network, you can still purchase insurance, but you will pay a lot more to see your dentist than a dentist in the network – so much more that you might not have a chance to go. go out being insured.

Monthly premiums will depend on the insurance company, your location, and the plan you choose. For many people, the monthly premium will be around $ 50 per month. This means that you spend $ 600 on dental expenses each year, even if you are not doing any work.

Waiting period for dental insurance

Most dental insurance policies provide waiting periods ranging from six to 12 months before standard work can be performed. Waiting times for major work are generally longer and can be up to two years. These time limits are put in place by insurance companies to ensure they get a new account and to discourage people from taking out a new policy to cover impending proceedings.

Deductibles, quotas and coinsurance

An insurance deductible is the minimum amount that must be paid before the insurance policy pays anything. For example, if the deductible is $ 200 and the covered person’s procedure is $ 179, the insurance does not take effect and the person pays the full amount. Copays, which are a fixed amount, may also be required at the time of the procedure.

When a dental deductible is met, most policies only cover a percentage of the remaining costs. The remaining balance of the bill paid by the patient is called coinsurance, which typically ranges from 20 to 80% of the total bill.

The costs and necessary procedures may also differ depending on the age of the patient. Seniors on Medicare, for example, will have a different definition of what constitutes the best possible dental insurance than other age groups.

Most dental insurance plans follow the 100/80/50 payment structure: they pay 100% for preventive care, 80% for basic procedures, and 50% for major procedures.

How dental insurance categorizes and pays for procedures

Dental procedures covered by insurance policies are generally grouped into three categories of coverage: preventive, basic and major. Most dental plans cover 100% preventative care, such as annual or semi-annual office visits for cleaning, x-rays, and sealants.

The basic procedures are treatments for gum disease, extractions, fillings and root canals, with deductibles, co-payments and coinsurance determining the patient’s personal expenses. Most policies cover 80% of these procedures, with patients paying the rest. Major procedures such as crowns, bridges, inlays and dentures are usually only covered at 50%, with the patient paying more in fees than for other procedures.

Each policy differs with regard to the procedures classified as preventive, basic and major. It is therefore important to understand what is covered when comparing policies. Some policies classify root canals as major procedures, while others treat them as basic procedures and cover the cost much more.

Patients who may need more expensive procedures should pay close attention to the details of dental insurance policies. For example, a single dental implant can cost anywhere from $ 3,000 to $ 6,000. Many basic dental insurance plans do not cover implants, and those that come with limitations and exclusions. With this in mind, many consumers choose dental insurance that will cover implants.

Dental insurance does not cover cosmetic procedures

Most dental insurance policies do not cover the costs of cosmetic procedures, such as teeth whitening, tooth shaping, veneers, and gum reshaping. Because these procedures are simply aimed at improving the appearance of your teeth, they are not considered medically necessary and must be paid for entirely by the patient. Some policies cover orthodontic appliances, but these generally require payment of a special endorsement and / or deferral of braces for a long waiting period.

Annual coverage maximums

Although most medical insurance policies have annual maximum amounts, the majority of dental policies cap the amount of annual coverage. Coverage limits generally range from $ 1,000 to $ 2,000 per year. As a general rule, the higher the monthly premium, the higher the annual maximum. When patients reach the annual maximum, they must pay 100% of all remaining dental procedures. Many insurance companies offer policies that carry over a portion of the unused annual maximum to the following year.

Claiming tax credits for dental insurance

Any remaining tax credit that you do not use to pay for your family’s health insurance purchased through can be applied against pediatric dental insurance premiums if your medical insurance policy does not include dental coverage. . If your health insurance policy includes dental coverage for children, you cannot use the tax credits to purchase an additional plan.

Can tax credits be applied to dental insurance?

Yes and no. You can use tax credits for dental insurance if your plan does not include dental coverage for children. If the plan includes dental coverage, you cannot use them to purchase an additional plan.

Does dental coverage cover cosmetic treatments?

No. Cosmetic dentistry such as veneers or adult orthodontic appliances are generally not covered by insurance.

Is there a limit to your dental benefit each year?

Yes, most plans cap at $ 1,000 to $ 2,000 per year for benefits. When this limit is reached, patients pay 100% of their dental costs.

Is my annual exam covered by dental insurance?

Most plans cover routine procedures such as exams, teeth cleaning and x-rays 100%.

Can I use my dental insurance immediately?

Most dental policies require a waiting period of six to 12 months for all restoration work. Routine examinations and cleanings should be covered immediately.

What is a franchise?

A deductible is the minimum cost that must be paid by the patient before your dental benefits take effect. Under a plan that covered routine maintenance exams, your deductible would start with any restoration work done. Once the deductible is reached, your insurance must pay the established percentage of any other bill.

Should I choose a dentist within my network?

To use your dental benefits, you must call on a dentist from the network. Check if your current dentist is covered by your plan before signing up.


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