What is Dental Insurance?

Thinking about getting dental insurance? Confused by all the details and pricing? You don’t have to be. Benzinga has put together this easy to follow and informative guide to help you find exactly the right type of dental insurance you’re looking for.

What is Dental Insurance?

Dental insurance helps you lower the cost of dental care by requiring you to pay monthly premiums in exchange for covered services, possibly with a co-pay or deductible.

Dental insurance breaks down into different types of care, including:

• Preventative
• Restorative
• Orthodontic

Your dental insurance plan should fit your needs, whether they be simply preventative or more advanced treatments like bridges, implants, or even dentures. Dental insurance is sometimes provided by your employer, or you can get an individual plan all on your own. Dental insurance typically does not cover anything cosmetic, like whitenings, veneers and braces.

Important Dental Insurance Terms to Know:

If you’re thinking about buying dental insurance, it’s important to know the different terms and exactly how they apply toward your policy. Having this information means finding just the right dental insurance coverage for you.

What is a deductible?

A dental insurance deductible works just like any other health insurance deductible, meaning that this is the amount you pay before the insurance policy kicks in. Let’s say for example you have a deductible of $500 but the procedure costs just $300. Don’t get surprised when your dentist tells you you’re going to be paying the full amount for the procedure. This typically applies to an annual deductible however, and the next time you use your insurance you will get a credit of $300.

If the procedure, however, is $1,000, that means you pay $500 and your insurance covers the rest, minus any coinsurance your plan may have. The amount of the deductible is important because it has a direct relation to the amount of your monthly premiums. The higher the deductible, the lower the premiums, and vice-versa. Most deductibles get calculated on an annual basis.

Depending on your policy, deducticles can be anywhere from:

• $50
• $100
• $250
• $500

What is coinsurance?

Along with your deductible, coinsurance is another way to share the cost with your insurance provider. Coinsurance may seem prohibitive at first, but in reality it actually helps lower your total costs. Because you pay extra only when you use the services, it helps lower the cost of your premiums. 

Here’s how it works: coinsurance works on a percentage basis. The coinsurance share can be anywhere from 20% to 50%, depending on your individual policy. Let’s say the amount of dental work you need done is $1,000 and your deductible is $500. The difference, or $500, you pay up front. 

Now, the coinsurance comes into play. If your coinsurance percentage is 20%, that means you pay $100 while the insurance company pays the remaining $400. Total cost to you for the procedure: $600. 

What is a waiting period?

Lots of insurance and insurance-like services have waiting periods. They must or people would just buy them in their immediate time of need. Take for example a car service like AAA. How could they stay in business if people only bought them after the fact? That’s not insurance at all.

Just like with other insurance, dental insurance often has a waiting period. These time periods can go anywhere from 1 month to a full year from the time you sign up. Certain procedures are not covered during this time period, although routine checkups and minor dental work are often included.

While a waiting period may seem prohibitive to the policyholder initially, in reality it helps keep costs down for the insurer and in turn for the insured. Insurance policies must be in force in times of health, not just emergency. This is what makes dental insurance affordable in the first place.

What is an annual maximum?

Before the passage of the Affordable Care Act (ACA), general health insurance plans had annual maximums, meaning there was a set amount where you, the insured, were maxed-out and no longer received coverage. While the ACA did away with annual maximums for health insurance policies, most dental insurance policies still carry annual maximums.

The annual maximum is, quite simply, the maximum amount a dental insurance provider will pay in any 12-month timespan, also known as a benefit period. A benefit period runs from any stipulated date to 12 months after, typically during a calendar year.

Let’s say your dental plan’s annual maximum is $1,500. This doesn’t mean you get just $1,500 worth of work done. This means your provider will payout $1,500 as their share toward your total costs after deductibles and coinsurance. This annual maximum gets reset at the beginning of the next benefit period.

What is an in-provider requirement?

Also known as in-network, the dental insurance in-provider requirement stipulates that HMO policy holders must choose a dentist inside the carrier’s network in order to take advantage of their benefits. Today, an estimated 8% of dental plans are HMOs, requiring the policyholder to have their primary dental physician in-network.

To make sure you’re covered, be sure to:

1. Ask your dentist if they are an in-provider to your network
2. Request a list of in-network providers
3. Find out what percentage of your plan your provider covers
4. Make sure the procedure and the provider are both covered
5. Check your plan’s description of covered services

While just 8% of dental plans are HMOs, 82% are PPOs. In a PPO, the policyholder is free to see dentists outside of the network, although they may face higher out-of-pocket expenses. 

What is a primary dentist requirement?

For general healthcare coverage you’re required to have a primary care physician (PCP). But does dental insurance also require that you have a primary dentist? It depends on what type of coverage you have.

Dental PPO plans (DPPO) do not require that you have a primary dentist. With a DPPO, you can visit any dentist you want, anytime. You can even switch your dentist without notifying your insurance company. With an HMO plan (DHMO), you’re required to designate a primary dentist.

With a DHMO, you can switch dentists, but are limited to how many changes you can make and you must call your insurance company first. What this means is waiting times if you want to switch dentists. Many times you will have to wait until the next month until you can see your new dentist, or even longer when they are not yet on the roster.

What is orthodontic care?

An orthodontist specializes in mispositioned or misaligned teeth. Orthodontic care is often not covered in a traditional dental plan. It is not covered by Medicaid or Medicare either, except in cases of medical emergency.

Orthodontic care is typically considered cosmetic, unless in case of accident or trauma. Orthodontists specialize in a variety of items including:

• Braces
• Aligners
• Retainers

If you’re looking for orthodontic care, make sure your plan contains that coverage. Basic dental plans do not cover orthodontic care. You have to add it. Make sure your annual maximum is high enough to cover the cost of orthodontic care as it can be quite expensive. Even if your plan does not cover orthodontics, there are discount services available.

What Does Dental Insurance Typically Cover?

Most dental insurance starts with a common list of procedures that are included and excluded.

Common inclusions

• Crowns
• Root canals
• Simple extractions
• Cleanings
• Fillings

Common exclusions

• Dentures
• Implants
• Veneers
• Braces
• Aligners

Orthodontic coverage

If you have dental insurance, you may or may not have orthodontic coverage for items like braces and aligners. The way to find out whether your plan covers orthodontics or not is to simply ask. Plans with orthodontic coverage will cost more than regular plans.

While most states require dental insurance to cover children’s braces, the same is not always true for adults. In the case of children’s braces, they are often covered if the necessity is medical, but not cosmetic. For example: Do they need their teeth straightened so they can chew correctly, or are they just wanting to look better?

Types of Dental Insurance Plans

When it comes to dental insurance, just like with general healthcare coverage, there are different types of plans. The most common include:

• Dental Preferred Provider Organization (DPPO)
• Dental Health Maintenance Organization (DHMO)
• Dental indemnity
• Dental Exclusive Provider Organization (DEPO)
• Dental Point of Service (DPOS)

Here are the different types in more detail. What exactly they do and do not cover are particular to each specific policy.

What is a Dental PPO plan?

Just like with PPO coverage, dental insurance has a DPPO plan. DPPOs do not require that you choose a dentist within their network, although having one outside the network will cost you extra. You are also not required to choose a primary care dentist.

Like any insurance, DPPOs have an annual deductible and coinsurance. Most in-network procedures are covered, like cleanings, exams and X-rays, at 100% once you meet your deductible. Copays are often required.

Best for: 

DPPOs are best for people who want the most flexibility from their coverage, and don’t mind paying more to get it. If you’re the type of person who wants the dentist of your choosing, then a DPPO is for you.

What it covers: 

• Preventive care
• Basic and major restorative care
• Root canals
• Bridges
• Cleanings

What it doesn’t cover:

• Braces
• Implants
• Veneers

DPPOs offer more choices at higher costs, and require the policyholder to pay for out-of-pocket expenses when going out-of-network. DPPOs account for 82% of all dental plans.

What is a Dental HMO Plan?

Dental HMO plans (DHMOs) are more affordable than DPPOs, although they offer less flexibility. DHMOs are more restrictive when it comes to choice of dentist and typically do not allow the policyholder to go out of network. 

DHMOs focus more on preventative care like cleanings and check-ups, than they do major restorative or surgical procedures. With a DHMO plan, unlike with a DPPO,you’re required to choose a primary dental physician.

Best for:

DHMOs are best for people who are on a budget. They offer lower premiums and often no deductible. Copayments are often minimal or not even at all when it comes to diagnostic or preventative care. With a DHMO, referrals are required when going to see a specialist. DHMOs account for 8% of all dental plans.

What it covers: 

• Cleanings
• Fillings
• Crowns
• Roots canals
• X-rays

What it doesn’t cover:

• Braces
• Implants
• Veneers

What is a Dental Indemnity Plan?

While DHMOs and DPPOs account for 90% of all dental plans, they both sometimes require that your doctor be in-network. If you want to have complete freedom of choice, then a dental indemnity plan is for you.

Dental indemnity plans are perfect for those people who already have their favorite dentist, and want to keep them. Dental indemnity means choosing exactly who you want to do your:

• Implants
• Dentures
• Crowns

As well as other procedures. 

Best for:

Dental indemnity, or fee-for-service plans, are best for people who have money to spend. With dental indemnity, the focus is not on saving money but seeing whichever dentist you choose. People who have these plans are generally not on a budget but looking for the best care possible. Dental indemnity plans typically cover 50% to 80% of all dental work.

On the downside, most indemnity plans have a maximum allowance per procedure. In these cases, insurance company’s use what is called a UCR, a usual, customary and reasonable fee. What this means is that the customer pays the difference between the cost of your dentist and the insurance company’s UCR. Indemnity plans require that the policyholder pay out-of-pocket and wait for reimbursement.

What it covers: 

• Crowns
• Root canals
• Fillings
• X-rays
• Extractions

What it doesn’t cover:

• Pre-hospitalization expenses
• Post-hospitalization expenses

What is a Dental EPO Plan?

Dental EPO plans mean there is no out-of-network care. You must stay within your network. While more constrictive, a DEPO plan does mean lower premiums than a DPPO. DEPOs are a fee-for-service program designed to save the policyholder money. Like a DPPO, DEPO plan members are not required to have a primary dental physician. They are also not required to get referrals to see specialists.

Because DEPOs are fee-for-service plans, they require payment at the time of treatment, followed by reimbursement. Your dentist sends in the claims to the insurance company, so you don’t have to deal with the paperwork.

Best for:

DEPOs are best for people who want all the benefits of a DPPO, but want to save money on premiums at the same time. Because the plan is exclusive to the dental network, the policyholder has network limitations.

What it covers (depending on the policy): 

• Roots canals
• Crown
• Extractions
• X-rays
• Fillings

What it doesn’t cover:

• Dentures
• Implants
• Veneers

What is a Dental POS Plan?

A Dental Point of Service Plan (DPOS) is a managed care plan that is like an DHMO and a DPPO all in one. Like with a DPPO, a DPOS does allow policyholders to seek treatment outside of the network. When the policyholder’s doctor makes a referral outside of the network, the plan will pay for services.

At the same time, a DPOS plan makes special contracts with network providers. This means often having to stray within the network when seeking services. Like with a PHMO, a primary care dentist is required.

Best for:

DPOS plans are best for people who want to avoid paying a deductible. Many DPOS plans do not require the policyholder to pay a deductible when visiting their primary dental care provider. The flipside to this is that when seeking services out of network, the policyholder will often pay the full costs of the procedure. 

What it covers: 

• Root canals
• Fillings
• Cleanings
• X-rays
• Crowns

What it doesn’t cover:

• Implants
• Veneers
• Dentures

What is a Dental Savings Plan?

Dental savings plans are a more affordable approach to dental insurance. Most dental savings plans only cost a few hundred dollars per year and offer discounted rates to their members. These discounted rates apply to:

• Dentists
• Orthodontists
• Oral surgeons

With a dental savings plan there are no copays or deductibles. There is no annual maximum. All of the restrictions of a traditional dental insurance plan are removed. Dentists perform services and offer discounted rates to the plan holder. Dental savings plans can save the customer anywhere from 10% to 60% off normal fees.

Best for:

Dental savings plans are best for people who want to save money and at the same time don’t foresee many dental services needed. They can choose the doctor they want as there is no network. The only caveat is that the dentist must be willing to participate in the savings program.

What it covers (depending on the plan): 

• Crowns
• Implants
• Dentures
• Veneers
• Braces

What it doesn’t cover:

• Hospitalization due to dental trauma
• Emergency room costs
• Ambulance costs

Comparing Dental Insurance Plans

When comparing insurance plans, it’s important to take into consideration your needs. Are you looking to save money, or do you prefer greater flexibility when it comes to choosing your dentist? Do you need just preventative care, or are you looking for the comfort a more comprehensive plan offers?

Procedures offered by most plans include:

• Cleanings
• Fillings
• X-rays
• Crowns
• Root canals

Procedures requiring more extensive coverage include:

• Implants
• Veneers
• Dentures

Where to Buy Dental Insurance:

• Through your employer group plan
• With your Marketplace health plan
• Through a private provider

Once you’ve decided which type of coverage you need, the next question is where do you buy it. Benzinga has put together a comprehensive list of companies where you can purchase just the right dental insurance that suits your needs.

Through your employer group health plan

If you work for a company, the most affordable way for you to get dental insurance is through your employer’s group health plan. A group health plan provides more affordable health insurance because the risk gets spread throughout the company. 

While sponsored by the employer, the employee often pays their own premiums and must pay deductibles and coinsurance like with any other health insurance plan.

With your marketplace health plan

If you don’t work for a big company, if you're self-employed or even unemployed, then buying insurance through the marketplace is the best way for you. The marketplace, also known as “the exchange,” offers affordable health insurance policies to those who otherwise could not afford insurance. 

Policies are made more affordable through subsidies provided by the federal government. Open enrollment begins November 1 and coverage is available at HealthCare.gov.

Through a private provider

If affordability is not your primary concern, but flexibility and the best quality care is, then private insurance is the best way for you. While private insurance is more expensive, you’re not limited to in-network providers and can choose your own dentist. Private insurance is available from any insurance company and does not require that you work for a business or obtain government assistance.

Protect Your Teeth with Dental Insurance Coverage

You need to protect your teeth like it’s the last set you're ever going to have, because it is. Protecting your teeth means the right preventative care, combined with the right kind of dental insurance just in case the unexpected happens. Check out these great Benzinga articles, and how you can find affordable yet comprehensive dental insurance.

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