Understanding Your Dental Insurance

Dental insurance can sometimes feel overwhelming, but we’re here to help make it simple. We have put together a guide to knowing how dental insurance works.

*This guide does not include all the terms and conditions of each individual insurance provider. Please call your insurance provider for more details.

How Dental Insurance Works:

• Dental insurance often comes with an annual benefit limit, typically ranging from $1,500 to $2,000.
• We find that individuals who require less than $1,500 in dental treatment each year benefit the most from traditional dental insurance.
• Dental PPO Basics:
  • Dental plans often follow a 100-80-50 model where:
    • Preventive care is covered 100%
      • Regular cleaning, Some X-rays, Most Exams,  Sealants, and Fluoride
    • Basic procedures are covered 80 %
      • Fillings (1-4 surfaces on any teeth once per year)
      • Deep cleaning (only covered once per 2 years)
      • Diagnostic (non-routine) x-rays
      • Simple (non-impacted) extraction
      • Emergency care for tooth/gum pain
      • Root canals (usually basic, but sometimes major)
    • Major procedures are covered 50%
      • Crowns (Limitation on type of material)
      • Surgical Extractions (Does not cover bone graft)
      • Root canals (limitation if done with a specialist)
      • Inlay and Onlay
      • Some will cover implants
    • Copays and Deductibles     
      • A Co-pay is the amount you pay at the time of your dental service which is the 'patient portion' of the treatment. It’s a shared cost between you and your insurance provider.  
        • Example: If your filling costs $100 and your insurance  covers 80% of the cost, then your copay would be $20 (the amount not covered by your insurance). 
      • A Deductible is the amount you must pay out-of- pocket for dental services before your insurance starts covering a portion of the costs. 
        • Example: If your deductible is $50 and your treatment costs $200, you’ll pay the first $50, and  your insurance will help cover the remaining $150 based on your coverage level (e.g., 80% for fillings) making your out of pocket $50 (deductible) + $30 (copay).

How is medical insurance different from dental insurance:

• Medical insurance does not have the three tiers (100-80-50) like dental insurance and it is designed to prevent financial ruin due to unexpected or severe health issues.
• Medical plans typically have deductibles (amounts you must pay before insurance kicks in) and may  have out-of-pocket maximums to protect against catastrophic costs. 
• This means once you reach the maximum limit, the insurance covers 100% of additional costs and your out of pocket it $0 beyond the maximum limit. THIS IS THE OPPOSITE OF DENTAL INSURANCE. 
  
• With dental insurance, once you reach your maximum benefits, members cover the cost of the remaining treatment 100% out of pocket and the cost is no longer shared by your insurance.  
• Understanding your insurance policy is essential, and we’re here to help you navigate the process. While we strive to provide guidance, it is ultimately the insured member's responsibility to be familiar with their coverage details. Any costs not covered by your insurance will be your responsibility.

*This guide does not include all the terms and conditions of each individual insurance provider. Please call your insurance provider for more details. We hope this guide was helpful.