Top 5 Signs You Picked The Wrong Dental Insurance

By Insurance Industry Expert & Author
Updated on

Small Scope of Coverage

Are you insured but your out-of-pocket costs for dental work are sky-high? Below is a list of five factors that may be contributing to the situation and point to the need for different dental insurance.

Dental plans differ in what services they cover. Most will pay for preventive care, such as annual cleanings and x-rays. Basic care such as fillings and tooth extractions is also covered by a great number of plans. The coverage of more expensive care is a more complicated matter. Some care, such as braces and cosmetic dentistry, are usually excluded from the services for which the dental plan will pay. Other expensive services such as crowns and implants be:

  • Covered
  • Covered but require a waiting period before you can use the coverage
  • Totally uncovered

It can be difficult to know what your dental needs will be in the future, so it is recommended that consumers consider full coverage dental insurance. If this is not an option for your budget, you should talk to your dentist about services you may need in the coming year and shop for a dental plan that covers those services and charges out-of-pocket fees that are reasonable for your budget. A dental plan with a small scope of coverage may result in you paying more out-of-pocket for your dentistry than the plan pays.

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Waiting Periods on the Services You Need Now

A dental insurance waiting period is a minimum period of dental plan enrollment before the enrollee is covered for a specific procedure. For example, a dental plan may say it has a 12-month waiting period for major care. This means that you need to be in the plan and paying premiums for an entire year before the dental plan will pay for services it labels are major care (e.g. crowns, implants, root canals, etc.).

If you need a certain dental procedure now but your dental plan has a waiting period, it can be a complicated situation. You need to ask yourself questions such as:

  • Can I responsibly delay the procedure until my plan's waiting period expires?
  • Is there a local dental plan I can afford that covers the procedure immediately and can have coverage active soon after I apply for the insurance?

A waiting period in and of itself is not the sign of bad insurance but it can be a sign of an insurance mismatched to your personal oral health needs.

Low Maximum Benefit

Most dental plans have a limit on how much the insurance company will pay each year toward a single enrollee's dental care. This limit is called the plan's "maximum benefit." Any cost of dental care that exceeds the annual maximum benefit is paid 100 percent out-of-pocket by the patient. Expenses counted against the maximum limit reset at the beginning of each plan year.

Maximum benefits vary significantly among dental plans. They may be very low such as $500. There are some limits that are quite high, such as the NCD Nationwide 5000 Plan, which has an annual limit of $5,000. HMO dental plans do not have maximum limits in most cases but they only cover dental care provided by dentists in their networks and these networks can be small (see below or our article HMO dental insurance).

If your current oral health requires substantial dental work, be careful to find a plan whose maximum benefit matches your need. If none exist in your area, you have some options:

  • Investigate a dental discount card where you can receive reduced price dental care with no limits on the amount of care or discounts you receive
  • Investigate whether your dentist accepts any HMO dental plans

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High Cost Sharing

Too many consumers shop dental insurance based on premiums alone when out-of-pocket costs for dental care may be a bigger expenditure across the length of a year. Dental plans have three main forms of out-of-pocket costs (also known as “cost sharing”):

  • A deductible
  • Copayments
  • Co-insurance fees

A deductible is the amount of money dental plan enrollees must pay toward their dental services before the dental plan will begin to contribute. For example, if a dental plan has a $100 deductible, an enrollee will pay the first $100 dental expenses and, after this, the insurance company will begin to contribute toward the cost of care. Most dental plans have low deductibles (many charge $50-$100 deductible per enrollee) and the deductible may be waived in the case of preventive care like annual teeth cleaning.

Co-payments are a fixed fee (such as $50) for a given service. Co-payments make it clear what an enrollee will pay for their care. In contrast, there is the co-insurance fee. A co-insurance fee is a charge to the patient that represents a percentage of the total cost of the dental procedure not paid by the insurance plan. If a plan pays 75 percent co-insurance on a $1,000 crown, the patient has an out-of-pocket fee for the remaining 25 percent ($250) toward the crown cost.

Some dental plans have very high out-of-pocket costs. As mentioned earlier, out-of-pocket costs can exceed the cost of dental insurance premiums and should be a major consideration when choosing a dental plan. If the plan you have has high out-of-pocket costs, it’s time to compare cost-sharing from other dental plans.

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Narrow Dentist Network

As healthcare researcher Kev Coleman says, “Dental insurance is only as good as the dentists that accept it.” A dental plan with a narrow network of dentists may force you to:

  • Stop using your preferred dentist
  • Travel far to reach the office of the nearest in-network dentist
  • Use a dentist whose quality is below your expectations

Given the importance of dentist quality with respect to the maintenance of good oral health, it's a bad idea to use insurance that restricts you to a dentist you don't like or a dentist so far away that appointments are an inconvenience.

What To Do If You Have The Wrong Insurance For Your Needs

If you think you have the wrong dental insurance, it's time to explore next steps. Immediately changing plans is not necessarily the right decision. First you need to:

  • Compare dental plans in your area to find options that have the benefits, out-of-pocket costs, dentist network, and annual limits that match your needs
  • Match your last day of coverage on your old plan to the first day of coverage on your new plan so there is no lapse of coverage during your transition

If there are no options in your area that meet your needs, you can explore nearby dental schools that provide reduced-cost treatment or local dentists that negotiate affordable rates for patients without dental insurance.

Need help choosing a plan? Call us at 800-296-3800

Our knowledgeable customer service team will assist you with any questions you may have prior to enrolling in a dental plan. They can guide you through the process of choosing coverage that matches your needs as well as your budget.

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