Dental Insurance FAQs
Happy new year! We have many inquiries regarding how dental insurance works. The confusion seems to revolve around a patient’s expectation that dental insurance should work much like health insurance or even car insurance – when the patient has a problem, insurance kicks in and pays for the patient’s needs. In fact, dental insurance works nothing like other insurance policies!!!!
What is a Yearly Maximum?
A yearly maximum is a set amount that a dental insurance company will pay out in a year. While most maximums run on a calendar year, beginning January 1 and ending December 31, some run on a fiscal year. It is an employer who determines if they want the insurance plan to be run on a calendar or fiscal year.
Generally, maximums will automatically renew each year and very seldom will roll over from year to year. In other words, if you do not use your entire yearly maximum, you loose it. Most dental insurance companies allow an average yearly maximum of $1,000 ~ $3,000.
What is a Deductible?
A deductible is a set amount that the insured must pay before a dental insurance company will pay out any dental benefits. Typically most insurance plans purchased by employers have a $50.00 deductible, so the first $50.00 of dental work an insured has done they will have to pay for.
Many dental plans waive the deductible for preventative procedures, meaning you do not have to pay out your deductible before the plan will pay for routine services, such as cleanings and examinations. It is very helpful to know if your plan waives the deductible for preventative services so you are not surprised to find you owe money for a cleaning or exam.
How Does Dental Insurance Work?
While all plans are different, the standard model for dental insurance is for the plan to have a yearly maximum, a deductible and to cover certain services at certain percentages. Once a patient has reached their maximum, dental insurance will not pay for any more treatment that may be needed for the year. The majority of dental plans have a benefit schedule similar to this:
Yearly Maximum/DeductibleCovered Percentages
Maximum Deductible Preventative Basic Major
$1,500.00 $50.00 100% 80% 50%
What procedures typically fall under “preventative?
While all dental insurance plans vary, most insurance companies consider routine cleanings, comprehensive and preventative examinations and standard x-rays as preventative services.
What procedures typically fall under “basic”?
While all dental insurance plans vary, most insurance companies consider fillings, simple extractions and root canals as basic services.
What procedures typically fall under “major”?
While all dental insurance plans vary, most insurance companies consider dentures, crowns, bridges and partials as major services.
What does it mean that my insurance downgrades to amalgam?
The vast majority of dental insurance plans will downgrade composite fillings to amalgam fillings when they pay their portion of dental services. To elaborate, there are two main types of fillings: 1.) tooth-colored composite fillings that are made of a resin material and 2.) silver-colored amalgam fillings that are made primarily of mercury and mixed with other metals. Amalgam fillings are made of less-expensive materials than composite fillings and require less of a dentists time to complete. For this reason, they are less expensive than composite fillings. Insurance companies often will pay for procedures based on what is called the Least Expensive Alternative Treatment (LEAT), so if you have a composite filling placed, they will pay their portion of the treatment at the rate of an amalgam filling and you will be responsible for the remaining balance.
Why doesn’t my dentist office know exactly how my benefits work?
Many patients seem surprised when they tell us they have Delta Dental, for example, that we don’t instantly know exactly what their plan covers. Unfortunately because of the sheer number of dental plans, and the hundreds of restrictions set per plan, it is IMPOSSIBLE to know exactly what an individual’s plan will cover for each dental procedure.
So even within a particular insurance company, such as Delta Dental, there are literally thousands of different unique plans and knowing the ins and outs of all of these plans is impossible.