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How Dental Insurance Works

9 November, 2021

Most people have dental insurance, but not everyone understands it. That’s nothing to be ashamed of – the insurance industry is full of jargon and confusing terminology. Nevertheless, it’s important that you take the time to understand the insurance you have, what it covers and what it doesn’t, because this can end up having a big effect on the amount you pay for dental services.

In this article, we’ll give you a quick-fire guide to dental insurance. We’ll explain what the key terms mean, and what you should look for in dental insurance.

What is Dental Insurance?

Dental insurance is just like health insurance, but it covers dental care. The specific procedures and treatments covered by dental insurance vary a lot between plans, but most plans include a basic range of treatments – x-rays, cleanings, and routine exams. More advanced plans cover a more extensive range of services like fillings, extractions, root canal treatments, and maybe even orthodontics.

How much dental insurance costs depends a lot on your circumstances. Some people receive dental cover via their employer, others decide to buy a policy for themselves. Some people prefer to opt for a minimal plan and pay for their treatment as it is needed, others pay a higher monthly premium in exchange for lower per-treatment costs.

Whichever route you decide to take, it’s important to understand what your dental insurance covers, and what it doesn’t, because that could save you facing a large unexpected bill.

Types of Dental Insurance

There are three main types of dental insurance plan, and which you have will determine which dentists you can see. Here they are:

  • Preferred Provider Organization: PPO plans offer you a range of dentists who will accept the plan, and these are known as “in-network” healthcare providers. With a PPO plan, your insurance company will pay the most toward your care if you visit one of the dentists on this list. It’s possible to see a dentist who is out of network, but you may have to pay more.
  • Dental Health Maintenance Organization: DHMO plans provide a list of dentists who will treat you for a set fee, but you have to use one of the dentists on the list. Otherwise, you are not covered at all, and you will have to pay for your treatment out of pocket.
  • Discount Plans: Discount plans are the most basic type of dental insurance. In this type of plan, a company will provide a list of dentists who will offer you a discount on their services, but you insurance company won’t pay anything toward your care.

Whichever type of plan you have, the first step in finding a dentist is to look for one who is covered by your insurance. That way, you will minimize the amount you have to pay out of pocket.

How Does Dental Insurance Work?

Once you have a plan and know what type it is, you can start to estimate how much you’ll have to pay when you visit the dentist. Unfortunately, this is easier said than done. That’s because there are hundreds of dental plans, and each one can have complex rules governing what the insurance company covers. Most plans have a “benefit year”, for instance, which determines when and how you can use the benefits of the plan.

A responsible dentist, however, will always give you their best estimate of what you’ll have to pay for the treatments you receive. Once the treatment is complete, your dentist will send a request for payment to your insurance company, and they will review this. If necessary, they will then send you a bill.

What Do Dental Insurance Terms Mean?

Beyond this basic description, the amount you will need to pay for dental treatment is determined by the details of your insurance plan. These details may include some of the following terms:

  • Deductible – An amount you must pay before the insurance company will pay anything.
  • Coinsurance – once the deductible is met, you may have to pay a percentage of the cost of covered treatment, for example, you may have to pay 50% of a major procedure.
  • Co-pay – a fixed cost for a certain procedure.
  • Annual Maximum – the maximum amount the insurance company will pay during the benefit year. Once that maximum is reached during a benefit year, you pay all additional expenses.
  • Preauthorization – some plans may require approval from the insurance company before treatment is done in order for the plan to pay benefits.
  • Exclusions – services and/or products that insurance won’t cover.
  • Waiting period – some plans won’t cover certain procedures until a certain amount of time has passed. These are usually major procedures like teeth replacement or crowns.
  • Limits – many plans have time limits for certain procedures. For example, many plans will cover two cleanings a year, as long as six months have passed between them. Limits may also apply to the frequency of x-rays and to treatments on a specific tooth.
  • Pre-existing conditions – some plans won’t cover conditions that you had before signing up for their plan, meaning you will be responsible for paying for treatment for that condition.

The ways in which these terms interact can be complicated, however. For that reason, it’s important to ask your dentist for their best estimate as to the cost of your treatment. A responsible dentist will always provide as much information as they can about this cost.

The Bottom Line

Ultimately, dental insurance is an important part of your health coverage. By helping you to pay for preventative dental services (such as cleaning and whitening) dental insurance can reduce the need for more serious procedures in the years to come.

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