How Does Dental Insurance Work?

Dental insurance helps overcome consumers’ top concern about getting the care they need. Plans typically cover procedures using a 100/80/50 payment model with preventive care (teeth cleanings, exam, X-rays) 100% covered, basic procedures like fillings at 80% coverage, and major work such as crowns or oral surgery at 50%. 강남역치과

Some plans have a deductible and/or coinsurance. Most have annual maximums, though some offer policies that roll over a portion of unused maximums from year to year.

Preventive care

Dental insurance plans typically cover preventive services, like cleanings and x-rays, at 100%. They also typically cover basic work (fillings, extractions) at 80% and major work (crowns, bridges) at 50%. Many plans have an annual maximum, which is the most they will pay toward care in a year. After that, costs become your responsibility, unless you have other coverage, such as a Medicare Advantage plan that includes dental benefits.

Do you or your employees have a tolerance for cost-sharing and prefer a low deductible? A Dental Health Maintenance Organization (DHMO) may be right for you or your workers. These types of plans offer predictability with co-payments stated as specific dollar amounts, and a limited network of providers that can help keep costs lower. However, DHMOs have the highest average premium among insured dental benefit products.

Basic care

Dental insurance works by paying a portion of the cost of treatment that the plan member must pay. Depending on the type of plan, this may include a deductible and coinsurance. The deductible is the amount that the policy holder must pay before coverage kicks in, and coinsurance is a percentage of the total costs that are shared between the insurer and the insured after the deductible has been met.

The types of procedures covered can vary by plan, so it is important to read the documentation for your specific policy. Most dental plans have a list of Preventive and Basic services (exams, cleanings, x-rays, etc…) and Major services, such as fillings and root canal treatments.

Some dental insurance plans also have a list of “Closed Panel” dentists that have contracted to discount their fees for the benefit of the plan subscriber. This means that the subscriber must use only this group of dentists or face a loss of coverage.

Major care

A dental insurance plan typically works on a tier system with Preventive and Diagnostic procedures (exams, cleanings, X-rays) covered in full and Basic procedure coverage at 80% with copays, deductibles and coinsurance determining the patient’s out of pocket expense. The more extensive work like Major procedures are covered only after a waiting period. Waiting periods are the classic way for an insurer to limit its financial exposure and are necessary in order for a plan to remain viable.

Insurance companies classify procedures into different categories using American Dental Association (ADA) 3-4 digit codes and terminology. Generally, treatments classified as Major are more costly and include crowns, dentures and implants.

Preferred provider organization (PPO) and dental health maintenance organizations (DHMO) plans typically come with a list of dentists that are part of the network. Those dentists offer a discounted fee for services and are the only dentists that will be paid by the plan. These types of plans also have a yearly maximum benefit which once reached becomes the responsibility of the plan holder.

Limitations

Dental insurance is a great way to keep costs down by spreading out the cost of care over a year, but there are still a lot of costs that patients are responsible for. These include premiums, copayments and deductibles. Some plans also exclude certain procedures or have annual coverage maximums.

For example, some plans may limit how many times you can visit a dentist in a year or only cover one set of bitewing x-rays each year. Most plans also exclude cosmetic services like teeth whitening and braces, and some have pre-existing conditions clauses that may prevent you from being covered for treatments like bridges or implants to replace missing teeth.

To help you find the best plan for your needs, use our online tool to compare dental plans. You can select your preferred dentist and filter by location, deductibles, coinsurance, annual maximums and more to see what plans might work for you. Also, verify that your chosen dentists and specialists are in the insurer’s provider network.