How Does Dental Insurance Work?

I have worked in the dental field for the last 23 years.  One thing I hear regularly from our patients is “will my insurance cover this?”  It seems that many individuals do not fully understand the way their dental insurance benefits work.  Insurance policies help people budget for the cost of maintaining a healthy smile. Most insurance benefits are very specific in what they will cover and how much you will have to pay out of pocket.  There are two types of dental insurance policies; HMO insurance and PPO insurance.  With an HMO insurance, you must be assigned to an in network dentist that is contracted with your insurance plan.  There is no yearly maximum, and there is a set fee schedule where the patient would pay all fees due for any type of dental service.  The HMO policy does not pay for any services, they only provide discounts.  Whereas, with PPO insurance you can see any dentist that is in or out of network.  PPO insurances have a deductible, yearly maximum of benefits and they only pay a certain percentage per procedure.  Yearly maximum means that the insurance gives you a certain dollar amount for the year.  This amount typically ranges from $750 to $2500. Once insurance has paid the yearly maximum amount on the policy, the patient will be responsible for any and all costs over the maximum benefit.  However, with PPO insurance policies the benefits reset on a specific date each year.  Once this happens the full maximum becomes available again.  Please note, that dependent on your particular policy, there are limits and exclusions on whether certain procedures are a covered benefit.

Dental procedures are usually grouped into three categories of coverage: preventive, basic and major. Depending on each individual’s specific policy the following are the “typical” guidelines but may vary from policy to policy.  Preventive covers regular cleanings, exams, and x-rays and is usually covered at 100%.  Basic procedures cover fillings, gum treatments, extractions and root canals covered at 50 to 80%. Major work covers dentures, crowns, bridges and implants at 50%.  We constantly remind patients that it’s possible their policy may have a waiting period.  A waiting period usually ranges from 6 to 12 months before they will cover basic and major services.  Insurance companies usually have the waiting period to prevent individuals from buying a policy, having all of their treatment performed in a short period of time, and then cancel the policy.  There is also an annual deductible, which is the minimum amount that must be paid by the patient before the insurance policy pays for anything.  Usually, the deductible is $50 but can go up to $200 depending on your plan.  The deductible must be paid prior to the insurance company paying for any benefits.  For example, if your deductible is $100 dollars and the cost of your visit is $89, the patient must pay the entire amount of the visit.  

We try our best to help our patients understand their insurances and we are always here to answer any questions you may have.