What Does Dental Insurance Cover?

A dental plan is a type of insurance designed specifically to cover procedures and services related to your teeth. Dental plans are usually purchased separately from your regular health insurance, which often doesn’t cover dental services.

Read on to get a better idea of what dental insurance covers and how you can find a plan that works for you.

How Dental Insurance Works

Dental insurance covers part or all of the cost of covered treatments and procedures related to caring for your teeth and gums. 

You’ll pay a premium to your insurance company and, in exchange, your insurance company agrees to pay for covered dental care up to a certain amount. Like with health insurance, you’ll likely have a deductible plus coinsurance and copayments related to your dental plan.

You can also purchase a dental plan on your own. For instance, if you’re eligible for a Marketplace Health Plan, which is health insurance available under the Affordable Care Act, you can purchase a plan with dental coverage or a standalone plan. In the latter case, you must buy a health insurance plan at the same time.

Key Dental Insurance Terms

• Annual Maximum: This is the maximum amount your dental plan will pay for services each year. For example, if your annual maximum is $1,000, your plan will only pay up to $1,000 of covered services after your deductible.
• Coinsurance: Coinsurance is the percentage of the cost of a procedure you’re expected to pay. Your plan might pay 80% for a specified service, meaning you’ll need to cover the remaining 20%.
• Copayment: A copay, or copayment, is the fixed dollar amount you’ll pay for a specified service after you pay your deductible. For example, your plan might require a $20 copay for a dental office visit. 
• Covered Services: The list of dental procedures, tests, and services your dental plan covers.
• Deductible: This is the amount you’ll pay out-of-pocket for dental service before your insurance kicks in. Preventive care like teeth cleaning is often covered even if you haven’t met your deductible.
• Waiting Period: You may have to wait a certain amount of time after joining a dental plan before you can use certain benefits, known as a waiting period.
• Out-of-pocket maximum: This is the maximum amount you could spend on covered services with your plan. If you spend up to the out-of-pocket maximum, your plan will cover 100% of the cost of covered services for the rest of the year.

Pay careful attention to a plan’s annual maximums and waiting periods when comparing plans and premiums. For example, if you need immediate care, you may want to consider a dental insurance plan that has a shorter waiting period, instead of one that has a one-year waiting period.

Types of Dental Plans

The most common dental plans include:

• Dental indemnity plans
• Dental preferred provider organization (PPO)
• Dental health maintenance organization (DHMO)
• Dental discount plans

Dental Indemnity Plans

Also known as a fee-for-service plan, dental indemnity plans are non-network dental insurance. There are usually no restrictions on which dentist you can visit. 

Your plan pays for covered dental care (minus your deductible) at a percentage of the cost of the service. The exact amount of coverage is determined by your plan. Indemnity plans may have deductibles, waiting periods, and annual coverage maximums.

Dental PPOs

A preferred provider organization (PPO) uses a network of dentists who contract with your insurance company to offer dental services at discounted rates. Your dentist is paid on a fee-for-service basis by your insurance company after each visit. Dental PPOs typically have a waiting period before services will be covered.

You’re allowed to go to dentists outside of your PPO network, but you’ll likely have higher out-of-pocket costs.

Dental HMOs

Dental health maintenance organizations, or DHMOs, use a network of dentists to provide care. Your insurance company pays each dentist in the network a set fee per month. When you visit an in-network dentist, you’ll usually have to pay a fixed payment for care. Unlike dental PPOs, DHMOs usually don’t have annual coverage limits or waiting periods.

Dental Discount Plans

Dental discount plans or dental savings plans can save you money at the dentist, but they’re not insurance plans at all. A dental discount plan is offered by a third-party company that has partnered with a network of dentists. The partner dentists agree to discount their rates for members of the discount plan. These plans may even include cosmetic procedures.

Since dental discount plans aren’t insurance, there are no waiting periods or coverage limits.

Coverage for Different Types of Services

Dental benefits cover specific treatments and services. Your plan will outline what dental services are covered and the amount your insurance company will pay for each service. The covered services are usually broken down into three categories:

• Preventive care
• Basic services
• Major procedures

Your plan will specify what percentage of the cost of a service it will pay. For example, let’s say your plan pays 100% of preventive services, 80% of basic care, and 50% of major procedures. If you go to the dentist for a major procedure that costs $800 after your deductible, the insurance company would pay $400 and you’d pay the remaining $400.

Preventive Care

Preventive care services are designed to help prevent oral health issues. Most dental plans include the highest level of coverage for preventive services because maintaining healthy gums and teeth lowers your risk of needing more expensive procedures in the future.

Common types of preventive care include:

• Semi-annual Exams
• Regular Teeth Cleaning
• X-Rays
• Fluoride Treatment
• Sealants

Preventive treatments are often fully covered by dental insurance with no deductible—meaning there’s often no cost to you for preventive services.

Basic Services 

Basic coverage helps pay for the cost of routine, non-preventive dental care, such as:

• Fillings
• Tooth Extractions
• Root Canals

Many dental insurers structure plans to cover 80% of basic dental care. You’ll also need to cover your deductible and any amount over your annual maximum when getting basic care.

Major Procedures

Depending on your dental plan, you may have coverage for major procedures. You can expect to pay a higher coinsurance or copayment for these services. Major dental procedures usually include:

• Crowns
• Dentures
• Implants
• Oral Surgery

Many plans cover 50% of the cost of major procedures. However, you may have to go through a waiting period before you can get a major procedure completed.

Some dental plans cover orthodontics, which can cost thousands of dollars. If your annual maximum benefit is $1,000, you’ll likely still have to cover several thousand dollars out-of-pocket.

What’s Not Covered?

The specific services that are and are not covered vary by dental plan. For example, you might choose a preventive-only plan that pays for preventive care but not major procedures. However, most dental plans do not cover services that are considered cosmetic, such as teeth whitening or veneers, and many don’t cover orthodontics.

Frequently Asked Questions (FAQs)