Sifting and sorting through insurance policies to find the best fit for you and your family can be a daunting task, often leading to more confusion about what you need and want your policy to cover. When it comes to your dental insurance, you want to ensure that you’re receiving appropriate coverage for a reasonable cost and not overpaying for services you don’t need. To help you make sense of it all, our Gainesville dentists have put together this guide to dental insurance.

Whether you have insurance or not, some preventive and restorative dental procedures are more affordable than you might think. Contact Comprehensive Dental Care to schedule a dental consultation today!

How Does Dental Insurance Work?

Luckily, dental insurance is much more straightforward than medical insurance. Most dental insurance clearly outlines what procedures are covered, what percentage of each procedure is covered, and how much you need to pay out-of-pocket. Dental insurance policies can be an add-on to medical coverage or purchased separately. Additionally, they can be available through group plans (your work) or an individual or family plan. The following are key features you should know when selecting a dental insurance plan.

Deductibles, Copays & Coinsurance

A deductible is the amount you must pay out-of-pocket before the insurance begins to cover procedures. For example, a covered dental procedure may be $150, but if you have a deductible of $200, you will have to pay for that procedure plus an extra $50 towards the next procedure before the dental insurance kicks in. Copay refers to a set amount that you’ll be responsible for paying out-of-pocket, is a fixed amount that the insurance company requires you to pay for office visits and emergencies, and is required even after you’ve reached your deductible. Finally, coinsurance is the remaining cost of a procedure after the insurance company pays its portion.

Dental Insurance Waiting Period

Some dental insurance providers require you to wait a period of time after enacting coverage before you can begin any standard dental work, ensuring the insurance company can make a profit off of a new account to cover the cost of the procedures. Dental insurance waiting periods usually range from 6–12 months. If you require more immediate procedures, prioritize dental plans that have shorter waiting periods or don’t have one. However, this may come with a higher monthly premium.

Yearly Coverage Maximums

The yearly coverage denotes the maximum amount the insurance company will pay towards procedures. Once you reach this amount, you will have to pay 100% of any procedure, even those covered under your insurance policy. Coverage maximums are usually $1,000 to $2,000 a year. Typically the higher the monthly premium, the higher the yearly coverage maximum. If you do not reach your yearly coverage maximum, you may be able to roll over that amount into the next year, depending on your policy.

In-Network Providers

In-network means that a dentist is part of your insurance’s network of providers. When opting for treatment, it’s important to select a dentist in your insurance network to ensure your insurance covers the maximum percentage of the procedure. In-network refers more to PPOs, as HMOs don’t usually require you to stay in the network. However, not all dentist offices accept HMOs. Keep reading to learn more about the differences between PPOs and HMOs.

What Does Dental Insurance Cover?

Most insurances cover 100% of preventive care (up to the yearly coverage maximum at least), including exams, x-rays, and dental cleanings. Basic procedures such as fillings, root canals, and tooth extractions are only covered up to 80% on average. Other major dental procedures, such as crowns, bridges, implants, gum disease treatment, and partial or full dentures, are typically only covered up to 50%. Braces and cosmetic dentistry, such as teeth whitening, are not deemed medically necessary and are not typically covered by most dental insurances. Your insurance policy and age can affect what percentage of each procedure is covered. For example, dental insurance plans for older people usually provide better coverage for procedures, such as dentures, because it’s more necessary.

Dental Plans

Dental plans are available in three different categories, and it’s important to understand the distinctions between each plan so you can select the best one for your unique situation.

Preferred Provider Organization (PPO)

A preferred provider organization is one of the most common insurance plans and is composed of a network of dentists who have negotiated their fee structure with insurers. These plans can be more expensive but provide greater flexibility due to a broader network of dentists. That means that you’ll have more options for dental care providers, giving you the ability to select a dentist who works best for you. Additionally, you do have the option of seeking treatment outside of the network, though prices will be higher and have less coverage.

Health Maintenance Organization (HMO)

A health maintenance organization is limited to in-network care, and you will pay premiums either monthly or yearly. You may also be required to live in an area that offers the HMO. Unlike most PPOs, HMO plans do not have an annual maximum or deductibles. You’ll also have to choose a primary caregiver that will act as a gateway to receiving care from other specialized providers, which is not a requirement of PPOs. Most HMOs do not have required waiting periods before receiving care.

Indemnity Dental Plans

Indemnity dental plans, also known as fee-for-service plans, are the least common type of plan and are often the most expensive. Insurance providers set caps for the amount they will pay per procedure, usually based on the amount set by the American Dental Association. You will be required to pay for the excess when procedures go over that amount. Additionally, you will most likely be required to pay the full cost of the procedure upfront, which can be reimbursed after filing a claim with the insurance company. The main benefit of this plan is that you can choose any dentist as there is no network to stay within.