How Does Dental Insurance Work?

Dental insurance is a complex and confusing system that many patients struggle to understand. Contrary to common belief, dental insurance is different from medical insurance in a number of ways.

One way in which the two plans are similar is that you pay a monthly premium to remain enrolled in dental insurance, whether you pay out of pocket or whether that comes out of your paycheck from your employer.

Beyond that, your dental insurance plan works differently in a number of facets that many find to be confusing and frustrating. Ultimately, it is the responsibility of the patient to understand the inner-workings of their personal insurance plan. With that in mind, here are 6 facts that you might not know about dental insurance plans.

1. Maximum Coverage

Most dental insurance plans come with a coverage maximum. This runs contrary to medical insurance plans, which might have a deductible before the plan begins to cover payments.

For example, your dental insurance may cover just $3,000 annually, and any services you require after that are fully out of pocket costs. Many patients fail to plan ahead with this knowledge in mind and end up getting hit with a bill they’re not prepared to pay for themselves.

Additionally, it’s extremely uncommon for dental insurance to cover procedures in full. If you look at the specifics of your plan, you’ll find that each dental service is covered at a certain percentage. For instance, your plan may cover implants at 40%, meaning you will need to pay for 60% of the cost of the procedure out of pocket. These coverage rates remain the same even if your dental insurance plan comes with an unlimited maximum.

What’s more, insurance coverages are never fully guaranteed. Insurance companies can adjust the amount of money they’re willing to spend to cover a patient’s procedure. Even if you get a pre-procedure estimate (also called a pre-authorization) from your insurance company, they reserve the right to adjust the amount after the fact.

2. Orthodontics

The money allotted to orthodontic care generally does not apply to your dental insurance maximum for the year – it usually comes from a completely separate pot of money. This means that you might be eligible for coverage on Invisalign treatment even if you’ve exceeded your plan’s annual maximum.

3. Insurance Year Variance

Not all dental insurance plans are the same, and that includes what insurance plans consider a “year” to be. Some plans reset their annual maximum in line with the calendar year, meaning your insurance coverage amount used would reset to $0 on January 1st. This is called a “calendar year” plan.

Other plans will use the fiscal year, which can vary from employer to employer. For example, the government fiscal year starts on October 1st, while the non-profit fiscal year starts on July 1st. Familiarize yourself with the rhythm of your insurance plan so you can plan the timing of your procedures accordingly.

4. Waiting Periods

Dental insurance plans frequently come with waiting periods, meaning you won’t be able to take advantage of your complete benefits for months (sometimes even a year) after you initially enroll. This is important to discern before you make an appointment with your dentist to ensure you won’t be making/incurring unexpected payments after your visit.

Generally, preventative care (such as general dentistry/routine cleanings) are not subject to the waiting period. However, if you’re expecting a more serious procedure such as a filling or a tooth extraction, you might want to find out how long your plan requires you to wait before you receive complete coverage.

5. Missing Tooth Clauses

Speaking of tooth extractions, many dental insurance plans will include what is called a “missing tooth clause.” Missing tooth clauses state that any dental implant you receive to replace a tooth extracted before your plan started won’t be covered by your current insurance plan. This also applies to bridge work or partials/dentures.

For example, let’s say you had a tooth extracted 5 years ago, but you only started your current dental insurance plan 2 years ago. Since your tooth extraction happened before you enrolled in your current plan, you would not be eligible for coverage on your implant to replace the tooth that was extracted.

Not all dental insurance plans include a missing tooth clause, but you should make sure yours doesn’t before you commit to getting an implant done.

6. Dual Coverage Insurance

Some patients are enrolled under dual coverage. This means that they might have dental coverage under two separate plans.

Generally, this will be if your primary medical insurance comes with a dental rider in addition to your separate dental insurance. Dual coverage can also occur when a patient has two completely separate dental insurance plans. If this is the case, your primary insurance will kick in first to cover dental procedures you receive. Your secondary plan may cover an additional portion, depending on your plan.

However, the dual coverage system can hold up the payment process because your primary insurance doesn’t necessarily know how much your secondary insurance plan will cover. This may lead to bigger out-of-pocket costs at the office when you have a procedure.

CNS Dental is a full-service dentist’s office serving patients all across the D.C. metro area. Give us a call to learn more about our services or to schedule your appointment today.