Unraveling the Mysteries of Dental Insurance and How it Affects You as a Patient

When it comes to dental insurance, many people are confused understanding the technical terms and specifications that define what is, and is not, covered for patients seeking treatment at their dental offices. While individual plans vary, all have common technical terms and plan limitations that, when understood, help budget treatment options for patients in need of treatment. Let’s take a look at some of the most popular features of dental insurance plans.

Yearly maximum benefits – This is the amount of charges that your insurance company will pay. The charges are for approved services that meaningful and necessary for a patient’s dental care. Most plans have an annual maximum of $1200, but this means $1200 maximum after the patient has paid their portion. A good example of this would be a root canal procedure which requires a crown. If you are told that the total cost will come to $2000 and your deductible requires a 50% cost share, you would pay the dentist $1000 and your insurance company would be billed the other $1000. This would still leave you $200 of your annual benefits left for additional procedures. If you, the patient, are unsure if a procedure is covered or not, ask your dentist to submit a predetermination before you have your procedure performed. The insurance company will outline the amount of money they will cover (allowable amount per procedure), as well as, your cost (patient share).


“Free” teeth cleanings – Sometimes, this is a bit of a misnomer. A teeth cleaning is only free if the amount that your dentist bills is the exact amount allowable by your insurance company authorized for the cleaning. For example, if your dentist charges $60 for periodontal maintenance and your insurance only covers $40, the patient is responsible for a $20 co-payment. There are also three types of cleanings: periodontal maintenance, debridement, and scaling/root planning. They vary in degree of intensive treatment needed, and are sometimes not covered by insurances. Debridement is the most common periodontal procedure not covered by insurance, and can cost a patient around $100 out-of-pocket, depending on provider.

Orthodontics – Many people become excited when they acquire dental insurance thinking that braces are covered; only to become disappointed and realize they are disqualified from this benefit. Most insurance companies will only authorize orthodontics to people 21 and younger, or 23 and younger if they are a full-time college student under their parent’s insurance policy. A little known secret is that most colleges of dentistry offer clinics and adults can receive braces for a discounted fee. The rates are almost the same, if not less, than if they had qualified for the insurance’s coverage of the orthodontics.

Implants – While this treatment is gaining in popularity, many insurance companies have been hesitant to cover this procedure. If your insurance company allows for partial payment, it is best to have this procedure at the end of a calendar year which did not require extensive procedures (root canals, crowns, etc.). The reason for this is because the implant procedure will most likely consume the entire allowable coverage amount of your yearly benefits; as most implant procedures cost around $3000 for a single tooth. If you and your dentist agree that is procedure is the appropriate treatment, have a pre-authorization submitted to your insurance company before the implant procedure in order to verify coverage of the treatment and get an estimated amount of the out-of-pocket expense you are responsible for paying.

Cosmetic Dentist

When in doubt if any procedure is covered and if there are any restrictions, have your insurance company proceed with a predetermination of benefits. This way you will know what is covered and what is not covered. By all means though, if a procedure is necessary and your cost share is more that what you are prepared to pay, talk to your dentist about payment plans. The longer a dental procedure is delayed the more costly to you, both physically and financially, it will become.