What Dental Insurance Does and Does Not Cover

Dental insurance plans are complex, confusing and completely different from policy to policy. If you’re unsure what your coverage options are, your dentist office should be able to do a price check before starting a service. More than 50% of American adults with private health insurance use dental insurance to pay for some or all of their oral care procedures. Let’s take a look at what dental insurance does and does not cover to help you plan for upcoming expenses.

Dental Insurance Basics – How Dental Insurance Works

Every dental insurance plan is unique. In fact, two plans from the same insurance provider could have vastly different coverage options. The basic elements are the same, but the upfront and out-of-pocket expenses may different considerably. Here is a general overview of how dental insurance works:

  1. You pay a monthly premium for dental insurance coverage. For most Americans, this is taken out of their paycheck, along with health insurance premiums and taxes. If you pay for your own dental insurance without an employer, you’ll pay that premium directly to the provider.
  2. You’ll complete a waiting period before coverage kicks in. Coverage for dental exams and teeth cleanings may be available right away, but other services may need to wait at least six months after the policy start date.
  3. You choose a dentist to work with. This may be an in-network or out-of-network dentist. See the next section for more info.
  4. Preventative care is usually free, but other services cost money. This means that you can get teeth cleanings and oral exams every six months without being charged, but other services will have a cost based on your coverage plan.
  5. You may need to meet a deductible before insurance covers costs. This will be an amount of money you must pay out-of-pocket for services before your insurance will start to cover partial expenses.
  6. You may be billed for extra expenses after your dentist office files an insurance claim. This is often the case when a policy’s parameters aren’t clearly outlined. The dentist office may not charge you at the time of service, but that doesn’t mean you won’t be charged at all.
  7. Coverage may vary once you meet your annual or lifetime limitations for dental insurance. We’ll explain more in the next sections.

In-Network Dentist vs. Out-of-Network Dentist

An in-network dentist has a working relationship with your insurance company. They have pre-established rates for select services, so they know what to charge you at the time of and what to bill your insurance company for.

Out-of-network dentists may offer the same services, but they will usually require you to pay for the services upfront and get reimbursed by your insurance company. In other words, the dentist waits for an insurance refund in an in-network relationship, but you’ll wait for the refund in an out-of-network relationship.

Annual Limits vs. Lifetime Maximums

The annual limit for dental insurance is the maximum amount of money your dental insurance will cover for the year. If you’re just getting routine cleanings, you’ll likely never reach these limits. If you’re getting crowns, dental bonding, oral surgery, etc., that number might dictate which procedures you do each year.

Lifetime maximums represent the total amount your dental insurance will cover for the lifetime of the policy. This is a much larger number than your annual limit, but it may impact your coverage if you’ve had the policy for multiple years. Again, this mostly applies to patients who need extensive dental work done.

What Most Dental Insurance Plans Cover

Most dental insurance plans will fully cover routine dentist visits, unless you’ve reached your annual limit for the year. They will also cover some or all of the cost for preventative dental care, such as fillings, tooth extractions, crowns and X-rays. The standard rule is 100-80-50: 100% coverage for routine care, 80% for basic procedures, and 50% for major procedures.

Your dental insurance may also cover some expenses for oral surgery, root canals, dentures, bridges, orthodontics, and anything that’s not considered cosmetic dentistry. Some services, like dental sealants for children, may be excluded from preventative dentistry coverage.

What Dental Insurance May Not Cover

Most dental insurance plans will not cover the full cost of anything beyond basic dental appointments. You should expect to pay some portion of the cost for anything outside of an oral exam and teeth cleaning. With this in mind, you can get a quote from your dentist office based on your coverage options. You may even be able to set up a payment plan for larger expenses to manage the cost over time.

Does Dental Insurance Cover Cosmetic Dentistry?

He short answer is no, most dental insurance will not cover cosmetic dentistry procedures. However, there is a blurred line between restorative dentistry and cosmetic dentistry in many cases. If a child knocks out two teeth in a sports injury, the prosthetics needed to restore his smile would be considered restorative. If someone gets a set of veneers to change the shape of their front teeth, those services would be cosmetic.

Once again, your dentist office can review the nature of your care plan to determine if your insurance would cover some of the expenses.

Does Dental Insurance Cover Braces?

Yes, most dental insurance will cover some portion of your orthodontics expenses. This includes invisible braces! The amount of coverage will be limited to your plan details, including the annual and lifetime limits. Your dentist can create an orthodontics plan that best aligns with your insurance, budget and goals.

How to Choose a Dental Insurance Plan That Fits Your Needs and Smile Goals

Typically, the more you pay for a monthly premium, the better your coverage will be. If you know you need some extensive dental work in the future, you may opt for a more expensive policy. You might also look into insurance riders that supplement a basic insurance policy.

If you have specific smile goals, such as invisible braces or dentures, you may compare plans that are targeted around those services. Coverage may be lacking in other areas to balance out the costs, so make sure you review the entire policy.

Verify what the waiting period is for each policy so you know when your coverage will kick in. This will also help you schedule your dentistry services and make a long-term plan for your smile.

Once you have dental insurance that balances your current and future needs, you can take the next steps in your smile journey. Here at Clinton Dental Center, we accept a wide range of dental insurance policies. We provide transparent pricing for our services and create custom care plans for every patient. If you’d like a consultation with a general dentist, cosmetic dentist, pediatric dentist or orthodontist in Southeast Michigan, please contact us at (586) 949-5363 to get started.