The Nitty Gritty Details of Dental Insurance Plans

Dental insurance, it’s the dreaded thing that confuses everyone and might be scarier than dentistry itself! Every day patients come into my office with questions about their insurance. In most cases, they ask how it works and want to know exactly how much their visit is going to cost them. What you may not know is that medical insurance is very different from dental insurance. In this article, I’ll provide you with the nitty gritty details you need to know before looking into different dental insurances.

1) Dental insurance vs medical insurance

The biggest misconception about dental insurance is that most patients think it works the same as medical insurance. In reality, dental insurance (i.e. a dental benefits plan) does not cover procedures in the same fashion that healthcare plans do.

For example, insurance plans are designed to reimburse you for a loss or injury, similar to how car or health insurance works. Dental insurance is quite different; it covers only certain costs or procedures while paying a percentage of other procedures. In fact, there will be some procedures recommended by your dentist that will not be a covered benefit. As a result, it’s important to check with your dental insurance to find out what’s included.

Honestly, dental insurance rewards those that get preventative care. Dental insurance is not like medical insurance, and they will not take care of full mouth reconstruction or catastrophic events.

RELATED: 7 Ways To Reduce Your Dental Expenses

2) Not all dental insurance is created equal

First and foremost, if you work at a company that provides or has a dental package to buy, take it. Most likely, they pay for a part of your premium and the upfront costs and percentages they pay will be higher. Also, many company offered dental plans have little to no waiting period. This means you as the patient can start using the plan effective immediately.

There are many different types of dental plans and this is where things get complicated. Most dental plans have a deductible. This is a set amount that needs to be paid for treatment prior to having your plan cover a part of the necessary services. Luckily, most plans do not require a deductible for preventive or diagnostic services and the deductible is usually much lower than most medical plans.

Unfortunately, there are a ton of dental insurances with many different names. This article isn’t about specific insurances but what to look for in a dental insurance plan. Therefore, I recommend doing some research to figure out which plan fits you best, as it can save you a lot of money in the long run.

Also, with current health reform laws, dental benefits are not mandatory for adults but considered essential for children. So be careful when looking at each plan. Make sure to pay attention to what type of dental insurance the plan falls into and for whom it covers.

3) HMO vs PPO vs discount or referral dental insurance

A PPO dental insurance, or preferred provider organization, is similar to a health care plan where you have a large network of doctors. Going out of network will cause you to have a higher out of pocket cost while using a dentist in your network ensures having set fees. Dental services covered vary plan to plan so be sure to check on what is covered. In most cases, a co-pay or predetermined percentage is owed at the time of service. Also, a PPO usually covers out of network dentists at a lower percentage so there is still some percentage of your dental bill covered.

An HMO/DMO dental insurance, or dental health maintenance organization, has a large network of dentists that are paid a set fee every month to provide covered dental services to the patient – whether you go to the dentist or not. Like a PPO, there may be a co-pay or percentage due depending on the service provided by your dentist. If you have an HMO, going out of network will not cover a percentage so you will be responsible for the full amount due for treatment.

Discount or referral dental insurance is sold by companies that work with a group of dentists that agree to discount their dental fees. All of the services have an agreed upon discount where the plan does not pay for services received, but instead you pay for treatment yourself at the reduced rate. This can be comparable to paying for a Sam’s club or Costco membership and getting discounted prices at that specific store.

RELATED: Baby’s First Dentist Appointment: What You Need To Know

Make sure you read the fine print when looking into dental insurance plans

4) Why looking at the contract is important!

Even when dental services are covered in the above plans, most services have some sort of upfront patient cost that goes along with treatment. If you have dental insurance through your work, the amount covered is determined by your employer and how much they contribute. On the other hand, if you buy an individual dental plan, the amount covered by your dental insurance will be clearly stated in the contract and likely at a lower percentage.

Unfortunately, most dental insurance providers expect the patient to pay a certain percentage of the cost of treatment. For example, your plan may cover basic fillings at 80 percent. However, for major work like crowns, implants, and partials, they may only cover at 50%. As a result, reading the fine print is extremely important. In fact, I recommend that you call the insurance company for clarification.

Another thing to pay attention to is the annual maximum. Once the annual maximum is met, or is not a covered benefit of the dental plan, the patient is responsible for anything after. In cases like this, the term “maxed out” is used and any additional amount over the allowed maximum is considered an out of pocket cost. If you believe that your annual maximum is too low for your specific needs, you can ask your insurance company how to get a higher annual maximum to meet your needs. In particular, braces can be tricky. Some insurances have a separate lifetime maximum or age limit for braces to so read the fine print.

Lastly, if you’re looking at replacing a specific tooth, lookout for a pre-existing condition clause. If your insurance has this clause, your dental plan may not cover missing teeth or conditions that are present before enrolling. Even worse, you may be responsible for paying for all costs associated to but not limited to replacing a tooth that was missing prior to the effective date of coverage. Also, services can be limited to frequency, aka the number of cleanings per year, or how often a crown previously done can be replaced.

5) Is dental insurance really necessary?

Honestly, it depends on the person, their budget, and the amount of dental care you need. If you don’t have many cavities, buying dental benefits may cost you more in the long run than paying out of pocket.

When considering a plan, try to add up the total costs of the plan. Also, don’t forget to add some of the things I have addressed above, including but not limited to the deductible, premium, and out of pocket costs. Compare all of this to what you’ve paid at previous dental visits. Have there been more expensive procedures or do you usually have routine cleanings and that’s it?

Lastly, your circumstances and health will change over time. As a result, I recommend evaluating your policy every year during open enrollment. There are also licensed insurance agents that deal specifically with dental insurance. If you have questions or your employer does not offer benefits, use them as a resource.

Finding the right dentist for your needs

One of the best ways to find a dentist is through word of mouth. If you have friends, family, colleagues that love their dentist, check if they accept your dental insurance.

The ADA has a program called Find-A-Dentist. It’s an excellent tool that lets you search for a dentist by distance. Also, with today’s technology, Google and Yelp reviews can provide you with great insight into a practice. Just make sure to take each review with a grain of salt.

If a dentist is in-network, they have signed a contract with a dental plan carrier accepting specific fees for their services. The fee is then paid by your dental plan and you then pay a portion of it through a deductible or percentage.

On the other hand, if the dentist is not in-network, you might have to pay a higher percentage or have some services that aren’t covered at all.

RELATED: Root Canal Treatment: Everything You Need to Know


In the end, I hope you’ve learned a lot about dental insurance plans. While tricky, not all dental insurance is created equal, so make sure you take the time to learn about your coverage. Also, a dentist can become a long time advocate for your well-being, so find a great one! A lot of offices will work with your time constraints and financial concerns so don’t hesitate to ask questions. If you have any questions about dental insurance, feel free to comment below.

Previous articleThe Incredible Nutritional Power of Pumpkin
Next article10 Alternatives To Candy For Halloween Trick-or-Treaters
Dr. Winnie Wong is currently a board certified general dentist practicing in the heart of downtown Cleveland. She graduated from Case Western Reserve University School of Dental Medicine with a Doctorate in Dental Medicine (DMD) and then went on to Loyola Medical Center in Chicago, Illinois, for a 1-year General Practice Residency (GPR). Dr. Wong has participated in several dental community outreach programs including Summer Medical and Dental Education Program (SMDEP), Healthy Kids Healthy Smiles, and Remote Area Medical (RAM). Dr. Wong strives to bring enthusiasm, compassion and high quality care to her dental practice. Dr. Wong is an active member of the American Dental Association, Academy of General Dentistry, Ohio Dental Association, and Greater Cleveland Dental Society. In her free time she plays and coaches volleyball, tries new restaurants and food, and gardens.