Insurance can be confusing, and the last thing you want to worry about when you need dental work is what is covered under your plan. Depending on the type of care you need, your dental insurance plan may not cover all expenses, resulting in an expensive bill that you may not be prepared for.
It’s better to know what your dental insurance covers now instead of being surprised later. Although plans can differ based on the provider, there are some commonalities that determine whether you’re covered beyond just preventative care. Fortunately, Rhoades Family Dentistry has all the information you need about dental insurance coverage.
What Does Preventative Dental Care Cover?
An important part of maintaining your oral health is having routine dental checkups at least once a year. Routine checkups and cleanings are covered under preventative care, and most plans allow you to schedule an appointment twice a year. Other services covered under preventative dental care include:
- Dental Sealants: By offering protection beyond what fluoride can provide, this thin, plastic coating is placed on the chewing surface of teeth to prevent cavities from forming. Typically, sealants are placed on the back molars when they first initially break through the gums, which usually occurs between the ages of 6 and 12.
- Fluoride Treatments: Professional treatments with fluoride can help to decrease the risk of cavities for both kids and adults. It’s recommended that children under 18 or adults with dental problems, like tooth decay, receive fluoride treatments.
- X-ray Imaging: Your dentist or dental hygienist will take x-ray images of your teeth during your routine checkup. These images give a more detailed view of your teeth and gums, allowing your dentist to identify any problems. Details on x-rays will vary depending on your dental insurance plan. Typically, most plans will cover x-ray imaging at least once a year. You may pay more out-of-pocket if you need x-rays more frequently, especially for those who have a higher risk of developing cavities or gum disease.
Preventative dental care is vital for keeping your gums and teeth healthy. However, many will experience dental problems beyond what’s considered preventative care, so you’ll want to be familiar with what insurance will and won’t pay for.
How Do I Know If My Insurance Covers More Than Preventative Care?
Dental insurance plans differ from regular medical insurance. With medical insurance, even if you have to meet a deductible before the insurance kicks in, there’s no real maximum spend amount. Dental insurance, on the other hand, usually caps coverage at a certain amount per year. This means that if you reach your annual limit, you will have to pay more out-of-pocket.
One of the most common dental plans is the 100-80-50 plan. This benefit plan covers:
- 100% of routine and diagnostic care, including cleanings, checkups, and annual x-rays
- 80% for basic procedures, such as fillings, root canals, or others
- 50% for major procedures, such as bridges, crowns, or others
Although your dental plan offers this coverage, it also has a maximum coverage amount every year. For a plan like the one above, the annual maximum is usually about $1500. This means that once you have any dental care or procedure, including a routine cleaning, it starts deducting from your maximum spend amount.
While this is a common dental insurance plan that many people opt into, others may want more coverage options and decide on a full coverage dental plan instead.
Full Coverage Dental Insurance
Full coverage dental plans are an insurance option that covers preventative care and more costly dental procedures, like bridges, root canals, dental implants, or even orthodontic treatment. Although full coverage does not mean that this plan covers 100% of costs, it does cover more types of dental procedures and services.
There are different types of full coverage dental plans, and depending on which one you choose, they will differ in costs, covered services, and limitations. Some common full coverage plans include:
- Dental PPO (DPPO)
- Dental HMO (DHMO)
- Dental EPO (DEPO)
- Dental POS (DPOS)
All of these plans will provide coverage for a wider range of dental treatments and services, but they will differ depending on each plan policy and your insurance carrier. Most insurance companies will determine what treatments are covered by defining each service into a specific category:
- Preventative Care: Cleanings, checkups, fluoride treatments, and sealants depending on the patient’s age and frequency of treatment
- Basic Restorative Care: Fillings, routine x-rays, and extractions
- Major Restorative Care: Crowns, bridges, dental implants, and dentures
- Orthodontic Treatment: Braces, space maintainers, and other devices used to align teeth
While costs and coverage vary between plans, all will cover certain treatments beyond preventative care, making full coverage dental plans a great option for those looking for more insurance coverage.
How to Get Coverage Beyond Preventative Care
It’s important to read your dental plan’s policy carefully to understand what all is covered. If you have an idea ahead of time of what you may pay out-of-pocket, you can try to plan accordingly by picking what’s right for you and your family. You can also try to anticipate what type of dental care you may need in the upcoming year to figure out what annual maximum spend amount will work for you.
Knowing what costs you are responsible for upfront will save you from any surprise later. Keep in mind that many insurance companies also have a UCR (Usual, Customary, and Reasonable) rate that they set for each treatment. Based on these price levels, your insurance company will cover what they believe to be the “set allowable amount” while you are responsible for the rest.
If you’re looking to get dental coverage for treatments beyond preventative care, you should look for full coverage dental plans. Plans can vary between insurers, so always review your deductible, coinsurance, premium, and annual maximum amounts to know what you would be covered for.