Understanding dental insurance coverage

October is National Dental Hygiene Month, a great opportunity to make sure you are up-to-date on your dental health and hygiene in order to keep your teeth and mouth healthy now and into the future. If you are planning to schedule that regular check-up (which you should do ASAP if you haven’t already!), it’s important to understand how your dental insurance coverage works and what you are and are not responsible for when it comes to paying for dental care.

Dental insurance coverage has some similarities to medical health insurance coverage, but there are also some big differences that can have an impact on your costs. Here are a few key things to keep in mind:

• Out-of-pocket costs – Similar to medical coverage, dental plans often have a deductible that you must meet each plan year before your coverage kicks in. Once you’ve met your deductible, you will likely still be responsible for a set co-pay or coinsurance, a percentage of the cost of care (a bit more on this below). These can vary by plan, so it’s important to review your plan information for details.
• In- vs. out-of-network – Like medical providers and facilities, dentists may not accept every dental insurance plan. It’s important to check if your dentist is in-network. If you choose to visit an out-of-network dentist or a practice that does not accept any insurance, you will be responsible for submitting the claim, and it may not be covered at the same rate as someone in-network. Make sure to review and understand this information in advance.
• Maximums – The Affordable Care Act got rid of the majority of lifetime and annual limits for medical benefits; however, dental coverage is not included under this change. Unlike medical plans, most dental plans have an annual maximum, meaning that once you have received this amount of care during the plan year, you are responsible for paying for anything else after that.
• Reimbursement levels – While most plans fully cover preventive dental care, including routine exams, cleanings, and x-rays, other services are reimbursed at different rates depending on how they are categorized. For example, fillings are often considered basic procedures, or Class II, which means that you may be responsible to pay coinsurance of 20-30 percent (this can vary) of the cost of the procedure. However, major procedures like root canals, categorized as Class III, may require coinsurance of 50 percent. Structuring dental plans with reimbursement levels is intended to encourage people to take advantage of low or no-cost preventive care and hopefully avoid more extensive, expensive procedures.
• Exclusions and limitations – It’s important to note that dental plans may not cover all services your dentist recommends. This could be for a number of reasons, including pre-existing conditions, the material used for the procedure, age limits, and more. Your plan may cover an alternate treatment option that is less expensive or extensive than the one your dentist suggests, so talk with your dentist to see if you can find out what your plan covers in advance of a procedure.

Good preventive care can have a major impact on the future of your dental health and help you avoid costly treatments later on. Call your dentist to schedule a routine exam and take steps to keep your smile healthy.

If you’re a Health Advocate member, contact your Personal Health Advocate to find an in-network dentist in your area or for help scheduling your next routine visit.