The Truth about Dental Insurance

The Truth about Dental Insurance

Matthew Norman, DDS and Michelle Phillips, RDH


Many people understand the basics of medical insurance and assume dental insurance will work in a similar way, but the two are very different.   Medical insurance tends to be financially comprehensive to the patient once a certain deductible is met, while dental insurance is simply a contribution to the patient based on a yearly maximum amount.  In fact, these yearly maximum contributions have not had a meaningful increase since the 1970’s, when dental insurance became common.  During that time the cost of dental care has risen substantially.  Dental insurance is intended to supplement treatment costs, unlike health insurance.

The number one question we receive about dental insurance is “Are you in my network?”  If a dental office is a part of a PPO (preferred provider organization), the office has signed a contract with an insurance company to set their fees at a level determined by the insurer.  In return, the insurance company will direct enrolled participants to dentists that participate in the network.  In essence, the dentist is accepting a lower fee-for-service in order to increase patient volumes.

Here are some key points about dental insurance:

Dental insurance companies set a deductible per policy.  Most policies have an annual deductible of $50 on any dental procedure that isn’t classified as Preventive.  This means if you only come in to the office for your hygiene visit, exams and x-rays, you will not have to pay the deductible; but, if you need to have a cavity filled, crown, root canal, tooth extraction, you will be responsible for paying that deductible.  The deductible is also per person on the policy…this means that if you have a family policy and one person has met their $50 deductible and another person on the same policy then needs restorative treatment, their deductible must be met as well.

Dental insurance policies have a yearly maximum.  Most policies tend to have a set maximum anywhere from $1000-1500.  Again, this is per person on the policy.  Another misconception is that preventive treatment isn’t a part of this, but it is.  Once the insurance company has paid its maximum per person for that year, any additional costs incurred are 100% paid by the patient.

Dental insurance policies set up a table as to how much they will pay per procedure.  Some common percentages are: Preventive at 100%, Basic at 80% and Major at 50%.  Common preventive procedures are dental cleanings, exams, x-rays, and sealants for children.  Basic procedures may include dental fillings and simple extractions.  Major procedures may include crowns and root canals.  Your insurance provider will then pay a percentage of the “usual and customary” fee charged by your dental office.  For example, if an office charges $90 for a dental cleaning but the fee established by the insurance company is $75, they will pay 100% of the $75.  The patient is responsible for paying the remaining $15.  Another example…if an office charges $200 for a filling on a front tooth but the “usual and customary” fee is $180, they will pay 80% of $180…your total portion of that filling would be $56 (your 20% would be $36 plus the additional $20 for the difference in the fee and the “usual and customary ” fee).  This assumes the deductible has been met.

Here are some other common stipulations with dental insurance:

Some policies do not cover a tooth-colored or composite resin filling on a back tooth.  In this case, they will pay what they would pay for a silver or amalgam filling.  Example: the fee for a silver filling on a back tooth may be $150 while the tooth-colored filling is $200.  The insurance company will pay 80% of $150…you will be responsible for the difference in cost, as well as your 20% co-insurance.
Dental sealants for children have an age limit.  Policies can vary on the maximum age this benefit is payable to.  Some policies me cover children up to 12 years of age, while some may will cover an individual up to 19 years of age.
Most dental x-rays have time restraints.  Most bitewing films will be paid once a year, whereas a panoramic film or full series is covered every three to five years.
Fluoride treatments often have an age limit.  Most policies will only cover a fluoride treatment for someone less than 18 years of age.
Most dental cleanings are covered at a rate of twice per year.  Some policies are written that they will cover two cleanings per calendar year (you can have one today and one tomorrow and they will pay for both).  Most policies are written to cover cleanings once every six months (meaning you have to wait six months and one day until they will cover another cleaning).
If you have a crown that needs to be replaced, most insurance companies will not cover a replacement unless it has been at least 5-10 years.
If you were to have a tooth extracted for any reason and do not have it replaced (i.e. with a bridge, partial denture or an implant) while on the same policy, your next dental insurance policy likely will not pay to have it replaced due to a Missing Tooth Clause.
If you do not use your entire maximum for one calendar year, it does not carry over.  If you don’t use it, you lose it!

Be sure you know your dental insurance policy.  The more you understand the way dental insurance works, the more prepared you will be in planning for dental care expenditures.