How Does Dental Insurance Work?

How Does Dental Insurance Work?

It is pretty easy to understand that how does dental insurance work. Most policies are straightforward about what they cover and what you have to shell out from your pocket. So, it is easier to choose a policy if you know how exactly things work. You can also purchase dental insurance as a stand-alone policy or as a part of medical insurance.

So, let’s begin!


An Overview Of Dental Insurance Plans

First of all, we need to understand how does dental insurance work. You choose one depending upon your choice of dentist and your budget.

Each insurance company has different types of networks, depending upon which they offer plans:


#1: Preferred Provider Organizations (PPO)

PPO makes available a list of dentists available to you that are in-network. The insurance company lets you see these dentists at low prices. But PPO plan is known for its flexibility. Say, some dentist you want to see is not on the network. Then you also get to see an out-of-network doctor. But, the cost of seeing a dentist outside the network is higher.


#2: Dental Health Maintenance Organizations (DHMO)

DHMO network types let you take services at a set dental insurance rate, which includes copays. You do not have to worry about your share of payment as the rates are standardized. What’s more, you do not have an annual benefit maximum or even a deductible.

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But where there are positives, are negatives too. This type of network does not cover you at all if you see an out-of-network dentist. Yes, you can only visit an in-network dentist.


#3: Discount Dental Plans

This network type is a third category and very different from the above two networks. It is not like insurance. Instead, they form a group of dentists. Now, when you see a dentist in the group, you can receive their services at a discounted price.

Unlike insurance, discount plans do not pay for your preventive care. This plan simply pays a percentage of the bill for a specific service.

Thus, you can choose a plan depending upon if you have already had a dentist and if it is on the group or not.


How Much Do I Need To Pay?

Many of us do not know that the insurance company does not pay the procedure’s full price. There is a 100-80-50 rule, and depending on the service you opt for, your share of the bill is decided.

All the services available under your policy are kept in three categories: Preventive, Basic, and Major.

Preventive care includes annual visits, cleaning, and X-rays, etc. Most insurance companies pay 100% of the cost of such dental care.

Next comes the Basic services, such as gum disease, fillings, etc. The insurance companies pay 80% of the cost of these services. Another thing to keep in mind is the final amount to pay is calculated after taking into account the deductible, copays, and coinsurance.

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Lastly, the Major services like bridges, dentures, inlays, etc., are covered 50%. Again deductible, copays, and coinsurance apply.

All policies categorize services differently. For example, few keep root canal as a Basic service and some as Major. Thus, do read the fine print before entering into a contract.


Important Insurance Terminology

It is essential to know the insurance jargon to understand the policy better. And it will help you make an informed decision.


#1: Waiting Period

There is a waiting period for most policies. This means that there is a period between you buy the policy, and you can use it. Usually, there is a six to twelve-month waiting period before using any standard services. At the same time, the waiting period for the Major services ranges from one to two years.

Although, this period can be waived off in some cases. But only if you can prove that you did not hide anything while applying for the policy.

The reason behind this clause is to discourage people from buying the policy for impending procedures.


#2: Deductibles

The deductible is a set amount you have to pay before the insurance company pays you anything. For example, let’s say the deductible is $150 and the procedure is worth $125. Then the insurance company will not pay for anything. You pay the whole amount from your pocket.


#3: Copays or Copayment

Copays or copayment is another set amount you have to pay each time you visit a dentist. You pay it along with the deductible. However, not all policies demand a copay. So, dig this out from your insurance agent.


#4: Out-of-pocket maximum

It is the maximum amount you will pay in a year. Let’s say it is $2000. So, you will pay deductibles approximately ten times a year, and the out-of-pocket expenses will be over. After this limit, you do not have to pay the deductible. You can reap the benefits of your policy worry-free.


#5: Coinsurance

Once you achieve the out-of-pocket expense maximum, you are required to pay the coinsurance amount. This coinsurance is sometimes fixed and sometimes flexible. It all depends on your plan and the service you want to avail. When flexible, it can range between 20% to 80% of the cost of the bill.



So, in a nutshell, dental insurance is pretty similar to health insurance. You need to choose from three major types of plans. PPO. DHMO, and discount dental plans, which is quite similar to health insurance.

Also read: 9 Factors to help you choose the best Disability Insurance?

Also, the 100-80-50 rule clarifies how the bills will be split between you and the insurance company. It helps gives a much clearer idea about how much you will have to pay overall.

Lastly, we will suggest you that please go through the fine print and all the related questions from your agent. A plan that fits your needs can be a boon and otherwise a bane.

So, this was all about how does dental insurance work. We hope you liked the article and that it was informative. But still, if you have any questions, please drop them in the comments section below. We reply ASAP.