Understanding Dental Insurance Options: What Is Covered and What Is Not?

Dental insurance is usually available through your employer as a secondary policy to your employer’s medical insurance plan. Otherwise, you can get coverage for oral care services through the private market or through Medicare or Medicaid, if you qualify.

Preferred provider plans (PPOs) and dental health maintenance organizations (DHMOs) represent a large portion of the dental insurance market, but other options exist, too.

Before purchasing a plan, acquaint yourself with coverage options and key terms so that you can understand what you are buying and what you get for your money.

Overview

Dental insurance helps cover the cost of dental care for you and for your immediate family members. Most dental plans split coverage into three tiers: preventive, basic and major.

All plans cover part of the cost of preventive care — annual checkups and cleanings — while others cover major procedures like implant surgery.

They rarely cover elective care, such as cosmetic dentistry, but sometimes guarantee a portion of the cost orthodontic care and other complex procedures.

Many Americans have access to dental insurance through their employer, but you can also buy coverage on your own. If you are self-employed or own your own business, you can get coverage through the government-run health exchange, provided you get your health insurance there, too. 

If you cannot afford private dental insurance, you may qualify for other dental coverage through other government or non-profit programs.

Dental Insurance Models

When you shop for dental insurance, you will discover you have a choice from among several different commercial insurance models. If you are already on Social Security if you do not qualify for coverage through your job or if you do not make enough money to pay for private insurance, there are government models in place for you.

Preferred Provider Organizations (PPOs)

Preferred provider organizations (PPOs) are networks of dentists who have contracted with an insurance company to provide services to insured patients at pre-negotiated rates. Set rates let everyone involved — the dentist, the insurance company and the patient — to understand all costs ahead of time. They also make it possible for the insurance company to discount the overall cost of the plan, for which they collect a monthly premium from policy holders. 

While you can use most PPO plans to pay for services at any dental office, they do come with restrictions. If you choose a dental office that is not in your plan’s network, you will only receive a fraction of the financial coverage you would get if you went to one of your insurance provider’s in-network dentists. 

Dental Health Maintenance Organizations (DHMOs)

Like PPOs, dental health maintenance organizations (DHMOs) are structured based on agreements between insurance companies and dentists. Participating dentists are pre-paid for their services in exchange for allowing policy holders to purchase those services at lower rates.

For comparable dental-care coverage, DHMOs are less expensive plans than PPOs.

But because DHMO plans involve pre-paid services, you can only use them with in-network dentists. This can make it difficult for some people to access care if they do not live in an area with many in-network dentists. It can also mean that if you move to a DHMO plan, you may have to change dentists for your coverage to kick in.

Indemnity Plans

Indemnity plans reimburse patients for a percentage of the cost of covered dental services. Some people also call these plans “traditional insurance” due to the way they follow conventional insurance structures. 

Indemnity plans do not have any restrictions about where they can be used. Not all procedures may be covered, and limitations and yearly maximums still apply. Each procedure is typically only covered up to a certain amount, leaving you to cover the remainder. Like PPOs and DHMOs, costs for various procedures are pre-set by the insurance company.

Direct Reimbursement Plans

Dental reimbursement plans offer coverage based on total expenses, not on the type of treatment you receive. For instance, a plan might cover 100 percent of your expenses under $200, then 80 percent of additional expenses up to $2,000. All non-cosmetic dental expenses are typically covered. 

This type of insurance is highly flexible and great for people with complex dental needs that require many types of procedures. In return for this flexibility, these plans are often slightly more expensive than comparable plans from other insurance models. 

Discount Plans

Discount plans are a less common form of dental insurance. They offer members the opportunity to purchase services from participating dentists at a reduced price. 

Plans offer no reimbursement for dental expenses. Instead, they reduce the cost of dental services at the point of sale. However, like DHMOs, they can only be used at specific dental offices. 

Government Models

The U.S. government provides dental insurance through Medicare and Medicaid, which is available to people who receive Social Security or who qualified for services based on their limited income. Coverage or financial assistance is sometimes available from state government programs, though no two states are alike.

Medicaid

Medicaid offers dental coverage for all eligible individuals under 21. Coverage varies from state to state but must always include:

• Dental exams and diagnostic services

• Tooth restorations

• Relief from pain and infections

If a dental condition is discovered during an exam that is covered by Medicaid, treatment for that condition is covered regardless of whether it is specified in your state’s pediatric Medicaid plans.

Medicaid also offers limited dental coverage to eligible individuals over age 21 in some states. If you are insured under Medicaid, ask your case worker about what kind of coverage is available to you. 

Medicare and Medicare Advantage

Standard Medicare coverage includes little dental coverage. Dental care is only covered if:

• It is performed in a hospital setting

• It is a necessary part of a covered medical procedure (for example, if you need jaw reconstruction after a car crash)

• You need a dental exam before undergoing a major operation (such as a heart valve replacement or kidney transplant). If any problems are found during the exam, the necessary treatments are not covered

Medicare Advantage plans offer dental care under many different insurance models, including PPOs and DHMOs.

Deductibles, Copays and Coinsurance Explained

Most dental plans involve deductibles, copays, coinsurance or some combination of the three. It is easy for consumers not to understand these terms and what they mean, but they are an important part of the health and dental insurance system.

It literally pays to understand them because choosing a dental plan that does not fit your financial needs can either cost you money or else can force you to leave money on the table during the course of the policy.

Deductibles

Deductibles are thresholds after which the financial benefits of dental insurance kick in. For example, if your policy has a $500 deductible, you must spend at least $500 on covered dental services in one calendar year before your insurance will pay any claims (not-including copays).

Copays 

Copays are a fixed dollar amount that policy holders must pay each time they need service. Not all policies include copays, and those that do may not include them for every covered service. 

For example, you may have to pay $50 for each claim you submit. Or you could pay more for a special procedure (think root canal). If any copays do apply, they will be noted in your policy documentation.

Copay amounts are pre-set, and you will know what they are prior to agreeing to a policy. 

Coinsurance

Coinsurance is the percentage of costs of a partially covered service that the individual must pay. Coinsurance fees are similar to copays, but they are less predictable. The higher your covered costs are, the more you will be asked to pay out of pocket.

Understanding Other Key Terms

There are many other key terms used in dental insurance policies that may not be clear to people outside the industry. Among them are:

• Yearly coverage maximums

• Waiting periods

• Exclusions

• Limitations

• Least expensive alternative treatment

• Coordination of benefits

Yearly Coverage Maximums

Yearly coverage maximums are the maximum amounts of money your insurance will pay for a particular dental service each year. For example, your dental plan might cover 80 percent of the cost of fillings but only up to a maximum of $1,000 a year. Once you have file $1,000 dollars’ worth of claims in one calendar year, you will not be eligible for reimbursement for the cost of fillings regardless of how much more you spend on this type of care.

Waiting Periods

Waiting periods are the number of months you must wait before you are able to access coverage on a new dental insurance plan. For example, you may not be able to file any claims through your insurance until you have paid into your plan for at least 90 days. Waiting periods are different for each plan, and some plans have different waiting periods for different services too. 

Exclusions

Exclusions are services that not covered by your dental plan. These will typically be listed in the plan documentation and may include qualifiers. One example: your plan may cover orthodontics for children but list them as an exclusion for adult patients. 

Limitations 

Limitations are restrictions on covered services. These restrictions may involve time, money or both. One plan might fully cover one dental cleaning every six months, but no more than that. Another plan might offer coverage for fillings but only up to $1,000 in a calendar year. 

Least Expensive Alternative Treatment (LEAT)

Plans with LEAT clauses only allow policy holders to claim expenses for the least expensive treatment available to address their condition. For example, a LEAT plan might cover a filling to treat a large cavity, but not a crown. 

Coordination of Benefits

Coordination of benefits is the process of combining two insurance plans to cover more of a single person's dental needs. This is often done when both adults in a family each have access to dental coverage through their employer. 

Typically, each person submits eligible expenses to their own insurance company first, then files a claim for the remainder of the balance through their partner's insurance. For children, claims are submitted to a primary and secondary insurance policy according to predetermined rules.

What Does Dental Insurance Generally Cover?

Insurance companies usually structure dental coverage into three tiers: preventive care, basic care and major care.

Preventive Care

The first tier covers preventive care (services that are intended to minimize your future dental problems). Expenses in this tier are often covered at 100%. Some of the procedures that fall under this category include:

• Dental cleanings

• Checkup exams

• Fluoride treatments

• Sealants (for children)

Basic Care

The second insurance tier covers basic care. This tier usually offers 60-80% coverage and includes procedures such as:

• Fillings

• Extractions

• Root canals

• Deep cleanings for gum disease

Major Care

The last tier covers major care. Not all insurance plans include coverage for this tier, and those that do typically cover it at just 50%. Typical procedures in this tier include:

• Crowns

• Bridges

• Implants

• Dentures

Certain procedures may be included in different tiers under certain plans, especially procedures from tiers 2 and 3. Some plans may also exclude certain procedures entirely. For example, many plans cover dentures, but fewer cover implants. Orthodontics are also sometimes classed under a separate tier.

What Is Not Covered?

Even the best dental insurance plans typically do not cover cosmetic procedures. These include:

• Teeth whitening

• Veneers

• Cosmetic bonding

• Elective procedures, such as crowns that are placed to enhance aesthetics and are not considered medically necessary

Orthodontic treatments like braces or clear aligners are sometimes covered under high-end plans, but this coverage usually comes with significant restrictions. Coverage is usually: 

• Limited to $1,000 to $2,000 over your lifetime

• Subject to a long waiting period

Coverage may also only be available in medically necessary cases or for children under 18.

How Dental Insurance Categorizes and Pays for Procedures

Dental insurance is billed according to a set of standardized codes called the Current Dental Terminology (CDT). This set of codes is maintained by the American Dental Association and is revised each year to include any new procedures that have become commonplace within that time. 

Each dental procedure has its own CDT code, allowing insurers to quickly understand what types of services were offered to their policy holder. If an insurance company wants more information on a specific procedure to help guide their decision-making during the claims process, they can request that information from the policy holder or their dentist using the same set of codes. 

When submitting dental insurance claims, some of the claim's CDT codes may be approved while others are disputed or rejected. If you choose to contest your insurance company's decision, you will need to refer to these CDT codes when filling out the necessary paperwork.

Children and Dental Coverage

As part of the Affordable Care Act, children under the age of 19 are required to have some form of dental insurance. This may be standalone dental coverage or coverage that is embedded into a health insurance policy. You can get this coverage through either public or private plans. 

There are no specific requirements concerning what your child's plan must cover, so you can choose the type of coverage that best fits their needs and your budget. If your family income is low, your child may be eligible for coverage through the Children's Health Insurance Program (CHIP).

Options and How to Apply

You can obtain dental coverage through:

Private plans. Private dental insurance is paid for entirely by you. This type of coverage is available through companies like Cigna and Sunlife. You can apply to these plans online on your chosen company’s website or through the ACA Marketplace.

Public plans. Public programs like Medicare Advantage, Medicaid and the Children’s Health Insurance Program (CHIP) provide free or low-cost dental coverage for eligible Americans. Dental coverage is not offered through these programs in all states, so be sure to research what coverage available where you live. You can apply for these programs online through government portals or through your social services case worker. 

Employer-sponsored plans. You may have access to one or more dental insurance plans through yours or spouse’s workplace. The cost of these plans is split between you and your employer, making them more affordable than private plans. Ask your employer’s Human Resources department about what dental benefits are available to you and how you can sign up for them.

Alternative Ways to Pay for Dental Procedures 

If you do not have dental insurance or need a procedure that your policy does not cover, there are other ways to pay for your dental care. You might use:

• Your savings. Putting away just a few dollars every paycheck could cover the cost of some of your dental care.

• A loan or credit card. Borrowing money to pay for dental care makes sense when the necessary treatments are urgent and will make a big difference in your long-term oral health. 

• Your FSA or HSA. If you do not have access to a dental plan through your work, you may have an HSA or FSA you can use to cover your dental costs instead.

• A payment plan from your dentist. Many dentists understand that their patients may have difficulty covering the cost of dental expenses all at once. To make care more affordable, they may offer payment plans to help you space out the cost of your treatments over multiple months. Some charge interest on these payments, but some do not. 

If none of those options are viable, you may be able to get free or low-cost dental care through a government program, a local non-profit organization, a nearby dental school, or other sources. Many of these sources are only available to people with low incomes. Research what is available in your local area to see if you qualify.