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Dental Insurance 101

By Insurance Industry Expert & Author
Updated on

Intro to Plan Types & Savings

Contrary to popular belief, dental insurance is not exactly like your health insurance plan. There are some key differences that could cost you thousands in uncovered expenses if you ignore them. Likewise, you can save money and buy better coverage with a little education. In this article, you’ll find out:

  • What are your dental plan options
  • What dental coverage pays & doesn’t pay
  • The big issue about dentist networks
  • Waiting periods
  • Premiums & out-of-pocket costs

What Are Your Dental Plan Options?

While dental plans are not one-size-fits-all, they do have many common elements. They typically have benefits regarding:

  • A monthly premium
  • The number of teeth cleanings & x-rays they will pay for per year
  • The maximum amount the plan will pay for your dental care within a year
  • The cost sharing (e.g. copayments) for specific dental services

Since “the devil is in the details” in dental insurance, be certain to compare plans against one another and read the “Plan Details” for the options that interest you. Most importantly, consider the services you are most likely to use in the coming year (e.g. preventive care, cavity fillings) and compare the benefits, out-of-pocket costs, and restrictions on those services. Additionally, compare the same issues for services that are less likely but still possible. For example, teeth can crack unexpectedly and you should understand how extraction or crown costs vary among plans.

This is different than many forms of plans in the health insurance market. Medicare Advantage plans, for example, have a limit on annual pocket costs called a MOOP (maximum out-of-pocket). Unfortunately, dental plans are normally the opposite. Many dental plans have a maximum benefit around $1,500 a year, with some plans having higher or lower options. There are plans where the maximum amount will increase after a set number of years of enrollment have been completed. Such a plan may have a $1,500 maximum for the first four years of enrollment but, in the fifth year and after, have a $2,500 maximum benefit.

After the maximum benefit is spent by the plan, the enrollee is responsible for any remaining dental bills until the next plan year when the costs applied against the maximum benefit begins back at $0.

What Dental Coverage Pays & Doesn’t Pay

Always read the Plan Details (or “Summary of Benefits”) document before enrolling. This document lists the dental benefits of a plan and the rules about accessing this care. Dental plans are often more restrictive than health insurance plans with respect to the services they will cover. For example, they may limit teeth cleanings to one or two a year. They may also restrict dental sealants (used to prevent tooth decay) to permanent teeth in beneficiaries younger than 16 years old.

Aside from annual cleanings, most covered dental services come with an out-of-pocket cost. This cost may be a flat fee (e.g. $74 for a simple one-sided filling) or a percentage of the total service cost (e.g. 50 percent). Often major dental work is charged a percentage of the dental cost.

Some dental care may not be covered at all by a dental plan. For example, orthodontic care (such as braces for a child) may be uncovered. Given that dental benefits are not standardized, it pays to compare plan details rather than assuming they’re all basically the same coverage.

The BIG Issue about Dentist Networks

If a health insurance plan is only as good as the doctors and hospitals that accept it, the same can be said for dental coverage. In other words, if quality dentists don’t accept the coverage, how good is it? While the average dentist accepts 6 different dental insurers, it still means that you need to find if both your specific dental plan is accepted. For example, a dental practice may accept Humana’s DPPO plan but not their DHMO plan even though both plans are from the same insurer.

If you do not have a regular dentist or you’ve moved to a new area and need one, it is recommended that you investigate the reputations of your dentist choices. Once you find a preferred dentist and establish that he or she is accepting new patients, you can review your dental plan options to determine which ones include this dentist in-network. In-network care is very important because dental care received from a dentist who is out-of-network may be completely uncovered by your dental plan.

Most dental plans have DPPO networks. In a DPPO, you have in-network dentists that are covered by the plan but the enrollee does not have to pick a primary care dentist and the enrollee does not need a referral in order to visit an in-network specialist. In contrast, a DHMO does require an enrollee to select a primary care dentist and this dentist is responsible for approving referrals for specialist care. For more information on these two options, see DPPOs vs DHMOs: What’s the Difference?

Waiting Periods

Dental plans wish to avoid consumers who wait to buy dental insurance until they have a dental problem needing to be addressed. Consequently, many plans have “waiting periods” on major services (e.g. root canals, crowns, dentures). A waiting period specifies how long a person must be enrolled in the dental plan before the plan will pay for certain services. A waiting period can apply for some services but not others. For example, a dental plan may have no waiting period for preventive care such as a teeth cleaning and fluoride treatment but have a six-month waiting period before the plan would pay money towards oral surgery or a crown.

If you know you are in immediate need of major dental care, you should not enroll in a dental plan until you verify whether the care you need has a waiting period.

Premiums & Out-of-Pocket Costs

Most consumers with dental coverage receive it through their employer. For individuals who buy coverage on their own, the average dental plan costs $50 to $80 a month in premiums for single coverage. A family plan, given the increased number of beneficiaries, cost more. Deductibles average $100 for covered services. For those unfamiliar with the term, a “deductible” is the amount to be paid by the plan enrollee alone before the plan will begin covering a share of the cost for covered dental services.

Plans have a set amount that must be paid for dental care before the plan begins to share in the costs. This set-amount that precedes cost-sharing is known as the deductible. The average deductible for a dental plan is $50 to $100 according to Consumer Reports. Some services, such as preventive care, may not be subject to an annual deductible. Deductibles reset at the beginning of a plan year, which means they’ll need to be paid again each year you use dental insurance.

As mentioned earlier, most covered dental services come with a cost paid out-of-pocket by the plan enrollee. This cost may be a flat fee copayment or a percentage of the total service cost called a coinsurance fee.