Understanding the Basics of Private Dental Insurance
Most dental insurance plans vary in their benefits and structures, and they may seem overly complex on the surface. On the contrary, dental insurance is often much more straightforward and more specific than many patients realize, especially in what treatments they cover. You just have to be familiar with how it works, what’s covered, what’s not, and how to make the most of your coverage.
At Beckham Square Family Dental, we receive questions from patients every day about what their policies cover. When we schedule appointments, we help patients understand how much of their treatment is covered and take the guesswork out of their dental policies.
The Basics of Private Dental Insurance
Most quality dental plans fully or mostly cover preventive care minus a copay. A copay is the fee you pay at the time of service, not including what your insurance will cover. Under some plans, certain routine corrective procedures, such as cavity fillings, may be covered at 80%, but this varies by insurance company. More complex restorative procedures, such as root canals, might be covered at 50%, but this also varies. Cosmetic dentistry procedures done for aesthetic purposes only are not typically covered because insurance companies typically claim they aren’t medically necessary.
The two main types of dentistry-specific insurance plans are DHMO (dental health maintenance organizations) and PPO (preferred provider organization). These will largely determine the details of the main factors in dental insurance. Here are the key differences between the two:
- DHMOs include a network of providers who accept these plans for a pre-determined copay. You’re limited to this group of dentists, and you typically need a referral to see a specialist. However, premiums for DHMOs tend to be lower than PPOs.
- PPOs typically cost more than DHMOs, but you’re not restricted just to in-network providers. However, you save money by staying in-network, and your copay is based on a percentage of the total cost rather than being fixed. Also, most PPOs don’t require specialist referrals.
Dental insurance plans have a few structural characteristics that determine your budget and out-of-pocket costs for dental care:
- Focus on preventative care
- A network of local dentists (sometimes you can choose, sometimes one is assigned to you)
- Out-of-pocket costs (deductibles and co-pays)
- Yearly cap on coverage (the maximum amount the company will pay out per year on dental services)
What’s Typically Covered in a Dental Insurance Plan?
Dental insurance varies in the amount of coverage provided. However, the dental services typically covered in most policies include:
- Regular preventive dental cleanings and exams
- Regular X-rays
- Tooth extractions
- Cavity fillings
- Root canals
- Emergency dental procedures
Services that are partially covered—when deemed medically necessary—typically include:
- Dentures
- Dental bridges
- Dental implants and implant crowns
Keep in mind that coverage may have a waiting period before they take effect. They are also subject to any plan limitations.
Why Isn’t Cosmetic Dentistry Covered?
Why don’t dental insurance plans cover cosmetic procedures such as teeth whitening and dental veneers? It’s for the same reason medical insurance doesn’t cover Botox injections or tummy tucks – they’re not deemed necessary. More specifically, some cosmetic procedures serve no health-related purpose beyond providing subjective aesthetic improvements. The exception is when a cosmetic treatment, such as a veneer, is placed to remedy a fracture or defect that compromises the tooth’s functioning.
What About Pre-Existing Medical Conditions?
Oral conditions that are secondary to other medical issues might not be covered under dental insurance. For example, a person with type 2 diabetes could develop bleeding gums or periodontitis (advanced gum disease). The amount of coverage depends on the limitations stipulated in the plan, and in many cases, whether the treatment falls under medical or dental billing criteria.
The structure of most dental insurance plans is pretty straightforward and standard. If you have questions about what’s covered in your policy or need help understanding certain terms, contact us at Beckham Square Family Dental. Remember that your insurer makes final decisions regarding coverage. However, we can review the specifics of your plan with you, as well as the upfront costs of an upcoming procedure so that you can make informed decisions about your care.