Dental insurance can be much less confusing for patients to understand compared to medical insurance, as the language used in dental insurance policies directly tells people what procedures receive coverage, how much they have to pay, and how much the insurance provider pays. Unfortunately, people still wind up leaving money on the table when their insurance plan rolls over at the end of the year.
To maximize the benefits of your dental insurance plan, you need to understand what is currently offered, what kind of procedures are offered, and how much your insurance will cover. Below, we cover everything you need to know about navigating dental insurance.
How Does Dental Insurance Work?
Dental insurance is designed to help you manage the cost of your oral health care throughout the year, rather than having to pay everything out of pocket at once. In most cases, you pay a monthly premium to keep your policy active. In exchange, your insurer helps cover a percentage of the cost of specific services.
To help you better understand what dental insurance is and what it covers, we’ve provided a brief description of important terms:
Deductible
Most dental plans also include a deductible. This is the amount you must pay out of pocket before your insurance starts sharing costs for certain procedures. Once you meet your deductible, your insurance company and you split the cost of covered treatments based on the plan’s coverage levels.
Copayment (or Copay)
This is a fixed dollar amount you pay for a specific service. For example, you might have a $50 copay for a filling, and the insurance pays the rest.
Annual Maximum
This is the total amount your insurance will pay toward your dental care in a given benefit year. Once you reach that maximum, you are responsible for the full cost of any additional treatments until the plan resets.
Provider Network
Plans often have a network of dentists they’ve contracted with. A PPO (Preferred Provider Organization) lets you see dentists both in and out of the network, but your costs will be lower if you stay in-network. An HMO (Health Maintenance Organization) usually requires you to see only in-network dentists to receive coverage.
Waiting Period
Some plans also have waiting periods for certain procedures, especially major ones like crowns or dentures. This means you may have to be enrolled in the plan for a set period of time before these services are covered.
What Dental Insurance Covers
Most dental insurance plans follow the 100-80-50 structure:
- They will cover 100% of the costs of minor adult and pediatric dental procedures, such as bi-yearly visits, teeth cleanings, X-rays, and dental sealant procedures.
- For things such as cavity fillings, root canals, and gum disease, your insurance will cover around 80% of the total cost after the deductible is met.
- Major procedures like crowns, bridges, inlays, or dentures will only have about 50% of the procedure covered.
Knowing how much your insurance policy will cover helps you plan out your visits and maximize the money still left on your account before losing it at the end of the year.
What Isn’t Covered by Dental Insurance?
While dental insurance can be extremely helpful, it doesn’t cover everything. One of the biggest surprises for many patients is that cosmetic dental procedures are usually not covered. Treatments like teeth whitening, veneers done solely for cosmetic reasons, and cosmetic bonding are generally considered elective. Since they’re not medically necessary, most plans will not pay for them.
Some policies also have limited or no coverage for orthodontic treatment, especially for adults. While children’s braces may be partially covered in some plans, adult orthodontics, clear aligners, and certain advanced orthodontic options might not be included, or they may have separate lifetime maximums.
Other services that may not be fully covered include:
- Dental implants and related procedures (some plans cover them, while others don’t or only cover a portion)
- TMJ (temporomandibular joint) treatments, if considered “experimental” or non-standard by your insurer
- Elective or “upgrade” materials, such as choosing a more aesthetic crown material when a less expensive option is available and covered
Every plan is different, so it’s always a good idea to review your benefits booklet or call your insurance provider before scheduling major treatments. Your dental office can also often help you estimate coverage and out-of-pocket costs before you move forward.
What if I Have an FSA Account?
Flexible Spending Accounts, or FSAs, are provided through employer-sponsored insurance plans and are designed to help provide flexibility in how you pay for specific procedures. During your enrollment period, you select which FSA account you want and determine how much money is in that account. These pre-tax dollars come out of your paycheck over the year and are then used to help cover the cost of these procedures.
The FSA plans work similarly to a debit card in that the money in the account can be withdrawn to cover expenses. However, like other benefits, once the new year comes and the plan rolls over into 2021, you lose whatever balance is left on the FSA account. This is why you should take the time to plan out what dental procedures you need done throughout the year and do what you can to maximize the money in your FSA account.
Making Dental Care Accessible and Affordable
At Hamilton Dental Associates, we believe that everyone deserves access to quality dental care without the financial stress. That’s why we’ve built a system designed to make dental care as affordable and convenient as possible. This includes:
- A dedicated, full-time financing team ready to help with insurance claims, payment plans, and questions.
- In- and out-of-network support to help you maximize your benefits, no matter your provider.
- 0% interest financing options for qualifying patients.
- Flexible payment plans tailored to fit your budget and treatment timeline.
Our goal is to ensure that cost never stands in the way of maintaining a healthy smile.
Book Your Dental Appointment Today
Since you only have a set amount of time left in the year to utilize your dental insurance benefits to their fullest, don’t wait! You can schedule an appointment for orthodontic services, cosmetic oral surgery, routine dental cleanings, and more with your friendly neighborhood dentists at Hamilton Dental. Contact our team in Hamilton, NJ, today to plan your next visit! We can also help answer some of your questions about dental insurance.
