Dental insurance can help alleviate one of the greatest challenges to receiving necessary oral healthcare: cost. But like other forms of coverage, dental plans include deductibles and coinsurance provisions that must be satisfied prior to receiving care. Most dental PPO and DHMO plans follow a 100/80/50 payment model, which covers 100% for preventative services, 80% of basic procedures, and 50% of major services; however, each policy varies.
1. Preventive Care
Most dental plans provide preventive care services such as exams and cleanings to keep teeth and gums healthy, thus reducing the need for more costly treatment solutions. Dental policies typically offer annual coverage maximums, copays or deductibles, and access to a network of dentists. Dental Preferred Provider Organization (DPPO) plans often contract with dentists to offer discounted rates; out-of-network dentists may incur higher costs.
Some dental plans also cover orthodontic and TMJ treatment, though these services tend to be more costly and involve longer wait times than traditional dentistry services. Such plans often make the expense well worthwhile for many patients.
2. Basic Care
Many dental insurance plans cover basic services, including amalgam and composite fillings, extractions, non-routine x-rays, and up to 80% coverage on non-routine x-rays. These procedures may cost 70-82% of total costs to the plan member.
Most plans feature both a deductible, which patients are responsible for meeting before their plan begins paying, and coinsurance, the percentage of costs that you and the plan share. Some plans also impose a maximum annual amount that must be reached before insurers will cover 100% of procedures. Some plans, like dental HMOs, require you to select providers within their network, while others, such as PPO plans, allow you to select dentists both within and outside their network.
3. Major Care
Once you reach the annual coverage maximums for a dental insurance plan, once they no longer cover all of your care, the remaining balance is your responsibility to pay out of pocket. Therefore, it is wise to opt for an inclusive plan that offers major and preventive dental services, as this will cover everything that arises during treatment and care.
Finding out whether your dentists are part of the network is paramount when selecting a plan, along with considering deductibles, coinsurance, and waiting periods as potential factors. Deductibles refer to an out-of-pocket amount you must cover before your plan will cover expenses; coinsurance covers a percentage of what costs may incur before being covered by your insurer.
4. Restorative Care
Most dental insurance policies feature deductibles – the upfront fixed amounts you must cover out-of-pocket before your insurance provider begins covering costs – and copayments (typically only required for preventive services).
Many policies include annual maximums, which set forth how much will be covered per procedure per year and reset at the end of their plan year. Some dental plans may impose waiting periods before offering certain forms of care, like fillings or root canals; this period can range anywhere from 12 to 36 months.
5. Emergency Care
Nearly all dental plans require you to pay a premium, typically monthly, in order to stay active. In some cases, you may also have to meet a deductible, which is usually an upfront fixed sum before the insurance plan covers costs. Furthermore, some plans have coinsurance provisions wherein a certain percentage of costs remains after your insurer pays out its portion.
Many plans provide annual maximums or caps on how much the plan will pay towards your care in any one year. Furthermore, time limits on treatments like X-rays or fillings exist in order to encourage you to visit your dentist regularly, which experts consider key for good oral health.
6. Diagnosis
Full coverage dental plans offer benefits for most treatments and procedures, such as preventive care, basic and major restorative treatments, orthodontic care, etc.
Diagnosis is the practice of reasoning backward from symptoms to identify likely causes, often through multiple rounds of gathering information and ruling out possible diagnoses until one – known as the working diagnosis – remains. Diagnostics is a difficult science and often causes errors; eliminating them would benefit clinicians, patients, and healthcare organizations alike.
7. Prescriptions
Americans with dental insurance save money on routine treatments while decreasing the chances that more costly care will become necessary down the line. Dental plans may feature deductibles, copays, and annual coverage maximums to suit individual needs.
Traditional indemnity plans, preferred provider organizations (PPOs), and dental health maintenance organizations (DHMOs) are the three main forms of dental insurance coverage. Each has different requirements; most plans have deductibles that must be paid out-of-pocket before sharing costs are shared among members, or annual maximums before coverage stops, or lifetime maximums for certain services or procedures.
8. Copayments
Most dental insurance plans feature deductibles and coinsurance – flat fees that the policyholder pays after meeting their deductible – which cover services rendered once their deductible has been reached. Some dental plans also have annual coverage limits or waiting periods in effect.
People who opt for plans with networks of dentists are more likely to save money by visiting in-network providers, since those dentists have agreed to charges according to the plan’s terms. Certain plans, such as DPPOs and PPOs, have deductibles; other plans (like DHMOs) don’t. Some plans even impose time restrictions, requiring you to visit at least twice annually.
9. Coinsurance
Similar to health insurance plans, dental plans often impose deductibles and coinsurance that reset every year. Some plans also feature annual maximums – the most the plan will pay out in any one year for care.
Some dental plans, known as Preferred Provider Organization (PPO) plans, restrict your choice to in-network dentists or limit who you can be reimbursed from. Other plans, like indemnity dental insurance or those available through the Health Insurance Marketplace, do not impose such limitations and allow you to visit any dentist you please.
