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How Does Dental Insurance Work?

How Does Dental Insurance Work?

Healthcare and benefits can be complicated, which can make the enrollment process confusing. As part of that enrollment process, employers often offer ancillary benefits like dental and vision insurance as well, but unlike health coverage, dental plans can be relatively easier to understand and compare.

So, how does dental insurance work? Here’s what you need to know, including what services and procedures dental plans typically cover.


How Does Dental Insurance Work?

Dental insurance is an ancillary benefit offered by many employers to supplement employees’ health coverage. Employees pay a monthly premium in exchange for coverage of preventative care and most dental procedures.

Dental insurance premiums are much lower than health insurance premiums—around $50 per month for an individual plan. The monthly payments are usually deducted from an employee’s paycheck and paid for by their employer on their behalf.

The details of particular dental plans can vary widely, but what follows is broadly true for most plans.

The most common dental plans are dental maintenance organizations (DMOs) and preferred provider organizations (PPOs). The difference between DMOs and PPOs comes down to affordability and flexibility.

DMOs work like health maintenance organizations (or HMOs) in which employees pay little or no premium but only have access to a small, limited network of dental care providers. Employees may be able to change their in-network primary care dentists, but specialists are only covered if an employee has a referral from their primary. 

Most DMO plans do not have a deductible, which means the insurer begins to share costs with the individual from the beginning of coverage. This cost-sharing is called coinsurance. DMO plans often do not have an annual maximum amount that the insurer will pay.

PPOs offer more flexibility for choosing dentists and specialists—but that comes at a higher price in the form of monthly premiums. Most dentists accept PPO insurance plans, and employees are usually able to see any specialist without a referral. 

Most PPO plans have a deductible, which means the individual is responsible for paying all costs up to a particular amount—at which point the insurance company begins to share costs for the remainder of the plan year. PPO plans often have an annual maximum amount that the insurer will cover—typically ranging from $1000 to $2000 per year.

Some dental plans also require a flat fee—called a copayment—for certain procedures.


What Does Dental Insurance Cover?

Dental insurance usually groups services into three categories of coverage:

  1. Preventative Care
  2. Basic Procedures
  3. Major Procedures

Plans can differ in how procedures are categorized, so employees should refer to a particular policy to better understand what’s covered.

Still, most policies cover 100% of preventative care with frequency limitations. That means an oral exam may be completely covered every six months—or no more than twice in twelve months. Preventative care often includes cleanings and X-rays as well. There is often no waiting period for preventative care.

As far as basic and major procedures go, a typical coinsurance arrangement is one in which the insurer will pay 80% of basic procedures and 50% of major ones. Basic procedures may include fillings, root canals, and treatments for gum disease. Major procedures may include dentures, inlays, and bridges. Most policies require waiting periods for basic and major procedures, but the amount of time can vary by policy and by procedure.

With that in mind, crowns are considered a major procedure under most policies, but whether or not dental insurance will cover them depends on medical necessity. Similarly, cosmetic procedures—including whitening, veneers, and some crowns—are usually not covered.

Orthodontics coverage also depends on the policy, the patient, and the purpose. For example, some policies do not cover braces under any circumstances while others cover braces for children or adolescents but not adults. Still, even if a policy does cover orthodontics, there are two things employees should keep in mind: braces may require a lengthy waiting period and may cost significantly more than the policy’s annual maximum amount.

Again, the details of particular dental plans can vary widely, so to make the best decision, it’s important for employees to understand their own dental needs and the policies under consideration.


Additional Resources

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