Dental Insurance Simplified: What You Need To Know

posted by Dr. Beau Beecher, DDS on 11/19/2023 in General

If you're looking to prioritize you and your family's dental health, enrolling in a dental insurance plan is a cost-effective way to ensure affordable access to dental care. But the world of dental insurance can seem complex, requiring you to research a myriad of insurance terms and options.

Fortunately, you don’t need to go down a rabbit hole to understand dental insurance. This article is your go-to guide for understanding essential details and helping you decide which insurance plan is the right choice.

What Is Dental Insurance? Do You Really Need It?

Similar to health insurance, dental insurance is a plan in which you contract an insurance company to provide coverage for various dental services from regular checkups and cleanings to root canals.

Dental insurance can significantly lower your out-of-pocket expenses for dental services. The extent of coverage depends on the type of insurance you enroll into and whether you visit an in-network dentist. In some cases, insurance can cover 100% of dental cleaning fees and other routine services.

For families with children, insurance is especially valuable, as kids may require future dental treatments as their teeth grow and change. If children are involved in sports or vigorous physical activity, there’s a higher risk of them breaking, cracking, or chipping teeth. Without dental insurance, you'll find yourself shouldering the entire cost of expensive restorative dental services.

Common Dental Insurance Terms Defined

Before exploring the different types of dental insurance, we’re defining common dental terms you might encounter while reviewing insurance plans, or when speaking to the insurance company or dental office.

• Member. An individual who has enrolled into an insurance plan.
• Copay. The amount you pay every time you visit the dentist. 
• Premium. Your monthly payment for dental insurance. If you enrolled in dental insurance through your employer, the premium can be automatically deducted from your paycheck. 
• Deductible. The minimum you need to pay before your insurance starts to cover dental costs.
• Coinsurance. The percentage the insurance company will pay for services after you meet the deductible. 
• Reimbursement. The amount the insurance company pays directly to the dentist for services. This is often paid after you receive the dental service. Some insurance companies can send you a reimbursement.   
• Annual maximum. The maximum your insurance will pay in a year to cover dental costs.
• In-network dentist. A dental care provider who is contracted with an insurance company to provide services at a discount rate. 
• Out-of-network dentist. A dental care provider who is not contracted with an insurance company to provide services. 
• Waiting period. Occasionally imposed on new members of an insurance plan, this is a duration of time when dental services are not eligible for coverage. However, preventative care services are often exempt from a waiting period.

Types of Dental Insurance

Dental Health Maintenance Organization (DHMO)

If you choose a DHMO plan you will be provided a network of dentists that accept the DHMO insurance plan. In-network dentists often charge a lower copay and your insurance is likely to cover a larger percentage or 100% of your dental costs. 

Benefits of a DMHO insurance plan:

• Potential lower copays, deductibles, and premiums.
• A larger percentage of fees covered by insurance. 

Not every dental office accepts or files DHMO plans. Check ahead with your dental provider to confirm.

Preferred Provider Organization (PPO)

If you’d rather go to a dentist who is not in a DHMO network, you’ll want to choose a preferred provider organization (PPO) plan. This plan provides freedom to choose your preferred dentist. This flexibility may be offset by a higher copay and deductible, as well as insurance covering a smaller portion of your dental costs.  

Benefits of a PPO insurance plan:

• Freedom to choose a dentist outside of your dental insurance’s network. 
• Option to stay with your current dentist even if they are an out-of-network provider.

Some insurance companies even offer a premier tier of coverage. Check with your insurance provider to see if this would be a better fit for your dental needs.

What Does Dental Insurance Cover?

Dental care is divided into three categories: preventative, basic, and major care. Once your deductible is met, most insurance companies follow the 100-80-50 coverage for in-network care:

1. Preventative care (100% covered by insurance). This includes costs associated with semi-annual dental appointments, cleanings, exams, and X-rays. Remember, for preventative care services there is no waiting period. This means you can schedule an insurance-covered cleaning or exam as soon as you enroll into your dental plan. 
2. Basic care (80% covered by insurance). Basic dental services include dental fillings and extractions.
3. Major or restorative care (50% covered by insurance). Dental crowns, root canals, dental implants, bridges, and dentures are classified under this category.

Since insurance covers a smaller percentage of major procedures, it's important to take preventative action to keep your  teeth clean and healthy. This means brushing your teeth twice a day, flossing effectively, using the right mouthwash, and going to your semi-annual dental appointments. Being proactive with your preventative care can help you avoid costly dental care in the future.

What Isn’t Covered by Dental Insurance?

Most dental insurance plans don't cover cosmetic procedures such as teeth whitening. Many also don't cover orthodontic treatments like dental braces. Dental insurance companies are likely to deny coverage for pre-existing conditions such as missing or damaged teeth. For more information about coverage for these conditions, consult your insurance company or research additional plans.

What To Consider When Choosing Dental Insurance

• Cost and coverage. From deductibles, premiums, annual maximums, and monthly payments, you want to know how much enrolling in dental insurance will cost you and the percentage insurance will cover for potential services.
• Is there a waiting period? Can it be waived? It’s a good idea to know when your dental coverage begins and if there are ways to waive the waiting period.
• Is your current or preferred dentist in-network? Visiting an in-network dentist can help lower your dental costs. If your current dentist is not in network, you can still opt into a PPO plan.
• Future services you or your family may need. If it seems your children or an older family member may need pediatric dental services or senior dental services, it's important to consider this when selecting a dental plan. You’ll want to choose an option that helps cover these upcoming costs.

Where To Purchase Dental Insurance

Employers often provide dental insurance, allowing you to enroll in a plan simultaneously with your health insurance during the open enrollment period. You also have the option to purchase individual dental insurance directly from insurance companies outside of the open enrollment period.

How To Use Dental Insurance at Your Dental Office

Whether you are a new or current dental patient, always provide your dental office with your most up-to-date insurance information. This allows the dental office staff to reach out to the insurance company with any questions and give you accurate information about insurance coverage and what your out-of-pocket expenses will be.

If your dentist recommends a procedure, the dental office will submit a claim to your insurance company for pre-approval. Once the claim is approved, the dental office will notify you of insurance coverage and the financial amount you will be responsible for.

Invest In Your Oral Health With a Kimball & Beecher Dentist

Kimball & Beecher is proud to provide high-quality, affordable dental services to patients throughout Iowa, regardless of their insurance provider.

If you're searching for a new dentist or need help navigating your insurance, we’re here to help. Schedule an appointment with us and take the first step towards improving your family’s dental health.