For many people, regular dental care is often placed low on the list of health care priorities – you’ll get to it when you get to it, right?
But your oral health is a big part of your overall well-being. In fact, studies show that gum disease can be linked to chronic conditions like heart disease, diabetes and more. This is a big deal, especially when you consider that the Centers for Disease Control and Prevention estimates that nearly half of all Americans over 30 years old show signs of gum disease.
Regular dental care is a must. But even if you have dental insurance, or you’re thinking of getting it, you still have to pay something, right? Let’s talk about factors that affect dental coverage, how dental insurance works and questions to ask when shopping for a plan.
What does dental insurance cover? It depends on the plan and the type of dental service
Your plan may cover a different percent of the cost of dental care services, depending on whether they’re considered preventive, basic or major.
Dental insurance plans typically cover preventive care services, like checkups, X-rays and cleanings. Depending on your plan, it may also cover a set percentage of the cost of other services.
Most insurance carriers take what’s known as the 100-80-50 approach to coverage. This means:
- 100% coverage for preventive dental care
- 80% coverage for basic dental care
- 50% coverage for major restorative dental care
Dental plans also have a maximum dollar amount that they’ll pay toward your care each year (often between $1,000 and $2,000).
Still, the covered services and amounts can vary by plan. So, make sure to check out the plan details when choosing a plan (more on that later in this post).
Types of dental services and how they’re covered
Before diving into the types of dental services, a good place to start is routine dental care. The good news is that by keeping up with your preventive care (which is usually covered at 100%), you’re less likely to need basic or major restorative care, but if you do, your dental plan is there to help. Here’s more about preventive, basic and major care and the types of procedures that fall within each of the categories:
Preventive dental care
Preventive care refers to a specific type of dental service that aims to prevent and diagnose disease and disfunction. These dental services help you maintain better oral health and avoid future problems. Most dental insurance plans cover a minimum of two preventive visits per year at 100%, but some offer more.
Coverage for preventive care expenses is one of the reasons why dental insurance is worth it. You’ll typically make up for the cost of the premiums just by going to your preventive care appointments. And if you need additional dental care each year, it could likely be more expensive than you think. The good news is that having dental insurance can provide savings.
What kind of dental services are preventive?
- Oral checkups and screenings
- Routine X-rays
- Cleanings and fluoride treatments
- Sealants to protect back teeth
Basic dental care
Basic dental care treats damage that has already happened, like cavities and gum issues. So, does that mean insurance covers fillings? Does insurance cover crowns? Yes, but it depends. Basic care is just that – basic! If you need more extensive work to restore your teeth, that can mean major restorative care.
Basic dental services
- Fillings
- Simple extractions (non-impacted)
- Treatment of gum disease (periodontics)
- Root canals (endodontics)
Major dental care
Does insurance cover dentures or wisdom teeth removal? Yes – and these are just some of the dental services often considered major restorative care. This type of dental work requires more complex or extensive procedures.
Most dental insurance plans will pay about half of the cost of major restorative care.
Major dental services partially covered
- Crowns
- Implants
- Bridges
- Dentures
- Complex extractions (impacted)
- Oral surgery
Does dental insurance cover braces or Invisalign?
Orthodontics is a specific type of dental service that assists with correcting or readjusting tooth alignment. Think braces, Invisalign®, and retainers. These services typically aren’t covered on individual or family dental plans. Group dental plans, like the kind you get at work, sometimes include orthodontics. But even then, an employer must elect to make orthodontic coverage available to employees and their families. In some cases, orthodontic coverage may only be an option for covered children under 19 years old or another age.
If you have a plan that provides coverage, there will likely be a separate lifetime maximum amount that the plan will pay toward orthodontics.
Does dental insurance cover cosmetic procedures?
Cosmetic dental services, like teeth whitening, veneers and bonding, are all about aesthetics. These services better the appearance of your smile. Since cosmetic procedures aren’t a medical necessity in managing oral health, they’re typically not covered under dental insurance.
Choosing dental plan coverage: Things to consider
While there are many different types of dental plans, it’s best to start your search by narrowing down where you can get dental insurance. You might be offered a dental insurance option through your employer, or you can buy a plan on your own. It’s also important to know how dental insurance works and the questions to ask when choosing between plans.
How dental insurance works
When looking for a plan, it helps to know the language insurers use to explain the extent and limitations of your coverage. A better understanding of how dental insurance plans work can help you choose the best plan for you and help you get the most out of your benefits. Here are some terms you need to know.
Dental insurance premium
The monthly payment for your dental benefits. Your monthly premium typically goes up with the amount of coverage a plan provides.
Dental insurance deductible
A deductible is the amount of money you pay for dental care before your plan starts helping with the costs of basic and major care (usually preventive care is fully covered even before you reach your deductible). This deductible is usually pretty low – about $50 for an individual or $150 for a family each year.
Dental coinsurance
Coinsurance is the percentage you pay for a service after your deductible has been met. As mentioned above, many plans cover basic services at 80%. In this situation, once you pay your deductible, your insurance pays 80% of the remaining cost of care. The remaining 20% is up to you to pay as your coinsurance.
Dental insurance annual maximum benefit
Your annual maximum benefit is the total amount that a plan will pay for dental care within a specific benefit period – usually a calendar year. Annual maximum benefits reset each year and often range from $1,000 to $2,000 per person. Unless a patient needs extensive dental work, they do not usually meet their yearly maximum.
Questions to ask when looking for dental insurance coverage
If you’re looking for a dental plan that meets your needs, there are a lot of details to consider. Here are a few questions to ask.
What type of insurance plan is it (and how much coverage do I need)?
One of the most important things to consider is which services are covered by the dental plan. Is it a maintenance plan limited to preventive care and possibly a few basic services like fillings? Or is it a comprehensive dental plan that covers preventive, basic and major restorative care?
The amount of coverage you need may be different based on your health and preferences. A comprehensive plan provides the most coverage, but premiums tend to be higher. As such, plans with less coverage may save you money, assuming you don’t need major dental care.
Discount plans are also an option. These are not insurance plans. Rather, the discount plan simply gives you access to discounts on services at a set of participating dental clinics. Discount plans do not pay anything toward your care costs. Also, if eligible, you might be able to get coverage through a Medicare Advantage plan.
What can I expect to pay for dental coverage and care?
When choosing a dental plan, consider how it would cover both preventive care and unexpected dental care. While your teeth may look and feel perfect right now, things may change in the coming months. Even if you brush your teeth properly and floss every day, you can still get a cavity or need a root canal.
So, make sure you look beyond the monthly premium and select a plan that covers the things that are important to you. Be sure to compare the coinsurance rates and out-of-pocket maximums between plans.
Which dental services are included, excluded or limited?
The point of dental insurance is to keep your mouth (and body) healthy. That’s why insurance covers services that are tied to your overall health. For example, it usually covers the cost of preventive care, like check-ups and cleanings. It also helps with the cost of more expensive services like fillings, extractions and crowns.
Common exclusions are aesthetic services such as teeth whitening and braces (orthodontics). The reason these services aren’t covered is because they are more about your appearance than your health. Dental plans are also unlikely to cover athletic mouthguards, night guards and use of nitrous oxide.
As for limitations, you may need to follow specific timing for services, such as bitewing X-rays being covered one time per calendar year.
Which services are considered basic dental care versus major dental care?
Different insurance carriers may consider some services like root canals to be basic care, but other carriers may treat them as major care, so it’s important to pay attention to the coinsurance amount.
Knowing how a plan covers specific dental services can make a difference if you need to have expensive dental work done.
Will I be able to see my current dentist?
If you want to continue going to your current dentist, check to see if they’re in network. You can likely find out this information on the insurance carrier’s website or by calling member services. If your current dentist isn’t in your network, explore your new insurance’s network – you’re sure to find an in-network dentist near you.
What’s the dental plan’s waiting period for dental services?
Your dental waiting period is the amount of time you must wait before you’re able to receive benefits for specific, often expensive treatments like crowns, implants and oral surgery. Depending on the plan, this waiting period can range from six months to up to a year. However, most often, routine checkups and cleanings are covered immediately.
So, why are waiting periods often part of coverage? They are intended to prevent people from seeking insurance in response to learning of the need for a crown, root canal or similar, often urgent, dental procedure.
Waiting periods can sometimes be waived if you’re able to show you’ve had continuous coverage between a prior dental plan and the new plan you have switched to.
Have more questions about dental insurance?
If you have questions about your current dental plan, contact your insurance carrier. If you’re looking for an affordable plan for yourself or family, let us know. Our experts are ready to help you find a dental plan that fits your needs.