Dental Insurance – What You Need to Know

Dental insurance helps to pay for a portion of your oral health care. It typically covers three areas of treatment: preventive, basic and major services.


Many dental plans have annual maximums and/or lifetime maximums, which can impact how much you pay out of pocket for treatment. These costs are usually based on American Dental Association (ADA) 3-4 digit codes.

Preventive care

Dental insurance can bring often-expensive tooth care within financial reach. It helps cover the costs of cleanings, X-rays, and other preventive services that can reduce risk of serious health problems. In addition, it covers some basic and major procedures, like fillings and crowns. Many people get dental insurance through their employer. Others buy a separate individual or family plan directly from an insurance company. Most plans come with a monthly premium, deductible, and coinsurance. Some have a network of dentists that members must use, while others allow patients to choose their own provider.

Most dental insurance follows a 100/80/50 payment structure, which pays 100% of preventive visits and 80% of the cost of basic and major procedures. Preventive care includes teeth cleanings, exams and X-rays, as well as fluoride treatment for children under 18. Most people benefit from regular dental visits because they help identify potential problems early on, when they are usually less expensive and easier to treat.

Different types of dental insurance are available, and it’s important to understand each before you purchase a plan. For example, dental HMOs (like DHMO and DPPO) are managed care plans that only pay for services provided by dentists in the plan’s network. PPOs and POS plans are more flexible and typically don’t require a referral to see a specialist. However, they generally have higher out-of-network costs than a DHMO or DPPO.

Basic care

There are different types of dental insurance plans. Some are direct reimbursement plans where patients pay for their care upfront and the plan reimburses them a percentage. Others are managed care plans that have a network of providers, similar to health insurance PPOs or HMOs. Depending on the plan type, these may be called Dental Preferred Provider Organizations (DPPO) or Dental Health Maintenance Organizations (DHMO).

Most dental plans have what’s known as a 100-80-50 approach to coverage: Preventive services are covered at 100%, basic procedures are at about 80%, and major restorative services are at 50%. The deductible, which is the amount the patient must pay before the insurance kicks in, also varies by policy.

Many dental plans have restrictions on the number of visits and/or dollar amounts that can be paid for a particular procedure. This helps keep costs down and encourages regular preventive visits.

Most dental plans also have waiting periods that apply to certain treatments, such as fillings and crowns. Some policies also have a maximum annual benefit. For example, the plan may only cover $1000 worth of services in a year. It is important to understand these limitations and talk with your dentist about them when selecting a plan. Many dental plans also have a preferred provider network that includes dentists who agree to charge less than the insurance company’s minimum fee.

Major care

Most dental plans break procedures down into three categories: preventive, basic, and major. Preventive procedures include regular cleanings and x-rays, which help to identify potential problems that can be treated early, saving you money in the long run by avoiding costly repairs or replacements. The cost of preventive services typically falls within the dental plan’s deductible and coinsurance amounts.

The Basic care category of procedures includes fillings and extractions. Indemnity and Preferred Provider Organization (PPO) insurance plans usually reimburse Basic treatments at rates on the order of 70 to 80% after the deductible is met. Most of these plans also have a copay that is applied to the procedure when it is performed.

It is common for these plans to require a waiting period before covering Class II procedures, such as composite or amalgam fillings on back teeth, and Class III procedures, such as inlays and on-lays and crowns or dentures. In addition, it is not uncommon for these types of procedures to have an annual maximum that can be reached.

Many companies are offering dual choice dental programs that allow their employees to choose between a Managed Care and Indemnity, Fee-for-Service Plan. Employees are happier with this type of plan because they can stay with their favorite dentist while benefiting from the lower costs and restrictions of a managed care dental program.

Out-of-pocket expenses

If you choose to get dental insurance, premiums aren’t the only costs you need to consider. There are also deductibles, coinsurance and annual maximums to take into account when choosing the right plan for you.

Deductibles are the flat amount you pay before your insurance company starts paying for services. Coinsurance is a percentage that you and the insurance company split up after the deductible has been met. For example, if you have an annual deductible of $100 and 20% coinsurance for major work like fillings or crowns, then you will have to pay $20 of each bill after the deductible is met.

Most dental plans have maximum annual limits that set the highest amount the insurance company will reimburse for the year for specific treatments. These limits apply to individual services or to groups of them, like orthodontics. The limits are established by the insurance contract and may be negotiated by each plan.

Most dental insurance plans come with a list of dentists that are part of the insurer’s network. You’ll want to make sure your preferred dentist is on the list before deciding to go with a particular plan. If you don’t mind seeing out-of-network dentists, there are plans that offer more freedom to select where you see your dentist. These are called preferred provider organization (PPO) or dental health maintenance organization (DHMO) plans.