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While more than 3 out of 4 Americans have dental insurance1, many don’t fully understand what dental insurance does and doesn’t cover. This quick guide to dental insurance can help you get a better understanding of how coverage usually works.
The purpose of dental coverage
Dental insurance is designed to help you offset the cost of your dental care and to help you maintain good overall oral health. That’s why we focus on preventive care to catch signs and symptoms of dental disease early. This could reduce the chance that you will need more complex treatment later. If an issue does arise, dental insurance will usually help cover a portion of the treatment cost, so you don’t have to pay the full bill yourself. This combination of preventive services covered at 100% and lower out-of-pocket costs makes dental insurance a valuable benefit.
What is covered: 100-80-50 coverage structure example
The emphasis on preventive coverage and sharing of costs on other procedures is reflected in the structure for most dental insurance plans. As part of this structure, an example of dental coverage may be:
100% of routine preventive and diagnostic care such as cleanings and exams.
80% of basic procedures such as fillings, root canals and tooth extractions.
50% of major procedures such as crowns, bridges and dentures.
Be aware that a deductible — the amount you pay before your dental insurance kicks in — may apply to these services, although it may be waived for preventive and diagnostic services.
What may not be covered
- Select procedures: While it differs from plan to plan, some dental insurance may not cover select procedures such as orthodontia.
- Cosmetic procedures: Coverage for cosmetic dental procedures like teeth whitening may not be covered.
- Pre-existing conditions: Some policies don’t cover certain pre-existing conditions such as missing teeth. If you had a condition before you got your dental plan, you may be required to pay treatment costs out-of-pocket.
Additional plan information
These limitations may also apply to your dental insurance:
- Waiting period: This is the period of time before you are eligible to receive benefits for all or certain dental treatments. Waiting periods are more common with individual plans2 but also apply to employer-sponsored plans in some industries. This can sometimes be waived if you prove you had no gap in your dental coverage before purchasing a plan.
- Other restrictions: In addition to some procedures not being available right away, your plan may require time limits between services like fillings, crowns and bridges on the same tooth or fluoride treatments for children. For example, a policy may only pay for a full set of X-rays once every five years3.
- Annual maximum: This is the total amount your dental insurance will pay for your coverage during a 12-month period. For instance, if your annual maximum is $1,500, you pay for all additional costs after your dental insurance has paid $1,500 for your care. However, only 2% to 4% of Americans typically exceed their annual maximums4.
Important terms to know
It helps to become familiar with the following terms to get a greater understanding of why some services are covered and others are not:
- Coinsurance/Copay: The patient’s share of payment for a given service. The copayment is usually expressed as a percentage of the dentist’s fee, but can be expressed as the enrollee’s preset share of payment for a given service.
- Dual coverage: If you have coverage from more than one dental plan through a spouse, more than one job, both parents or other means, it is called dual coverage. While dual coverage does not double your coverage or pay more than 100% of expenses, it may help you reduce your out-of-pocket costs.
- In-network dentist: Dentists who have agreed to accept pre-established costs for services, saving you money over an out-of-network dentist are referred to as in-network dentists. You will save the most by visiting a dentist in your plan’s network. In fact, a dentist participating in your plan’s network generally won’t be able to bill you for the difference between what they usually charge and the fee they have agreed upon with Delta Dental.
View your dental coverage specifics by logging in to your Member Account here.