Dental Insurance - Understanding What it is and How it Pays

Dental Insurance - Understanding What it is and How it Pays

Traditional dental insurance is available for individual and families to cover the cost of dental care without paying directly out of pocket. The most common mistakes people make is failing to understand exactly what dental insurance pays for. Traditional dental insurance usually pays for three classes of service: preventative or diagnostic, basic and major services.

The first class of service is preventative. Usually dental insurance will pay 100% for preventative services with no deductible and no waiting period. That means that as soon as you purchase the dental insurance you can get your preventative services immediately and at no cost.

What are preventative services? Plans may differ slightly, but most insurance will pay 100% for an oral examination and dental prophylaxis (cleanings). Each person on the plan will get two of these services per year.

In addition, insurance will pay 100% for Bite-Wing X-rays once a year and a full mouth series every 2 to 3 years. For children, preventative services paid at 100% will also include fluoride treatments and sealants.

The next class of service is usually called basic services. Dental insurance will pay for a percentage, often 80%, of these services. Again, insurance plans vary, but most define basic services as fillings, space maintainers, root canals and root planing, simple extractions, periodontal surgery and palliative (relief of pain) treatments. The percentage paid on these services will vary based on the plan selected and the premium paid. The most common percentage paid is 80% but there are insurance plans that pay anywhere from 50% to 90% of the fee charged.

The last category of services covered by dental insurance plans is called major services. These are the most expensive services and also the cause of the most confusion as to what is covered. The kinds of things covered by this category are bridges, overlays, dentures and crowns or caps. Generally insurance plans pay only 50% of the cost of these services. However, patients expecting their plan to pay 50% of the cost of these service are very often caught unawares because of another provision of dental insurance, the annual maximum.

Why is this so confusing? Let's look at an example. Say a person needs 4 crowns or caps. The average cost of a crown is $900. 4 crowns would therefore cost $3600. Many people who have dental insurance think that the insurance will pay 50% of the total cost or $1800. But that is not the case.

Because dental insurance plans always have annual maximums written into the plan, the plan will only pay up to that amount for any single insured. The most common annual maximum is $1000 per person per year. In our example, therefore, the amount that will be paid to the dentist by the insurance for the 4 crowns will not be $1800 but only $1000.

Another thing that often results in the insurance not paying anything are the waiting periods. Preventative services usually have no waiting periods but both basic and major services do. The waiting period for basic services can be 3 to 6 months. The waiting period for major services is almost always 12 months. That means that an insured must be on the plan for 12 full months before the plan will pay anything for major services and then will only pay the annual maximum.

Traditional dental insurance is often written by the major health insurance companies such as Aetna, Blue Cross or United Healthcare. These traditional plans are primarily offered to groups under employer sponsored health plans. However, recently it has become possible to find traditional dental insurance plans written for individuals. The rates will vary depending on geography and the service selected, but the premiums will be comparable to the premium charged employer groups.

If dental insurance is so expensive and has such limitations on benefits why do people want it? After health insurance, dental insurance is the single most requested benefit by employees. For most people, the cost of the premium often equates to the cost of preventative services each year. By purchasing dental insurance the person is pre-paying their routine dental care with a fixed monthly premium. Furthermore, because many employers may pay a percentage of the monthly premium for their employees making the cost for the individual employee more affordable.

Obtaining dental insurance for yourself and your family will insure that you get regular and proper dental care. Failing to do this can result in medical problems which affect overall health and well being.

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