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  • Writer's pictureGaby

Demystifying Dental Insurance: Your Guide to Preventive, Basic, and Major Procedures Coverage

Updated: Dec 21, 2023

Dental coverage typically includes a range of services categorized into preventive care, basic procedures, and major procedures. These categories help insurers and policyholders understand the types of dental services covered and the associated costs. Keep in mind that the specifics can vary among different dental insurance plans, so it's essential to review the terms and conditions of your specific policy.

Here's a general overview of these categories:

Routine Check-ups and Cleanings: Regular dental check-ups, typically recommended every six months, help in early detection of dental issues.

X-rays: Diagnostic X-rays are often covered to identify problems not visible during a regular examination.

Fluoride Treatments: Application of fluoride to strengthen teeth and prevent decay.

Sealants: Protective coatings applied to the chewing surfaces of molars to prevent decay.

Preventive Care:

  • Preventative services include routine cleanings, exams, x-rays, sealants, and fluoride treatments. These maintain health and catch problems early.

  • Most dental insurance plans cover 100% of the allowed fees for preventative services. This is usually twice per year.

  • The annual deductible does not apply to preventative services under many plans.

  • Some plans may limit preventative coverage to 1-2 times per year, especially for cleanings. High-risk patients may qualify for 3-4.

  • Full mouth or panoramic x-rays are often covered once every 3-5 years. Bitewing x-rays have varying limits.

  • Sealants are typically covered for unfilled molars until age 16. Some plans cover sealant repair.

  • Fluoride treatments are fully covered 1-2 times per year until age 16. Some plans extend this.

  • No waiting periods usually apply to preventative services under dental insurance.

  • Using an in-network dentist can minimize out-of-pocket costs for preventative visits.

Checking the preventative benefits and frequency limitations is important when comparing different dental insurance plans. Taking advantage of fully-covered preventative services can help maintain dental health.

Basic Procedures:

Fillings: Restorative treatment for cavities using materials such as amalgam or composite resin.

Extractions: Removal of a tooth, usually due to severe decay, damage, or overcrowding. A tooth extraction (EXT) sometimes fall under major coverage. Make sure you are clear on where an EXT procedure falls with your plan.

Root Canals: Treatment for infected or damaged tooth pulp, involving the removal of the pulp and sealing the tooth.

Root Canal (RCT) sometimes fall under major coverage. Make sure you are clear on where an RCT falls with your plan.

  • Basic services include fillings, simple extractions, root canals, and minor gum disease treatment.

  • Most plans cover basic services at 80-90% after you meet the annual deductible, often $50-$150 per person.

  • An annual maximum benefit for basic services may apply, commonly $1,000-$2,000 per person.

  • Many routine dental procedures like filings are covered at the same percentage (e.g. 80%) but have a different maximum.

  • Some frequency limitations may exist, such as for bite-wing x-rays, gum maintenance cleanings, or root planing.

  • Waiting periods are uncommon for basic services, but some plans require 6-12 months before coverage kicks in.

  • Pre-authorization may be required for some procedures, like root canals. Make sure to check first.

  • Using in-network dentists is advised as they accept discounted fees negotiated by the insurer.

  • Carefully review the plan's limitations on services like occlusal guards and occlusal adjustments.

Checking the details of basic dental coverage under any insurance plan can help avoid surprise costs. Taking advantage of regular basic services maximizes your dental benefits.

Major Procedures:

Here are some key things to know about major coverage in dental insurance plans:

  • Major dental services include things like crowns, bridges, dentures, and dental implants. These are more complex, expensive procedures.

  • Major coverage is usually the most limited.

  • Most plans cover major services at 50% of the cost after you meet the annual deductible. Some only cover them at 20-30%.

  • There are usually annual maximum benefits for major services, commonly around $1,000-$1,500 per year.

  • Many plans have waiting periods for major services, often 6-12 months before coverage kicks in.

  • Procedures almost always require pre-authorization and cost estimates before insurance covers any part.

  • If using an out-of-network dentist, your out-of-pocket costs will be higher. In-network dentists agree to accept set fees.

  • Carefully review exclusions. For example, dental implants may not be covered at all or have very limited benefits.

  • Check frequency limits. You may only be covered for a crown/bridge once every 5-7 years on the same tooth.

Be sure to understand the major dental coverage limitations in any insurance plan you're considering so there are no surprises when you submit claims.

Crowns: Custom-made caps that cover a damaged tooth to restore its shape, size, strength, and appearance.

Bridges: Replacement for missing teeth using artificial teeth anchored to adjacent natural teeth or implants.

Dentures: Removable appliances to replace missing teeth and surrounding tissues.

Dental Implants: Surgical placement of artificial tooth roots into the jawbone to support replacement teeth.

Orthodontics: Corrective procedures to align and straighten teeth, including braces or clear aligners. Here are a few key things to know about ortho coverage in dental insurance plans:

  • Orthodontic coverage is often an optional add-on to standard dental insurance plans. Not all plans include ortho coverage automatically.

  • Plans that do include ortho generally only cover a portion of the total cost, often 50% of the total fees up to a lifetime maximum limit (usually $1,000-$2,000).

  • There is usually a waiting period before ortho services are covered, often 12-24 months. This means you need to be enrolled in the dental plan for that period before ortho coverage kicks in.

  • Many plans only cover orthodontics for dependent children under age 19. Adult ortho may not be covered.

  • Treatment plans, payment plans, fees all need to be approved by the insurance provider before coverage applies. Make sure to check your plan details.

  • Monitor claim reimbursements closely. Insurance may not cover the full 50% of fees if they deem certain services unnecessary.

  • Check if your dentist is in-network. Using an out-of-network orthodontist means you'll likely have higher out-of-pocket costs.

The best thing is to carefully review the details of any dental plan you're considering to understand the specifics of the ortho coverage. Check with the insurance provider directly if you have any questions.

It's important to note that some dental insurance plans may have waiting periods, exclusions, and limitations on coverage for certain procedures. Additionally, coverage may be subject to annual maximums and deductibles. Preventive care is often more generously covered than major procedures, with insurers encouraging policyholders to prioritize preventive measures to maintain good oral health and prevent more extensive treatments. Before selecting a dental insurance plan, carefully review the policy documents, understand the coverage details, and consider your own dental health needs. It's also advisable to check if your preferred dental providers are in-network to maximize coverage and minimize out-of-pocket costs.

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