Dental Insurance Explained: How It Works

Have you ever applied for a job and seen that it includes “dental”? It’s a benefit most Americans look for. And a quick look at dental statistics in the US will give you a clue why. They show that tooth decay affects 90% of adults aged 20 to 64, and gum disease affects almost half of adults aged 45 to 64.

Those are frightening statistics and an excellent reason to focus on oral care and have dental insurance. Dental insurance operates much like other types of insurance. But whereas medical insurance covers health care and procedures, dental insurance only covers dental services. 

And you don’t have to get it through an employer. You can sign up for dental insurance on your own. Do you need the ins and outs of dental insurance explained? Read our guide below to learn how it works, what it covers, and much more. 

How Dental Insurance Works

Dental insurance is a policy that you pay with monthly premiums. When you go for dental services or oral care, the costs will be covered to some degree by your dental plan. 

This can help you deal with unexpected dental work and routine oral healthcare expenses. However, some procedures may not be covered. Dental insurance works much like major medical insurance, as there will usually be some out-of-pocket costs.

What Does Dental Insurance Cover?

There are different types of dental insurance plans, grouped into three categories of coverage: preventive, basic, and major dental care. 

The definition of services in each category differs from one plan to the next. Also, some plans offer greater coverage than others. This is why it is always a good idea to do your research first to pick the dental plan that best suits your needs (and those of your family).

However, these are the basic definitions of the three categories of dental insurance coverage.

Preventative Care 

Preventive care generally includes routine dental check-ups, teeth cleaning, dental x-rays, and sealants. 

Most dental plans offer 100% preventive care coverage, with no waiting period for coverage of these services. There may be limits – for example, your insurance may only cover two or three dental exams and teeth cleanings per annum. There’s usually no waiting period.

Basic Dental Care

Basic dental procedures include services like extractions, fillings, root canals, and treatments for gum disease. 

Most policies cover up to 80% of the costs of these procedures, and the policyholder pays the rest. Out-of-pocket expenses like deductibles, copays, and coinsurance will apply. Waiting periods can range from 6 to 12 months.

Major Dental Care

Major dental insurance is designed for procedures like crowns, bridges, inlays, and dentures. 

Root canals may be categorized as major dental procedures on some policies yet be listed as basic procedures on others. Getting dental implants would qualify as a major dental procedure, but not all dental plans cover them. 

These procedures are typically only covered at 50%. The policyholder pays the rest. Therefore, major dental insurance includes more out-of-pocket expenses than other dental coverage. 

The waiting period for major dental work is typically 12 months. But it can be shorter than this or even longer, depending on the terms of your specific dental plan. 

Limitations Of Dental Insurance Plans

Dental insurance plans are beneficial to people with frequent dental issues. Dental work is expensive and can quickly dent your budget if you don’t have insurance. If you have a family with small children, dental insurance can help with their regular oral care costs.

But dental insurance has its limits – quite literally. 

  • Most plans have an annual limit (a specific dollar amount) for the dental benefits covered. Once you reach that limit, you’re 100% responsible for your dental expenses. Most dental plans have a limit of anywhere from $1,000 to $2,000. Policyholders with higher limits rarely reach them, but it’s something to consider if your dental needs are high.
  • Another serious limitation is that many dental plans don’t cover procedures like dental implants, which can cost thousands of dollars each. Cosmetic dental procedures like teeth whitening are also not typically covered.
  • Your monthly premiums will depend on the insurance company and the plan you choose. Your location will determine what is available. Although much cheaper than medical insurance, you’ll be paying hundreds of dollars at least per year, regardless of whether or not you have dental work done. 

Waiting Periods 

The waiting periods stated above are typical, but these may differ from one plan to the next and from one insurer to the next. This is something to bear in mind when choosing a dental plan. If you cannot wait until the period ends, you will be paying the total cost of your dental work.

However, you may still be liable for out-of-pocket payments even once your coverage has kicked in. Dental insurance is similar to medical insurance, as it can also carry deductibles, copays, and coinsurance. 

Deductibles, Copays, Coinsurance, And Maximums

As you’ll no doubt know from medical insurance, almost all insurance policies carry out-of-pocket costs to some degree. But in case you are unfamiliar with them, here is a quick breakdown of these and what they mean for you.

Deductibles

On any insurance policy, there may be a deductible. This is the minimum amount that you will pay out-of-pocket before your insurance takes over. 

On plans with a lower deductible, your coverage will come into effect sooner. But lower deductibles often go hand-in-hand with higher premiums. And vice versa – if you find a plan with lower premiums, your deductibles may be higher. 

Preventive care is exempted from the deductible on many dental plans, but always check the fine print.

Copays And Coinsurance

Even once the deductible is met, it doesn’t mean that your dental policy covers all dental procedures completely. You may still have significant out-of-pocket costs. This is where copays and coinsurance come in.

A copay is the dollar amount you must pay for a specific procedure. Coinsurance is the percentage of the bill you’ll have to pay for dental work. 

But there are different dental insurance policies, just like with medical insurance. This will determine if you must pay a copay or are subject to coinsurance. The dental plan you choose may have one or the other – either specific copays or coinsurance terms.

Annual Maximums

Most dental policies cap the amount that they will spend on your dental procedures for the year. This annual limit (or coverage maximum)  typically ranges from $1,000 to $2,000 annually. 

But, as with the relationship of deductible/premium, higher maximums usually carry higher monthly premiums. So, before committing to a dental plan, ask yourself if you need a high maximum. This will depend largely on your unique dental needs. 

You won’t need a higher limit if you generally only need routine oral care and preventive services. But if you have ongoing major dental issues, that higher limit will benefit you.

How Dental Insurance Pays For Procedures

You pay a monthly premium and present your insurance card whenever you go for dental services. The services provider submits a claim to your insurance company for reimbursement.

If the deductible has been met, or you had treatments not subject to the deductible, the insurer will foot the bill. If your deductible has yet to be met, you will be billed. However, copays and coinsurance may also apply, in which case you share the costs.

Dental insurance typically doesn’t cover cosmetic dentistry and orthodontics. So dental veneers, bonding, veneers, teeth whitening, and braces for adults generally are not covered. You will have to pay for such services out-of-pocket.

How To Get Dental Insurance

The Affordable Care Act (ACA) oversees modern insurance plans in the US. But while ACA insurance marketplace plans must offer dental coverage for children, this is not always offered to adults. However, some ACA plans do include adults’ dental care.

Stand-alone dental plans are available, but unlike comprehensive ACA health insurance plans, these are not eligible for federal subsidies. This can make them less affordable. Always match your plan to your needs as well as your budget.

Securing dental insurance through a trustworthy broker guarantees coverage that suits both your needs and budget. Our skilled agents at Enhance Health will help you find the right dental plan should your health insurance plan not provide dental coverage. 

Dental Insurance Tax Credits 

Like with medical insurance, dental insurance premiums can be tax deductible. 

Dental tax credits are subject to certain conditions. To qualify, you must have dental expenses with receipts, be a taxpayer, and itemize deductions on your tax return. You don’t have to make a separate application but must file your taxes using IRS guidelines.

You must itemize each expense on your tax return. The amount that exceeds 7.5% of your adjusted gross income (AGI) may be deducted from your taxable income. 

Conclusion

Dental insurance is designed to help with expenses related to oral care and dental procedures. But, as with medical insurance, there are different types of plans. There are also varying out-of-pocket costs. 

Do you need help securing affordable dental coverage for yourself and your family? We can help

Contact Enhance Health today for assistance with choosing the ideal ACA-compliant insurance plan with the benefits you need at a price you can afford.

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