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It Pays to Know About Your Dental Insurance Benefits!

07/09/2021, by Maria Van Huffel DDS, in Dental Insurance | General Dentistry, 0 comments

It Pays to Know About Your Dental Insurance Benefits!

If you have dental benefits, they can be confusing to navigate. To make the most of your dental benefits, it’s important to know as much as possible so you can make the best decisions about your dental health. If you are a patient of any type of practitioner, it is your duty as a patient to know and understand your benefits.

Most people have private coverage, usually from an employer or group program. You may also purchase an individual policy.

To be as informed as possible, you need to research your dental plan benefits.

Dental Plan Categories

Although the features of plans may differ, the most common plans can be grouped into the following categories:

  • Direct Reimbursement programs are self-funded by employers and pay patients directly a certain amount of their dental care expenses. This method has benefits determined by the plan administrator, allows patients to go to the dentist of their choice, and encourages them to work with the dentist toward healthy and economically sound solutions.
  • “Usual, Customary, and Reasonable” (UCR) programs usually allow patients to go to the dentist of their choice. These plans pay a set percentage of the dentist’s fee or the plan administrator’s “reasonable” or “customary” fee limit, whichever is less. These limits are the result of a contract between the insurance and the plan purchaser (usually an employer).  These plans are not necessarily a contract between the insurance company and your dentist.  Although these limits are called “customary,” they may or may not actually reflect the fees that your dentist charges. There is a wide inconsistency and lack of government regulation on how a plan determines the “customary” fee level. Often this is determined by geographical area surveys performed by dental insurance providers.

Types of Plans

Dental plans are similar to health insurance plans in some respects, but very different in others. You will generally have the following options:

  • Preferred Provider Organization(PPO): As with a health insurance PPOs, these plans come with a list of dentists that have contracted with the insurance company to accept the plan.  Be aware that the dentist is accepting cut-rate reimbursement for the procedures, and this can affect the quality of care.  You have the option to go to an out-of-network dentist.  Although your out-of-pocket costs may be higher, the quality will likely be higher as well.
  • Dental health maintenance organization (DHMO or DMO): Like health insurance HMO, these plans provide a network of dentists that accept the plan for a set co-pay, or possibly no out-of-pocket fee. However, you will not be able to see an out-of-network dentist.  As above, be wary of the quality and individualized care you may or may not receive.

Annual Benefits Limitations

To help contain costs, your dental insurance plan may limit benefits to a number of procedures or dollar amount in a given year. In most cases, especially if you’ve been getting regular preventive care, these limitations allow for adequate coverage. By knowing what and how much the plan allows, you and your dentist can plan needed treatment in a way that will minimize out-of-pocket expenses while maximizing compensation by your benefits plan.  Good preventive care and treating problems before they become larger and more costly is key to maximizing your insurance benefits over time.

What They Cover

Generally, dental policies cover some portion of the cost of preventive care and cleanings, fillings, crowns, root canals, and oral surgery, such as tooth extractions. They might also cover orthodontics, periodontics (the structures that support and surround the tooth) and prosthodontics, such as dentures and bridges. You’re usually covered for two or three preventive visits per year.

Some plans follow the 100-80-50 coverage structure. That means they cover preventive care at 100%, basic procedures at 80%, and major procedures at 50%, of the amount they consider usual and customary. Dental plans may elect not to cover some procedures, such as sealants, at all.  Each individual plan is different, dependent on what plan you and your employer purchased.

Although we attempt to get basic information on our patients plans as a courtesy, insurance companies will not give us all details of a policy.  It is every patient’s responsibility to become familiar with their own benefits and limitations. 

Limitations of Dental Insurance Plans

Because dental insurance coverage differs so greatly from medical insurance, it is more appropriate to call it a dental benefit. Dental benefits act as more of a dental gift card to put toward a limited portion of your treatment and dental care. Once the maximum dollar amount is reached, the “gift card” runs out.

Every plan has a cap on what it will pay during a plan year, most are between $500 and $1500. This is the annual maximum. If your plan has a $1000 maximum, your insurance will pay a portion of each procedure until it has paid out $1000.  Once your insurance company has paid $1000 in benefits, you would be responsible for the full fee of additional treatment. There is generally a separate lifetime maximum for orthodontics costs. Some plans may totally exclude certain services or treatment to lower costs. You will want to know specifically what services your plan covers and excludes.

There are certain limitations and exclusions in most dental insurance plans. All plans exclude experimental procedures and services not performed by or under the supervision of a dentist, but there may be some less obvious exclusions. Sometimes, dental coverage and medical health insurance may overlap. Read and understand the conditions of your dental insurance plan. Exclusions in your dental plan may be covered by your medical insurance.


Experts generally encourage adults and children to see their dentist 2-3 times per year. Patients with medical conditions, orthodontics or periodontal disease should be seen 3-4 times per year.  Most dental benefit plans support this, although they vary.

It may be that your policy will pay for a preventive visit every 6 months (but no closer together), or twice per calendar year, or twice in a 12-month period. Get to know your policy so you understand how it works. That will help you avoid having coverage denied for an appointment not scheduled per your plan’s rules.

There are usually time limits on other services as well, such as X-rays, fillings on the same tooth, crowns and bridges on the same tooth, or fluoride treatments for children. For instance, your policy may pay for a full series of X-rays only once every 3 years.

Missing Tooth Clause

Some dental insurance plans do not provide benefits for conditions that existed before you enrolled, such as teeth that were missing before you enrolled in this current dental plan. If that is the case for you, your insurance plan will not cover any services to restore a tooth to that space.

What to Do Before a Procedure

Read your dental policy closely to see whether your procedure is covered. Call your insurance company if you have questions.

If you need a major procedure, you can ask the dentist to submit a pre-treatment estimate. This will help you know what you’ll likely owe after any coinsurance, deductible, and policy maximum- but it is still just an estimate.  Dental insurance companies will always reassess your benefits at the time the claim is filed.

There is so much to know about your Dental Benefits.  We try to help you navigate these waters, but every policy is different.  Read your plan and let us help you keep your smile healthy and beautiful!

Watch for our next blog, Dental Insurance Benefits Part II!

Dr Maria Van Huffel

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