How Does Dental Insurance Work?

Dental insurance policies help many people effectively budget for the cost of maintaining a great smile. Compared with medical insurance, understanding dental insurance policies is a breeze. Most policies are straightforward and specific regarding which procedures are covered and exactly how much you have to pay out of pocket. Dental insurance is available as part of medical insurance plans or as a stand-alone policy.

Overview of the System

First, here’s a breakdown of how private dental insurance works. You select a plan based on the 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 in the insurance company’s network, you’ll be able to opt for one of the less expensive plans.
• If you don’t have a dentist at all, you can choose from the dentists who are in the network and again have the option of a less expensive plan.
• If your existing dentist is not in the network, you can still get insurance, but you’ll pay significantly more to see your dentist than an in-network one—so much more that you may not have any chance at coming out ahead by being insured.

The 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 a month. This means that you’re spending $600 on dental costs each year even if you don’t get any work done.

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. Waiting periods for major work are typically longer and can be up to two years. These periods are set in place by insurance companies to guarantee that they profit off a new account and to discourage people from applying for a new policy to cover impending procedures.

Deductibles, Co-Pays, and Coinsurance

An insurance deductible is the minimum amount that must be paid before the insurance policy pays for anything. For example, if the deductible is $200, and the covered individual’s procedure is $179, the insurance does not kick in and the individual pays the entire amount. Co-pays, which are a set dollar amount, may also be required at the time of the procedure.

Once 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.

How Dental Insurance Categorizes and Pays for Procedures

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

Basic procedures are treatment for gum disease, extractions, fillings, and root canals, with deductibles, co-pays, and coinsurance determining the patient’s out-of-pocket expenses. Most policies cover 80% of these procedures, with patients paying the remainder. Major procedures such as crowns, bridges, inlays, and dentures are typically only covered at 50%, with the patient paying more out-of-pocket expenses than other procedures.

Every policy differs in which procedures are categorized as preventive, basic, and major, so it is 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 much more of the cost.

Patients who may need costlier procedures should pay particular attention to the details of dental insurance policies. For instance, a single dental implant can cost $3,000 to $6,000. Many basic dental insurance plans don’t cover implants, and those that do come with limits and exclusions. With that 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 any costs for cosmetic procedures, such as teeth whitening, tooth shaping, veneers, and gum contouring. Because these procedures are intended to simply improve the look of your teeth, they are not considered medically necessary and must be paid for entirely by the patient. Some policies cover braces, but those usually require paying for a special rider and/or delaying braces for a lengthy waiting period.

Yearly Coverage Maximums

While most medical insurance policies have yearly out-of-pocket maximums, the majority of dental policies cap the amount of annual coverage. Coverage maximums typically range from $1,000 to $2,000 per year. Generally speaking, the higher the monthly premium, the higher the yearly maximum. Once the yearly maximum is reached, patients must pay for 100% of any remaining dental procedures. Many insurance companies offer policies that roll over a portion of the unused annual maximum to the next year.

Applying Tax Credits for Dental Insurance

Any leftover tax credit not used to pay for your family’s health insurance purchased through Healthcare.gov may 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 tax credits to buy an additional plan.

Dental Insurance FAQs

Can tax credits be applied to dental insurance?

Yes and no. You may use tax credits for dental insurance if your plan doesn’t include children’s dental coverage. If the plan does include dental coverage, you may not use them to purchase an additional plan.

Does dental coverage cover cosmetic treatments?

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

Is there a limit to your dental benefit each year?

Yes, most plans cap out at $1,000 to $2,000 a year for benefits. Once that limit is met, patients pay 100% of their dental costs.

Is my annual exam covered by dental insurance?

Most plans cover routine procedures such as exams, tooth 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 deductible?

Your deductible is the minimum cost that must be paid by the patient before your dental benefits kick in. In a plan that covered routine maintenance exams, your deductible would begin with any restorative work completed. After the deductible is met, your insurance should pay the established percentage of any further bills.

Do I have to choose a dentist within my network?

To use your dental benefits, you must use an in-network dentist. Check to see if your current dentist is covered by your plan before signing up.