How Dental Insurance Works

Dental insurance provides benefits that can help protect you from the high cost of dental care. How dental plans work and what they cover, can vary significantly.

How does dental insurance work?

Dental insurance can help lower the cost for dental care that you would have to pay on your own if you didn’t have the plan. This is how most dental plans work:

  • You pay a premium. This is often a monthly amount you pay for having the dental insurance. If you get dental coverage through an employer it may be deducted from your pay. If you buy a plan on your own, you pay the monthly cost directly to the insurer.
  • There may be a waiting period. This means you may have to wait a maximum of 6 months before you’re covered for dental care that goes beyond preventive oral exams.
  • You may need a primary dentist. Some types of dental insurance coverage, may require you to choose a primary dentist. This is the dentist you will see for any problems and they will coordinate any specialized dental care you may need. Learn about Dental HMO vs. PPO plans
  • In-network or out-of-network? Depending on the plan you get you may or may not be required to see dentists in the plan network.
  • Frequency and limitations are important. These terms of dental coverage tell you what you’re covered for and not covered for. For example, you can get a no cost dental exam and cleaning once every 6 months. And you may only be covered for a limited number of different types of dental care and treatment, from basic to major care.
  • Your dental insurance may come with one or more deductibles. A deductible is the amount of money you must pay out-of-pocket for dental care before your plan starts to share those costs.
  • Other costs associated with your plan. Once you meet your dental deductible you and your plan start sharing a percentage of the costs for your dental care. This is called coinsurance. Your dental insurance may also have an annual maximum. This is the most your plan will pay for dental care in a plan year. After that you will pay any additional costs for care. Some plans also require you pay a small fee at the time of a dental visit. This is called a copay.
  • Preventive dental care is often no cost. This means you get an oral exam every 6 months, along with certain types of routine X-rays. Children may have more routine care provided as part of their preventive care. This is no cost to you as part of your dental insurance when you choose a plan with no cost preventive care.
  • Dental insurance coverage is broken down into certain types of dental care, such as preventive, restorative, orthodontic, etc. Depending on the type of dental plan you choose, you may have more or less coverage for certain types of dental care. This is why it’s important to plan ahead for the type of dental care you and your family might need. For example, if you expect to just need preventive dental care, maybe a basic dental plan that primarily covers preventive dental care is enough. If you expect to need things like crowns, root canals, bridges, implants, etc., then a dental plan that covers more specialized dental care and treatments may be better for you. Full coverage dental insurance may cost you more in monthly premiums, but it will also help control your out-of-pocket expenses for costly dental procedures.

How do you apply for dental insurance?

There are a couple of ways you can get dental insurance:

  • Your employer may offer you dental coverage as part of your employment benefits. If so, you can apply for that during annual open enrollment. There may be different types of dental plans you can choose from that can help cover the type of dental care you expect to need.
  • If your employer doesn’t offer dental insurance, or if you lose a job or work for yourself, you can buy a dental plan on your own. You can do this either through a state health exchange or directly from a health insurance company like Cigna.

What does dental insurance cover?

What your dental insurance covers depends on the plan you choose. Here are the types of coverage you may consider when shopping for a dental plan:

  • Preventive dental care: Most dental plans cover you for certain preventive care at $0 cost. This often includes a dental exam and cleaning every six months, as well as certain types of mouth X-rays. There may also be coverage for sealants, fluoride, and more for children.
  • Restorative care: This includes everything from fillings for cavities and tooth extractions, to root canals, crowns, bridges, dentures, and more. Treatments like these range from basic to major. The more complex and specialized your dental care, the more costly it may be. If you expect to need dental care that goes beyond your preventive dental exams, you may want to explore dental plans that offer you more coverage for restorative services like these.
  • Orthodontic care: This area of dental specialization is focused on correcting teeth and bite alignment. If you or a family member expect to need this type of dental care, look for dental insurance that includes coverage for orthodontic services.

What is not covered by dental insurance?

This depends on the type of dental insurance plan you choose. For example, dental services like bridges, crowns, dentures, and root canals may not be covered if you only buy a preventive dental plan. Here are some kinds of dental treatments that may not be covered:

  • Anything cosmetic, such as teeth whitening and veneers.
  • Orthodontic appliances such as braces, removable teeth aligners, or retainers may not be included in all types of dental plans. If you are looking for dental insurance with orthodontic benefits, be sure you understand the details of any plan you’re considering. For example, there could be differences in coverage for the orthodontist’s services vs. the coverage for the actual orthodontic appliances, like braces or retainers.

The key to making sure your dental plan covers certain types of treatment, is to plan ahead for the dental care you and your family expect to need.

Dental deductible, copay, and coinsurance explained

Here are the basic costs associated with most dental plans. You’ll want to make sure you understand them when choosing a plan:

  • A dental deductible is a set dollar amount you are required to pay before your dental plan starts to help pay. You will pay your dentist for any non-preventive dental care until you meet this plan deductible. Preventive dental care is covered 100% by most dental plans, so the deductible doesn’t apply to these plans.
  • Dental copays are fees you may have to pay when you visit a dentist. Usually you pay the copay at the time of the visit. It may count toward meeting your deductible.
  • Coinsurance is the term used to describe how you and your dental plan share costs, once you meet your deductible. In your dental plan details, coinsurance is often shown as a percentage of what you will pay vs. what your plan will pay. For example, a coinsurance of 80%/20% means the plan pays 80% of the costs and you pay 20%.

What are the benefits of having dental insurance?

The benefits of dental insurance can include:

  • Lower out-of-pocket costs for non-preventive dental care. Without dental insurance you end up paying the full cost for dental treatments and procedures. Your insurance company negotiates with the dentists in its network to offer you lower costs. This is how a dental plan helps protect you from the high cost of dental care.
  • $0 preventive dental care. Most dental plans cover you 100% for routine, preventive dental care. These plans include a dental exam, cleaning, and some X-rays every six months. For children it may also include fluoride and other pediatric preventive dental care.
  • Good dental health impacts other health, too. Good dental health can help you identify health problems before they become major. During your regular oral exam, your dentist not only cleans and polishes your teeth, but they also check your whole mouth, throat, and tongue for cancer and other potentially serious issues. Keeping teeth and gums healthy can also help avoid serious health problems like heart disease. For existing health problems, poor oral health can actually worsen things like diabetes and coronary artery disease.1

Sources:

1 Will taking care of my teeth help prevent heart disease?, Mayo Clinic, November 2020, https://www.mayoclinic.org/healthy-lifestyle/adult-health/expert-answers/heart-disease-prevention/faq-20057986#.

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