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Dental Insurance 101: A Guide to Understanding Your Dental Plan
Article updated: June 4, 2023
Dental Insurance: The Basics
While dental insurance helps to reduce your out of pocket dental costs, prevention is the best way to minimize your out of pocket dental care costs.
Recipe to minimize dental treatment costs
Brush 2X day
Flossing daily
Dental exam & Professional teeth cleaning 2X year
Maintaining good daily dental health habits will help reduce the need for extensive dental treatment.
Understanding Dental Insurance
Dental insurance policies are written by underwriters and reviewed by attorneys. Most people rely solely on their HR representative or insurance broker to decipher and understand what services are covered, not covered, at what rate, and how often.
While this is helpful, there’s often fine print, that if overlooked, can result in unexpected out of pocket expenses for you. Companies are beginning to invest in insurance agency management software to prevent any confusion. This software will make it easy for customers to access their documents and anything else they need to find out regarding their policy.
If you’re at all uncertain about your insurance coverage, it is best to contact your dental insurance company directly.
Dental insurance questions? Don’t assume, ASK.
Assuming or relying on what the insurance salesperson told you will not help you when you receive a dental bill you had not expected. Don’t assume…ASK.
- Call your dental insurance’s helpline
- Contact your dental insurance or human resources representative
- Or ask any one of our patient care coordinators
Dentistry for the Entire Family patient care coordinators are happy to answer your dental insurance questions.
Call (763) 586-9988 or email us your question(s).
Most dental insurance carriers provide each covered person with an identification card.
This card contains pertinent information regarding your insurance policy.
- Name of covered person
- ID or group number
- Network if applicable
- Copayment if applicable
- Phone number for dental insurance customer support
- Address to remit dental insurance claims for disbursement of benefits
- Website address of dental insurance company
Be sure to bring your dental insurance card with you to each dental appointment. We will scan the front and back of your card and retain this information in your electronic record.
Dentistry for the Entire Family’s patient care coordinators will submit your dental benefit claims on your behalf provided your dental insurance information is on record. Copay, coinsurance, and any dental treatment costs not covered by your insurance are due on the day of service.
If you prefer to submit your own dental insurance claims, just let us know. One of our patient care coordinators will print out your claim for you to submit for reimbursement. If you elect to submit your claim, full payment for all dental treatment rendered is due on the day of service.
New Year = New Dental Insurance Coverage Period
The beginning of a new year often signals a new dental insurance coverage period for many. Dentistry for the Entire Family recommends that your review your dental insurance policy annually for any changes and/or updates regarding coverage.
Doing so will help you to maximize your benefits and minimize your out of pocket costs for you and your family. If your policy is a renewal policy, new coverage periods often include changes and/or updates to a policy. Be sure to review your policy for the following:
Any changes in covered/excluded services
A change in annual maximum
A change in annual deductible
A change in coinsurance
A change in copays
Dentistry for the Entire Family’s patient care coordinators are more than happy to assist you and answer any dental insurance questions you may have. Simply call (763) 586-9988 or email us your questions.
Dental Insurance Terms & Conditions
Listed below are easy to understand definitions for commonly used terms and language that you likely will encounter while reading your insurance policy.
Click on the desired term below for more information.
Dental insurance policy coverage period
Dental insurance policy maximum
Dental insurance policy deductible
In network & Out of network dentist provider
Dental insurance reimbursement levels
Predetermination of dental benefits
Dental insurance policy limitations & exclusions
Non-duplication of benefits clause
Dental insurance policy coverage period
Dental benefits are calculated within a defined coverage period, typically 12 months. This coverage period is defined by your employer or insurance administrator. Most coverage periods are based on an annual or a company’s fiscal calendar.
Examples
January-December (annual calendar)
June-May (fiscal calendar)
Dental insurance policy maximum
Most dental plans have an annual dollar maximum. This is the maximum amount your insurance carrier will pay towards your dental care during the policy coverage period.
Example
Many plans have a $1500 annual maximum. Translated, this means that your dental insurance company will provide benefits according to your policy up to $1500 during your coverage period. Once dental insurance has paid $1500, any
additional services will not be covered and are your responsibility.
Dental insurance policy deductible
Many dental insurance plans have a deductible or a specified dollar amount that must be paid before your policy benefits will take effect. Each policy varies. Some policy deductibles apply to all covered dental services while others may only apply to individual services such as dental fillings or dental crowns.
Example of $50 deductible
Say your first dental bill during the coverage period totals $400. You’re responsible to pay $50 plus any coinsurance. Any additional dental treatment will be covered according to your policy benefits until the end of your policy period.
Waiting period
Some dental insurance plans have a waiting period. A defined period of time that must pass before your dental benefits become effective. Waiting periods vary widely among dental plans. Some plans only have waiting periods for dental treatment and not for preventive care.
Example: 90 Day waiting period
If your insurance coverage period begins on January 1 and you have a 90 day waiting period, any dental treatment you receive in the first 90 days of your coverage period will be your responsibility. Dental treatment received after 90 calendar days have passed will be paid according to your insurance policy.
Dental coinsurance
Coinsurance, also known as patient responsibility, is your share of the costs for dental treatment completed. It’s usually defined as a percentage 80% / 20% or 50% / 50% are common examples. Your plan deductible must be met before your dental policy benefits take effect.
Example #1: 80% / 20% coinsurance assuming yearly deductible has been met
80/20 means that if a dental treatment costs $100, your dental insurance will pay 80% or $80 toward the cost of your dental treatment. The remaining $20 or 20% is your responsibility, out of pocket costs.
Example #2: 80% / 20% coinsurance and annual deductible of $25 has not been met
Using the same scenario above that dental treatment costs $100, your patient responsibility would be an additional $25 for the deductible for a total out of pocket cost of $45. Any additional dental treatment received during the coverage period would be paid similar to example one.
Dental insurance copay
A dental copay is a fixed amount you pay for a specific dental treatment on the day you receive the specific dental treatment.
Example $15 copay for teeth cleaning
The $15 copay is paid on the day you have your teeth cleaned. Most people pay their copay when checking in for their dental appointment. Once your copay is paid, your dental insurance provider will pay remaining teeth cleaning benefits to your dentist. There will be no additional out of pocket costs for you for having your teeth cleaned.
In network & Out of network dentist provider
A network provider, also known as a participating dentist, is a dentist who has completed a credentialing process and signed a contractual agreement with a dental insurance company to provide dental treatment for specific dental insurance plans.
It is important to note that dental insurance companies offer multiple plans. A dentist’s contract may not be a participating or in network provider for all offered plans from an insurance company.
Example #1: Teeth cleaning appointment with in network dentist
You have scheduled to have your teeth cleaned. Your dental insurance policy states that they will pay 100% for your teeth cleaning if your dentist is an in network provider. Your dental insurance company will pay your dentist for your teeth cleaning according to terms defined in their contract. You will not incur any out of pocket costs for having your teeth cleaned.
Example #2: Teeth cleaning appointment with an out of network dentist
You have scheduled to have your teeth cleaned with a dentist who does not have a contract with your insurance company. Your insurance policy states that they will pay 100% for your teeth cleaning if your dentist is an in network provider or 75%
if you have your teeth cleaned by an out of network dentist. In this scenario, you and your insurance company will share the cost of having your teeth cleaned. Your dental insurance company will pay 75% and you will pay 25%. This 25% is due on the day you have your teeth cleaned.
Dental insurance reimbursement levels
Insurance companies divide dental services into four main categories: preventive, basic, major, or not covered.
- Preventive
- Basic
- Major
- Not covered
Preventive dental services
Preventive services often include but are not limited to:
- Dental examinations
- Dental x-rays
- Teeth cleaning
- Application of dental fluoride & dental sealants
Basic dental services
Basic dental services often include but are not limited to:
- Dental fillings
- Gum disease (periodontal) treatment
- Teeth partials
- Dentures
Major dental services
Major dental services may include but are not limited to:
- Dental crown
- Dental bridge* see missing tooth clause
- Root canal
- Oral surgery aka tooth extraction
- Dental braces
Predetermination of dental benefits
A predetermination of dental benefits is an itemized list of proposed dental treatment options that is submitted to your insurance company to determine if proposed services are eligible for coverage. For covered services, the predetermined benefits summary will include the insurance benefit dollar amount and your patient responsibility.
This estimation of benefits will help you to know your anticipated out of pocket cost for each discussed treatment option. This information along with the advantages and disadvantages of each discussed treatment option should be carefully considered before making an informed decision regarding proposed dental treatment. Once you have decided, it is appropriate to schedule your
dental treatment.
Dental insurance policy limitations & exclusions
A dental insurance plan is meant to help defray your out of pocket dental expenses. Your policy will clearly specify what it will and will not cover.
If you receive any dental treatment services and/or related costs rendered outside of your dental insurance policy terms, you will be responsible for 100% of dental treatment costs. These costs are due on the day that dental treatment is received.
Examples of policy limitations & exclusions may include:
- Type or number of service procedures rendered (Ex. 2 teeth cleanings are allowed per year)
- Time or required interval before service is covered (Ex waiting 6 months between teeth cleanings)
- Age limits (Ex. No coverage for the application of preventive dental sealants over 18 years old)
- Lifetime benefit (Ex. Will pay 1 time for the application of a preventive dental sealant on each permanent molar as long as you remain a policyholder).
Dental insurance policy limitations and exclusions are detailed in your policy handbook. It is best to ASK or have us send in a predetermination of dental benefits for any proposed treatment you are unsure if you have coverage for.
Missing tooth clause
A missing tooth clause describes a situation in which your insurance carrier may decline to provide tooth replacement benefits for a tooth that was extracted prior to your current dental insurance contract.
Example
Say you had a toothache 2 years and elected to have the tooth extracted because you were uninsured. Now, you have dental insurance and wish to fill the space of your missing tooth with a dental bridge. Your insurance may offer dental benefits for the two teeth adjacent to your missing tooth and decline benefits for the tooth you had pulled.
If this is the case, your out of pocket costs would be higher than you may have planned for. In these situations, Dentistry for the Entire Family highly recommends to submit a predetermination of dental benefits prior to scheduling your appointment.
Dual dental coverage
Dual dental coverage is when you are eligible for dental benefits under two dental insurance policies. Dual coverage does not mean that you have double the coverage. For most people dual coverage results in minimal out of pocket costs.
If you are dual covered, typically the plan that covers you as an enrollee is referred to as your primary insurance and the plan in which you’re enrolled in as a dependent is referred to as your secondary dental policy.
Non-duplication of benefits clause
A non-duplication of benefits clause is a provision if you have dual dental coverage. This provision states that your secondary
dental policy will not provide benefits if your primary dental insurance plan paid the same or more than what the secondary plan provides coverage for.
Questions?
Dentistry for the Entire Family’s patient care coordinators are more than happy to assist you and answer any insurance questions you may have. Simply call (763) 586-9988 or email us your questions.
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