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What does my dental insurance cover?

Updated on April 9, 2013

The patient is always responsible for the balance

Many patients with dental insurance feel they are well covered when they visit the dentist. They are quite surprised when they find out they have to pay more than expected or for the entire treatment even with their insurance coverage. Most patients are well informed through their company on the basics covered, cleanings, x-rays, fillings, etc. Since it is ultimately the patient's responsibility to pay the final balance, it's a good idea to know the underlying details behind insurance coverage in most cases.

Since I am mostly experienced with PPO dental insurance, I will provide a summary of information on the cases I've run into. Each plan is different and you should understand your plan completely. I am hoping my article will at least help you ask the right questions when you are faced with these situations or thinking about purchasing dental insurance.

Dental Insurance Highlights

  • Yearly Maximum - This the total amount your insurance company will issue in checks to your provider during a 12 month period, if you have a $1500 maximum it doesn't mean you can go out and get two treatments for $750 each. Your insurance covers a percentage of each treatment, they will continue to pay on approved treatments until they reach the maximum within the time allowed. The benefit year doesn't always run from December to January, you should be aware of when your coverage year ends in order to coordinate your treatments in a timely manner and not loose any of your yearly benefits. Remember, if you don't use your maximum, you loose it. Some plans allow a separate maximum for orthodontic treatments.
  • Deductible - This is a yearly fee paid by you and must be met before your insurance starts paying your treatment claims. This is generally collected by the dental office during your visit. Understand what your individual and family deductible is. If you're a family of 3 and your family deductible is $150, each family member will pay $50, until the $150 is met. Most plans do not require you to pay this deductible during your initial diagnostic and preventative visit (routine cleaning, x-rays, exams), but when you have an actual treatment performed.
  • Frequency limitations - This is the number of times you can have a certain procedure performed during your coverage year. Many plans allow 2 cleanings a year. You must really understand whether you can have 2 cleanings "anytime" during the year or exactly 6 months apart. If for any reason you were to go to a dentist and in less than 6 months go to a different dentist and have a cleaning done. You will get that surprise statement in the mail to pay for a visit.
  • Co-Pay - This is a comfusing subject for most patients, they often comfuse co-pay with deductible. Co-Pay is the percentage of the treatment you share in paying with your dental plan, if something costs $100 and your plan covers 80%, you pay $20 and they pay $80. It is essential that you find a dental office that not only accepts but is contracted with your insurance company. A contracted dentist agrees to accept the plan's discounted fee schedule which translates to savings for you. By visiting a contracted dentist, your yearly maximum covers more treatments. A non-contracted dentist usually gets paid based on his usual and customary fees (UCR). 

Even if you have a full understanding of the items above, sometimes you are faced with additional financial responsibility, let's take a look at some other situations that tend to occur regarding certain treatments:

  • FILLINGS - Many plans will not pay for all composite fillings, they downgrade any fillings done on posterior (back) teeth to Amalgam (black/metal) fillings. If your insurance plan covers 80% of fillings, your co-pay is 20% of the Amalgam fee and you are also responsible for the difference in fees between the two types of fillings. Generally, an insurance company will pay for a filling on the same tooth every two years. Obviously, this doesn't apply if you switch insurance companies, but if you recently got a filling and it broke 1 month later for whatever reason, guess what, you're paying for it unless you have a good, honest, dentist that is willing to repeat it at no charge.
  • CROWNS PRIOR PLACEMENT- Many plans have what they call "prior placement", this means that if your crown is to replace an existing crown, they want to know when the existing crown was placed in your mouth. The insurance company will not pay for a replacement crown if the existing one is less than 5 years old. If the original crown was done at a different dental office, the doctor will rely on your statement of when you think it was originally done and notify the insurance company. Many plans will only pay for a certain type of crown (metal, porcelain over metal). If you want a cosmetic rated product, such as full ceram Zirconia crowns, you will be responsible for your co-pay plus the difference in the product fee.
  • BRIDGE MISSING TOOTH CLAUSE - Let's say years ago you had a tooth extracted and you left that spot open because you couldn't afford a bridge or implant. Now you have dental insurance, you're excited and you go to see your dentist, you're finally going to have a bridge placed to fill that gap right?, well, I hate to burst your bubble but if your insurance plan has a missing tooth clause, it means that if the tooth was not extracted in the last 6 months, they will not authorize your claim for a bridge and you will be responsible for the entire treatment. Bummer!
  • Waiting Period - Many insurance plans have a waiting period on major services, the amount of times varies, but what this means is for a period of time, your insurance will only pay for diagnostic, preventative and basic services (x-ray, cleaning, exam, fillings). You can only use your insurance for major services (crown, bridge, etc) after you've had the plan for a period of time. You need to be aware of this if you rush out to buy dental insurance because you need immediate major services, only to be disappointed with such a small statement.

I can't say your plan will have all these limitations, but I can almost guarantee it will have one or more of these. A well informed patient, is empowered to make the right decisions. Here's a quick matrix to help you quickly view everything mentioned:

The amount your insurance will pay for a plan year
How much is the yearly maximum? and when does my plan year start and end? Do I have a seperate maximum for orthodontic treatments?
The amount you're responsible to pay once a year
Do I have an individual/family deductible and how much? Does my deductible apply to diagnostic and preventative?
How often you can have routine visits
How often am I allowed cleanings?, if twice am I allowed anytime or exactly every 6 months?
The percent your insurance covers for a group of services
What is the percent covered for each service group?
Amalgam or Composite
Are fillings downgraded on posterior teeth?
Also known as a "cap"
Does my plan have a prior placement stipulation?
A minimum of 3 crowns, 2 serving as anchor for the one in the middle covering the area of a missing tooth
Does my plan have a "missing tooth clause"
A period of time you must wait before your insurance will pay for certain services
Does my plan have a waiting period? if yes, how long? and for what?

What can the dental office do for you?

Most dental offices will request a complete breakdown of your coverage during your first visit, don't be shy, ask for a copy of the breakdown, you can also request this directly from your insurance company. Any good dental office, will take the time to explain your coverage in detail to you and answer any questions you may have.

I always say, better safe than sorry. Anytime you have non-emergency treatments to be done and they fall under major services (crown, bridge, etc..) ask your dental office to submit a pre-authorization. This will require the dental office to submit your x-rays and a claim asking your insurance company to approve the treatment and estimate the amount they will pay. Most insurance companies will send you a statement in the mail and this will confirm they have approved the treatment and gives you clear guidelines on your out-of-pocket costs. If additional fees apply your dental office should notify you before proceeding with the treatments.

Most importantly, always begin by finding the right dental office, I will try to add more situations and tips if I come across them, but this article provides you with enough to get you started, if you have any questions specific to your situation, please feel free to ask below in the comment section, I will do my best to answer you. Please remember each plan is different, but what's listed above affects the majority of patients on a daily basis.

Thank you for reading and remember to share a smile.


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