How Does Dental Insurance Work?
How does dental insurance work? It doesn’t. Just kidding. Dental insurance does work, it just doesn’t work the same way as health insurance, which most people assume it does. When most people think about health insurance, they think first about covering costs of treatment for serious medical conditions or accidents. But, dental insurance is a completely different animal.
“Dental insurance” is not really insurance, it’s more like a benefit. Most dental plans are chosen and by employers to save you some money on your dental care, but it does not relate at all to your personal dental needs or “catastrophic” dental needs.
That being said let’s look at a little history of dental insurance.
Dental insurance was first introduced in 1954 and gained popularity in the 60’s. By the 70’s, many employers offered dental insurance plans. These plans typically covered 100% of preventive care, 80% of minor dental work, or basic dental work, such as fillings and simple extractions, and 50% of major work such as crowns and bridges.
The annual maximum annual coverage of dental plans in the 70’s was $1000. Back then, $1,000 bought a lot of dental care. Today, the average cap on dental plans is…wait for it… $1,000. Um what? Yep, you read that right — most plans still offer $1,000, some plans offer $1500, and the rare plan offers more, but the average is still $1000. So in over 40 years, dental maximums have not gone up. Based on the Consumer Price Index, $1000 in 1970 would now be around $6258. Yes, you read that right. What you could have bought in 1970 for $1000 would cost you over $6000 today.
Let’s take a look at how most dental insurance plans work these days.
First, you have a deductible, which is typically $25 or $50. This is applied and paid by you when you have your first appointment for dental treatment like a filling or crown. Most plans do not apply this deductible toward your exams and cleanings, therefore no money is due from you during these types of appointments, unless your plan does not cover certain procedures such as fluoride for adults.
Then, you have your reimbursement levels, or the percentages of what your dental plan will cover. Most plans are typically grouped into three categories:
- Type 1 (Preventative/Diagnostic) 100% coverage – exams, x-rays and cleanings, fluoride and sealants for kids up to a certain age.
- Type 2 (Basic restorative) 80% coverage – fillings, root canals, extractions, periodontal procedures.
- Type 3 (Major restorative) 50% coverage – crowns, dentures, bridge work.
The coinsurance would be the percentage of the covered dental expense you pay, after the deductible has been met. So, if your plan covers 80% of a procedure your coinsurance would be 20%.
Next, is the annual maximum benefit. Most plans have a maximum of $1000.00 – $1500.00. Once you have reached that maximum, dental insurance will not pay for any more treatment that may be needed for the year. Which leaves you paying out of pocket.
Looks pretty straight forward doesn’t it? But hold on, many plans have exceptions especially with dental insurance. Here are some possible exceptions that dental plans may have:
WAITING PERIODS: Woops! You have to wait 6 months from your effective date on the group dental plan for Type 2 services to be covered!
MISSING TOOTH CLAUSE: If the tooth was missing prior to your effective date with the group plan, too bad. They are not going to pay to replace it with a bridge or implant.
FREQUENCYS: The group plan allows certain services at certain intervals. Cleanings every 6 month plus 1 day. (I’m not kidding, have your cleaning 1 day too soon and you insurance won’t cover it.) Full sets of x-rays are usually limited to every 3-5 years. That means if you switch dentists you want to have those x-rays sent over before you arrive.
DOWNGRADES: Most plans have “downgrades”, meaning the insurance may approve a procedure, but pay for a less expensive procedure (Example: You have a tooth colored filling on a back tooth. Your insurance pays what it would pay for silver, leaving you with the difference in cost).
So, that’s basically how dental insurance works. As you can see it can be easy and confusing at the same time, and, not a whole lot hasn’t really changed with dental plans in over 40 years!
If you have any questions about your dental insurance please feel free to call us here at 972-242-2155. Or you can use the “Ask Dr. Griffin” link at the top of this page.