Deductibles? Maximums? Exclusions? Just How Does Dental Insurance Work?

January 2, 2019

The new year means new dental insurance for many of us. And while you might believe having and using dental insurance is important, you might also find understanding your dental insurance to be confusing. Deductibles, maximums, exclusions, waiting periods, networks, missing teeth clauses – it all might leave you scratching your head and asking the question, “How does dental insurance work?” Not to worry, we’re here to help decipher what all of it means so you can understand how dental insurance works and get the most out yours.

how does dental insurance work

What Is Dental Insurance?

Dental insurance is a type of insurance that helps individuals pay for their dental care. While the specifics features of dental insurance plans differ, typically they will include coverage for preventive care like routine exams, x-rays and cleaning. Most plans will also include coverage for dental services like fillings, extractions, root canals, crowns, and in some cases orthodontics.

The plan you choose will dictate how much you will pay, how much the insurance company will pay and it might even dictate which dentist you need to visit. It’s important that you understand your coverage so that you can take advantage of your benefits and understand what you are responsible for.

Types Of Dental Insurance

So, where do you start?  A good starting place is understanding what type of dental insurance plan you have. Most plans fall within one of the following categories:

  • Preferred Provider Organization (PPO): PPO plans have a list of dentists who will accept their plans, referred to as their provider network. Visiting an in-network dentist (a dentist on that list) will give you the greatest savings. Typically you can see a dentist who is out of network (not on the list) but you’ll pay more out of pocket.
  • (Dental) Health Maintenance Organization (DHMO, DMO or HMO): these plans provide a list of dentists who accept these plans for a set fee. But you have to see a dentist on that list to get the benefits
  • Discount Plan: again, there is a list of dentist who you can see but your coverage simply gives you a discount with them, the company providing the plan doesn’t pay anything for your care.

Once you know what kind of plan you have, you’ll want to find a dentist on the list. Nearly all plans will have a phone number or website to help you find a participating dentist.

How Does Dental Insurance Work?

Finding a dentist is just one piece of the puzzle, once you have one, you’ll likely want to know what you will have to pay when you go to the dentist. That will depend on the specifics of the plan. Most plans use a “benefit year,” to determine when the benefits are available for use. Your dental office will typically verify your dental insurance for an estimate of how much you will be expected to pay. After a visit to the dentist, a request for payment will be sent to your insurance company; this is called a claim. The insurance company will review and process the claim and then explain how the claim was paid with an EOB, or explanation of benefits.

Ultimately, your financial obligation is based on the treatment you receive and the specifics of your plan some of which might include the following:

  • Deductibles – an amount you must pay before the insurance company will pay anything.
  • Coinsurance – once the deductible is met, you may have to pay a percentage of the cost of covered treatment, for example you may have to pay 50% of a major procedure.
  • Co-pay – a fixed cost for a certain procedure
  • Annual Maximum – the maximum amount the insurance company will pay during the benefit year. Once that maximum is reached during a benefit year, you pay all additional expenses.
  • Preauthorization – some plans may require approval from the insurance company before treatment is done in order for the plan to pay benefits.
  • Exclusions – services and/or products that insurance won’t cover
  • Waiting period – some plans won’t cover certain procedures until a certain amount of time has passed. These are usually major procedures like teeth replacement or crowns
  • Limits – many plans have time limits for certain procedures. For example, many plans will cover two cleanings a year, as long as six months has passed between them. Limits may also apply to the frequency of x-rays and to treatments on a specific tooth.
  • Pre-existing conditions – some plans won’t cover conditions that you had before signing up for their plan, meaning you will be responsible for paying for treatment for that condition.

how does dental insurance work

Hopefully this post has helped answer the question, “How does dental insurance work?” because understanding your dental insurance is a part of feeling comfortable going to the dentist. Knowing how dental insurance works will ultimately help you to make better choices about your dental care so that you can achieve a healthy and happy smile! Remember your dentist and dental team is here to help you achieve that goal while maximizing the benefits of your dental insurance.  Have questions about your dental insurance and the benefits of a dental plan? Just ask! Find a PERFECT TEETH dental office online here or call us at 844-717-9588 to get scheduled!