What does dental insurance cover?

Understanding the alphabet soup of dental insurance plans can be a difficult endeavor for most people. Two common insurance acronyms include PPO and HMO. Managed care plans are often either PPO or HMO, standing for preferred provider organization and health maintenance organization.

With PPO insurance plans, the companies negotiate fee schedules with dentists in exchange for the dentist being put on a list of “preferred” providers. Employers give the list to their employees to match them up with dentists who participate with the dental plan. Dental insurance can help people pay for dental treatment, but it has its limitations. Most insurance plans have a deductible of $50 to $100, pay only a specified percentage for each type of treatment, and have a yearly maximum amount of funds available for dental care.

Most PPO plans cover preventive care, cleanings, check-ups, protective dental sealants, x-rays, and fluoride treatment at 80-100%. Basic care, including root canal therapy, extractions, and fillings are usually covered at 80%. Major care such as crowns (caps), permanent bridgework, and full and partial dentures as well as periodontal (gum) care are often covered at 50%.

Many insurance companies have a yearly maximum of a $1000-$2000. Dental insurance is not cumulative, so if you don’t use it, you lose it.

HMO’s have received a barrage of negative publicity in recent years, primarily in the medical community, for dubious “gag” clauses in the contracts, bureaucratic snafus, and the limitation of appropriate care of patients by their physician. Due to the high overhead of most dental practices and very low reimbursement rates to the dentist, there are not many offices that accept dental HMO plans.
Dr. Michael Roizen, MD
Internal Medicine

If you are about to get a tooth repaired, you will soon learn that the guy who is making your teeth feel good, if you had a toothache, or bad if you didn’t, wants to get paid for his time and the products he uses. That’s when you will want to learn real fast about dental insurance and if you can pay for it retroactively. Well, not so fast -- like so many things in life, it depends. Based on the plan that you choose or your employer provides, coverage varies as much as seasonal fashion trends. Some plans are very “bare bones” and may only cover a percent of even dire dental emergencies (that curve ball that went straight to your mouth instead of the bat). Other plans may cover a great percent of routine dental care, like twice-a-year visits to your friendly dental hygienist and your equally friendly dentist. Still other dental benefits (insurance) plans may include emergency care, routine care, and preventive treatments like fluoride, sealants and x-rays.

The only way to get a clear-cut answer is to check in with your benefits office (if your dental benefits come through your employer) or with the membership services number on the back of your dental benefits card.
Dental insurance can cover many services at various benefit levels or very few services at 100% if you go to a dentist who participates with your carrier.

There are HMO type plans in which the patient must see a specific dentist. HMO type plans usually have diagnostic, preventive and sometime basic services covered at no additional copay, beyond the minimal per visit copay. In this type of plan more involved procedures such as root canal treatment, gum treatment, crowns and partials have copays that are significantly less than usual fees, but still may be several hundred dollars. There is usually no yearly maximum for benefits in this type of plan. There are often numerous dentists who do not participate in this type of plan, and therefore, the patient may not be able to utilize their insurance to see their current dentist or a particular specialist unless they participate with the plan.

Other plans may offer a reduced fee schedule and, therefore, reduced out-of- pocket expenses if a participating dentist treats the patient. If a non-par dentist treats the patient and if the plan pays non-participating dentists (and some do not), then the patient would have greater out-of-pocket costs since services would not be provided at the reduced fees. There are usually yearly maximums of $1000-$2000 with services covered at different percentages of benefits until the maximum is reached. Again, a patient’s dentist may elect not to participate in a given plan for a variety of reasons.

There are other “plans” which are not really insurance in which the patient receives a reduced fee based on a particular schedule, if the patient sees a participating dentist. In this case the patient pays the reduced fee and, therefore, saves some money.

Obviously, dental insurance, coverage and plans are unlike medical insurance, home and auto insurance. It is important to understand the basics of your dental plan, its coverage and restrictions.

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Important: This content reflects information from various individuals and organizations and may offer alternative or opposing points of view. It should not be used for medical advice, diagnosis or treatment. As always, you should consult with your healthcare provider about your specific health needs.