How does dental insurance work? Just like health insurance, right? Not quite. While there are similarities between many health insurance plans and dental insurance plans, there are also differences.
We’ll take a closer look at:
- How dental insurance works
- How dental insurance is different from health insurance
- How to use dental insurance
- How to get the most from your dental insurance premiums
We’ll also touch on where to get dental insurance and how to use your policy after you enroll.
How Dental Insurance Works
When talking about how dental insurance works, it helps to discuss a couple of different areas:
- Dental service categories
- Types of dental plans
- Dental insurance terminology
Dental Services Categories
Dental insurance policies usually offer “100-80-50” coverage, meaning they pay 100% of the cost of routine preventive and diagnostic care, such as checkups and cleanings; 80% for basic procedures such as fillings and root canals, and 50% for major procedures such as crowns and bridges.
Some policies differ in how they categorize basic and major services, so it is important to carefully compare plans. For instance, some policies classify root canals as “major procedures,” while others treat them as “basic” and cover more of the cost.
Most policies don’t cover services considered to be cosmetic, such as orthodontics, whitening or veneers. Some policies cover braces, but that usually involves a waiting period or a requirement to buy a rider.
Types of Insurance Plans
There are three main types of dental insurance plans available – HMOs, PPOs and indemnity plans.
- An HMO, or health maintenance organization, limits coverage to dental providers within a network.
- A PPO, or preferred provider organization, is similar to an HMO but allows patients to see dentists outside the network. However, sticking with an in-network dentist usually means lower out-of-pocket costs. Most dental insurance plans are PPOs.
- An indemnity plan allows a patient to see any dentist and typically picks up a percentage of the costs.
Because HMOs and PPOs use networks of providers that have agreed to charge a lower rate, there is usually a financial advantage to those types of plans. Indemnity plans, on the other hand, offer more choice.
How Is Dental Insurance Different From Health Insurance?
While they often use similar language and both help with health-related costs, there are a number of ways that dental and health insurance differ. Let’s take a look…
Pre existing conditions
Major medical health insurance (with the exception of grandfathered health plans), cover pre existing conditions. However, non-qualifying limited-benefit plans like short term medical and hospital indemnity plans still perform individual underwriting, meaning you may not be allowed to enroll in a policy due to a pre existing condition.
Dental insurance usually covers pre-existing conditions, though often they exclude missing teeth among some other conditions.
With health insurance, a waiting period generally refers to a period of time after you start a new job, no more than 90 days as required by law, before you can access employer-sponsored group insurance benefits.
With dental insurance, there is usually a waiting period before a policy will cover anything beyond a dental cleaning. For example, it might be three months for fillings and six months to a year for more costly procedures.
Insurance companies that offer dental plans often implement waiting periods to discourage people from obtaining coverage for a needed service and then canceling the policy afterward.
Premiums and out-of-pocket costs
Both dental insurance and medical insurance have monthly or annual premium amounts that you pay to maintain your policy. However, the way costs are shared between you and the insurance company can be quite different.
With major medical health insurance, you are responsible for 100% of your medical costs until you reach your annual deductible amount. That said, some preventive services are covered before you reach your deductible.
After that, your insurance begins to share the costs of covered services with you (coinsurance) up to the annual out-of-pocket limit or maximum. At that point, your policy will pay 100% of your covered costs until the next policy year begins. There is no cap on essential health benefits for ACA-compliant major medical policies.
With dental insurance, you may also have a deductible, but it is usually relatively low compared to a major medical health insurance deductible.
Once you’ve paid your dental deductible, your insurance policy pays a percentage of covered costs based on the category of service you received, up to your policy’s maximum annual benefit amount.
Annual Maximum Benefit
For major medical health insurance, you’re less likely to hear about “annual maximum benefits” because the Affordable Care Act eliminated annual maximums for essential health services. Many non-ACA qualifying insurance policies (like short term medical or hospital indemnity) do have annual benefit limits.
For dental, this refers to the most a dental plan will pay for covered services in a year. Different dental policies have different annual benefit limits. A higher monthly premium usually means a higher maximum. After you’ve reached your maximum limit, you’re responsible for 100% of your costs for the remainder of the policy term.
How to Get the Most From Your Dental Insurance Premiums
One of the key differences between major medical health and dental insurance that you’ll notice as you start shopping for plans is that dental insurance tends to have significantly lower premiums, because, in part, of the annual benefits maximum. The cost to buy a typical individual dental policy is about $350 a year.
It’s still a good idea to get the most out of every dollar, though. Here are some tips to make sure you’re getting the most out of your dental insurance.
- Take advantage of preventative care – such as cleanings, checkups and x-rays – that is usually covered 100%. Regular dental visits can help prevent and detect any early signs of cavities, gum disease, oral cancer and other dental and health problems. Plus, regular brushing and flossing may make it less likely you’ll need more serious dental care down the road.
- Know if/when there’s a waiting period and when your annual maximum has been reached before you schedule a basic or major dental service. Unless it’s an emergency, schedule services to avoid unnecessary out-of-pocket costs. On the other hand, delaying needed dental treatment now can mean risking more serious and expensive treatment later. This year’s cavity might become next year’s root canal.
- Make sure there are dentists convenient to you who are taking new patients if you don’t already have a preferred dentist in the network of the policy you choose. Also, try to find a dentist you are truly comfortable with – it may make it more likely you will get needed care.
Get a quick quote online and compare dental coverage and costs.
How to Use Your Dental Insurance
After you locate a dental policy and enroll, using the benefits is fairly straightforward. Here’s how to use your dental insurance:
1. Become familiar with your benefits
Because some policies categorize certain services — like root canals — differently, and cover them at different levels, it’s important to verify how different services you may need are covered.
2. Schedule an appointment
If your dental plan requires you to visit network providers or offers a discount when you use providers in a certain network, search the insurance company’s provider directory to locate a provider that accepts your policy. Once you’ve located a provider, contact them to verify that they are still in your network and, if so, schedule your visit.
3. Present your ID card and pay your copay, if applicable
When you check-in for your appointment, have your dental insurance card handy. At that time, you may owe a copayment for services. Not all plans and services require copays, which is another reason to become familiar with your dental benefits.
4. Look for an explanation of benefits (EOB) and your bill — these are not the same thing
Dental claims are paid much like healthcare claims. When you visit a participating provider, that provider will submit your dental claim. Your dental plan will pay its share, if any, and send you an explanation of benefits (EOB) that details how the claim was processed including the portion paid by the plan and the portion you can expect to pay. An EOB is not a bill. You will receive a bill separately.
How to Get a Dental Insurance Policy
If you’re in the market for individual dental insurance because your employer-sponsored health plan doesn’t include dental coverage, you buy your own health insurance, you’re on Medicaid or you’re a senior on Medicare, you have two basic options:
- Enrolling directly from an insurance carrier or insurance agent or
- Your state-based or the federally facilitated insurance Exchange
While the ACA Exchange can be convenient, buying dental coverage away from the Exchange instead has some advantages:
- You can buy dental insurance anytime
- There’s usually no requirement to purchase a medical plan at the same time
- There may be more dental insurance companies and policy options in the private marketplace than there are in the state and federal Exchanges
Summary + Next Steps
While there are similarities between many health insurance plans and dental insurance plans, there are also important differences, especially when it comes to how dental insurance works, which we covered in detail in this blog post. We discussed:
- How waiting periods and annual maximum benefits work with dental plans
- The different levels of care and how they’re covered at different cost-sharing rates in a dental policy
- Where and how to get dental benefits
- How to use your dental insurance policy