How Does Dental Insurance Work? (2024)

Dental insurance is similar to health insurance in some ways. For example, it has deductibles and coinsurance—but dental coverage has its own unique characteristics.

If you know the details about how dental insurance works, it can be easier to take advantage of the services covered by the policy, including preventive care.

What Is Dental Insurance?

Dental insurance provides coverage to help pay for dental care. You generally pay a premium to have coverage unless your employer offers it to you for free.

These policies often have deductibles, copayments and coinsurance, which you pay when you receive care. You may also have to stay within the dental insurance plan’s provider network and policies generally have a maximum that it will spend on your dental care.

Many people get dental insurance through their employer and it’s typically separate from health insurance. You can also buy an individual or family dental insurance policy directly from dental insurance companies.

How Does Dental Insurance Work?

You pay premiums to the dental insurance company to buy coverage—unless you have free coverage through an employer. Premiums may be taken directly from your paycheck if you get coverage through an employer, or you may pay monthly, quarterly or annually to a company

Premiums aren’t the only dental insurance costs. You also have out-of-pocket costs when you need care. Dental insurance companies also have annual maximums for their coverage. Those caps limit how much the company will pay for dental care.

What Does Dental Insurance Cover?

Dental insurance coverage typically helps pay for three areas of dental care: preventive, basic and major services.

• Preventive care usually includes cleanings, exams and X-rays, as well as fluoride treatment for patients age 18 and younger. Dental insurance typically covers 100% of these costs.
• “Basic” services generally include fillings and non-surgical extractions. Dental insurance typically covers 80% to 100% of those costs, depending on the policy.
• “Major” services cover almost everything else, which is where you usually find exclusions. Dental insurance may cover between 50% and 80% for these services.
• You may find additional categories in a policy, like orthodontia or dentures, with their own coverage limits.

Keep in mind that most dental insurance policies are focused on prevention. That means they typically provide coverage for services like routine checkups, cleanings and exams at no extra cost and should include regular teeth cleanings and fluoride and sealant treatments, says Dr. Joseph Dill, chief dental officer for Delta Dental Plans Association.

A good dental plan should also at least partially cover crowns, root canals, oral surgery, panoramic X-rays and periodontitis treatment.

What Does Dental Insurance Not Cover?

Dental insurance usually does not cover services such as:

• Cosmetic dentistry
• Teeth whitening
• Orthodontics (braces) may be covered but have a lifetime maximum benefit (check your policy for coverage details)

If your policy provides coverage for one or more of these services, it may be at a smaller percentage.

Deductibles, Coinsurance and Copays

Deductibles, coinsurance and copays are costs associated with dental insurance.

Deductible: A deductible is the dollar amount you pay toward covered services before the dental insurance company starts paying for care. For instance, if you have a $100 annual deductible, you pay for services up to that amount in a year before the insurance pays.

Coinsurance: Coinsurance is the percentage you and the insurance company each pay for services after you reach your annual deductible. Let’s say you get $200 worth of dental services and haven’t paid anything toward a $100 deductible yet. In that case, you would pick up the first $100 (the deductible) and then you and the dental insurance company would split the remaining $100. If you have a 20%/80% coinsurance, you would pay $20 and your insurance company would pay $80. That means your bill for those $200 worth of dental services would be $120.

Copay: The copay is what you pay at the time of the service at the dentist’s office. This is typically a small amount like $20.

Annual Coverage Maximums

A plan’s annual coverage maximum is the most your dental insurance will pay toward the cost of dental services within a benefit plan year.

“Every time a dental claim is submitted, your dental insurance provider will subtract the amount that they paid for the service from your annual coverage maximum. Once the annual maximum is reached, you become 100% responsible for the costs of any further dental services you receive until the next plan year begins,” says Dill.

Assume your annual coverage maximum is $1,500 and imagine you have $3,000 worth of dental services performed within that plan year. You would be responsible for any costs that exceed the $1,500 until your next plan year. In that case, you would be on the hook for the other $1,500 not paid by the insurance company.

How Dental Insurance Reimbursem*nt Works

With most dental insurance plans, you present your insurance card at the time of service. The dental office submits a claim to your insurance company for reimbursem*nt and the company will then pay the dentist what it owes and bill you what you owe.

Many dentist practices will pre-screen you for dental insurance before services are rendered and confirm what the insurer will pay versus what you will pay. Your out-of-pocket payment may be requested before or after you receive dental treatment. Your dentist may process the claim with your insurance company to be reimbursed or require you to process the claim.

If you have a fee-for-service/indemnity plan or visit an out-of-network dentist in your PPO plan, you may have to pay the entire bill upon receiving services from the dentist. You would then submit a copy of the bill to your insurer yourself and wait for reimbursem*nt for any portion your insurer covers.

What Are Dental Insurance Plan Types?

It’s essential to understand the different types of dental insurance plans available. Here are the different types of dental insurance plans.

Dental Preferred Provider Organization (DPPO)

A DPPO is a network of dentists who have agreed to charge lower fees than their usual rates, according to Dill.

A PPO allows the flexibility to visit any licensed dentist—even one out of the PPO network—but that care generally costs more than staying within the PPO network.

Dental Health Maintenance Organization (DHMO)

A DHMO offers lower premiums than PPO plans and often don’t have a deductible.

“With DHMO plans, there are set copayments for services, often with minimal or no copayments for diagnostic and preventive care. Also, typically, there is no annual maximum for covered benefits,” Dill explains. “DHMO plans are designed to support the concept of a dental home, with a primary care dentist supervising any necessary referrals to specialists.”

A DHMO network is usually smaller than a PPO network, and you generally don’t get reimbursed for any out-of-network care.

Discount Plans

Discount plans require you to select from a panel of participating dentists who charge reduced fees for their services. You pay these fees directly to the practitioner at the time of treatment.

Discount plans cost less than a PPO, but they aren’t insurance. The discount plans get you lower costs for care, but an insurance company doesn’t help pay for that care.

Fee-for-Service Plans

Traditional or indemnity plans, also known as fee-for-service plans, allow you to see any dentist. There is no dental network, which you find in an HMO and PPO.

“The plan will pay a certain percentage of each service provided by the dentist, and you will pay the remainder. While this type of plan is similar to a PPO plan, it lacks the discounted fees and other protections of a contracted network of dentists,” adds Dill.

How Much Does Dental Insurance Cost?

Forbes Advisor’s analysis of dental insurance prices found that a comprehensive dental insurance plan costs an average of $47 a month.

A preventive care plan costs an average of $26 a month. Dental insurance costs differ based on multiple factors, including the levels of coverage, company and benefits.

How Does Secondary Dental Insurance Work?

You may have more than one dental insurance plan in place, which is called “dual dental coverage.” Dual coverage can occur when you have two jobs that each offer dental benefits or when you’re covered by your partner’s dental plan as well as your own.

“Having dual dental coverage doesn’t mean you have double your benefits. But it will likely reduce your out-of-pocket expenses compared to being covered under only one plan,” says Dill.

If you’re covered by two plans, the companies determine who pays what and to what extent via coordination of benefits contractual language found within the plans.

The companies typically use the birthday rule, which is a method that determines when a plan is primary or secondary for a dependent child when covered by both parents’ benefit plans (referred to as dual dental coverage). The parent whose birthday falls first in a calendar year is the parent with the primary coverage for the dependent.

How Do You Get Dental Insurance?

If you’re wondering how to get dental insurance, you’ll find that you can typically get it through an employer-sponsored dental insurance plan. Other ways to get dental insurance are by purchasing a private plan on the Affordable Care Act health insurance marketplace at HealthCare.gov or directly from an insurer.

Group dental insurance is generally cheaper than buying an individual or family policy on the Affordable Care Act marketplace or directly from an insurance company. Group plans also don’t typically have a waiting period to get dental care, which may be part of an individual policy.

How Does Dental Insurance Work Frequently Asked Questions