While more than 3 out of 4 Americans have dental insurance1, many don’t fully understand what dental insurance does and doesn’t cover. This quick guide to dental insurance can help you get a better understanding of how coverage usually works.
The purpose of dental coverage
Dental insurance is designed to help you offset the cost of your dental care and to help you maintain good overall oral health. That’s why we focus on preventive care to catch signs and symptoms of dental disease early. This could reduce the chance that you will need more complex treatment later.
If an issue does arise, dental insurance will usually help cover a portion of the treatment cost, so you don’t have to pay the full bill yourself. . This combination of preventive services covered at 100% and lower out-of-pocket costs makes dental insurance a valuable benefit.
What is covered: 100-80-50 coverage structure
The emphasis on preventive coverage and sharing of costs on other procedures is reflected in the structure for most dental insurance plans. As part of this structure, your dental insurance usually covers:
Be aware that a deductible — the amount you pay before your dental insurance kicks in — may apply to these services, although it is usually waived for preventive and diagnostic services.
What may not be covered
Select procedures: While it differs from plan to plan, some dental insurance may not cover select procedures such as orthodontia.
Cosmetic procedures: Coverage for cosmetic dental procedures like teeth whitening may not be covered by employer plans and is rarely covered by any type of dental insurance.
Pre-existing conditions: Some policies don’t cover certain pre-existing conditions such as missing teeth. If you had a condition before you got your dental plan, you may be required to pay treatment costs out of- pocket.
Additional plan information
These limitations may also apply to your dental insurance:
Waiting period: This is the period of time before you are eligible to receive benefits for all or certain dental treatments. Waiting periods are more common with individual plans2 but also apply to employer-sponsored plans in some industries. This can sometimes be waived if you prove you had no gap in your dental coverage before purchasing a plan.
Other restrictions: In addition to some procedures not being available right away, your plan may require time limits between services like fillings, crowns and bridges on the same tooth or fluoride treatments for children. For example, a policy may only pay for a full set of X-rays once every three years3.
Annual maximum: This is the total amount your dental insurance will pay for your coverage during a 12-month period. For instance, if your annual maximum is $1,500, you pay for all additional costs after your dental insurance has paid $1,500 for your care. However, only 2% to 4% of Americans typically exceed their annual maximums4.
Important terms to know
It helps to become familiar with the following terms to get a greater understanding of why some services are covered and others are not:
Copayment (also known as copay) : The patient’s share of payment for a given service. The copayment is usually expressed as a percentage of the dentist’s fee, but can be expressed as the enrollee’s preset share of payment for a given service.
Dual coverage: If you have coverage from more than one dental plan through a spouse, more than one job, both parents or other means, it is called dual coverage. While dual coverage does not double your coverage or pay more than 100% of expenses, it may help you reduce your out-of-pocket costs.
In-network dentist: Dentists who have agreed to accept pre-established costs for services, saving you money over an out-of-network dentist are referred to as in-network dentists. You will save the most by visiting a dentist in your plan’s network. In fact, a dentist participating in your plan’s network generally won’t be able to bill you for the difference between what they usually charge and the fee they have agreed upon with Delta Dental.
While there are many different options for dental insurance, most people have coverage through employer-sponsored plans. You can also purchase individual dental insurance or a dental discount plan, which offers discounts on treatment in exchange for a membership fee*.
For more details about what dental insurance covers, check the coverage on your policy or a policy that you may be considering. And learn more about the cost of dental care by using our Delta Dental Cost Estimator.
*There can be variations in available offerings and coverages from plan to plan. Check your plan for these details
Get additional resources from Delta Dental
Looking for more information? Delta Dental can help you learn how to keep your smile healthy with these articles:
1. 2018 National Association of Dental Plans Dental Benefits Report
2. 6 dental insurance plans no waiting period. Investopedia
3. Dental insurance coverage – WedMD
4. Is Dental Insurance Worth It – Money Under 30