How does dental insurance work?


Dental insurance policies help many people effectively budget the cost of maintaining a beautiful smile. Compared to medical insurance, understanding dental insurance policies is a piece of cake. Most policies are straightforward and specific about 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 standalone policy.

Key points to remember

  • Dental insurance covers problems related to teeth and gums, as well as preventive care such as annual cleanings.
  • Not all procedures are covered; for example, cosmetic procedures, such as crowns or whitening, are not.
  • Deductibles, copayments, 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 can opt for one of the cheaper plans.
  • If you don’t have a dentist at all, you can choose from network dentists and again have the option of a cheaper plan.
  • If your current dentist isn’t in the network, you can still get insurance, but you’ll pay a lot more to see your dentist than an in-network dentist – so much more than you might have no chance of getting. go out with insurance.

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. That means you’re spending $600 on dental bills every year, even if you don’t do any work.

Waiting period for dental insurance

Most dental insurance policies have waiting periods ranging from six to 12 months before any standard work can be done. Wait times for major works are generally longer and can be up to two years. These periods are put in place by insurance companies to ensure that they benefit from a new account and to discourage people from taking out a new policy to cover impending proceedings.

Deductibles, copayments and co-insurance

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 come into effect and the person pays the full amount. Copays, which are a fixed dollar 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 required procedures may also differ depending on the age of the patient. Seniors with 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 preventative 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% of preventative care, such as annual or semi-annual visits to the office for cleaning, X-rays, and sealants.

Core procedures are treatments for gum disease, extractions, fillings, and root canals, with deductibles, copayments, and coinsurance determining the patient’s out-of-pocket 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 than for other procedures.

Each policy differs in terms of procedures categorized as preventative, basic, and major, so it’s important to understand what’s covered when comparing policies. Some policies classify root canals as major procedures, while others treat them as basic procedures and cover more of the cost.

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 between $3,000 and $6,000. Many basic dental insurance plans do not cover implants, and those that do 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 contouring. Since these procedures are simply to improve the appearance of your teeth, they are not considered medically necessary and must be paid for entirely by the patient. Some policies cover braces, but these usually require paying a special endorsement and/or delaying braces for a long waiting period.

Maximum annual coverages

Although most medical insurance policies have annual caps, the majority of dental policies cap the amount of annual coverage. Coverage maximums generally range from $1,000 to $2,000 per year. Generally, 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 next year.

Application of tax credits for dental insurance

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

Does dental coverage cover cosmetic care?

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

Is there a limit to your dental benefit each year?

Yes, most plans cap $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 at 100%.

Can I use my dental insurance immediately?

Most dental policies require a six to 12 month waiting period for any restorative work. Routine exams 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. In a plan that covered routine maintenance checkups, your deductible would start with any restoration work completed. Once the deductible is reached, your insurance must pay the established percentage of any other bills.

Should I choose a dentist within my network?

To use your dental benefits, you must use a network dentist. Check if your current dentist is covered by your plan before enrolling.


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