What Is Dental Insurance and What Does It Pay?

Traditional dental insurance is available for individuals and families to cover the cost of dental care without paying directly out of pocket. The most important question people have about dental insurance is what does it pay for? Traditional dental insurance pays for three classes of treatment, usually called preventative, basic and major services.

The first class of service is preventative or diagnostic. Usually dental insurance pays 100% for these services. What are preventative services? Plans may differ slightly, but most insurance will pay 100% for oral examinations and dental prophylaxis (cleanings). Each person on the plan will get two of these services each year.

In addition, insurance plans will pay for Bite-Wing X-rays once a year and a full mouth series of X-rays every 2 to 3 years. For children, preventative services paid at 100% will also include fluoride treatments and sealants.

The next class of service is usually called basic services. Dental insurance will pay for a high percentage, often 80%, of these services. Again, insurance plans may vary, but most define basic services as fillings, space maintainers, root canals and root planing, simple extractions, periodontal surgery and palliative (relief of pain) treatments. The percentage paid on these services will vary depending on the plan selected and the premium paid. The most common percentage paid is 80% but there are insurance plans available which will pay anywhere from 50 to 90%. How much is paid is directly related to the premium.

The last category of services covered by dental insurance plans is called major services. Included in this category are the more expensive services such as bridges, dentures, overlays and crowns or caps. Generally insurance plans pay only 50% of the cost of these services and it is important to know that traditional dental insurance always has an annual maximum that it will pay out for any one participant.

Why is this important? Say a person needs 4 crowns or caps. The average cost of a crown is $900. 4 crowns would therefore cost $3600. Many people who have dental insurance assume that their plan will cover 50% of this cost or $1800. But that is not the case.

Because of the annual maximum written into traditional dental insurance, the plan will only pay up to that amount for any participant. The most common annual maximum is $1000 per person per year. In our example therefore, the amount paid to the dentist on the bill for 4 crowns will not be $1800 but only $1000.

In additional to annual maximums, dental insurance will also have waiting periods before the insured can receive benefits. Preventative service is generally available with no waiting periods, but basic services often have waiting periods from 3 to 6 months and major services are almost always have a 12 month waiting period. This means an insured must be on the insurance plan for 13 months before the plan will pay anything for major services and then will only pay up to the annual maximum,

Most traditional dental insurance is written by the major health carriers such as Aetna, United Healthcare, Blue Cross and others. These traditional plans are usually offered only to groups under an employer sponsored medical plan. However, recently it has become possible to find traditional dental insurance plans written for individuals. The rates will vary depending on the service selected but usually they are close to the premiums charged by employers for group plans.

If dental insurance is so expensive and has such limitations on benefits why do people want it? After health insurance, dental insurance is the single most requested benefit by employees. For most people, the cost of the premium often equates to the cost of the preventative services each year. Basically, by purchasing dental insurance, the insured is pre-paying their routine dental expenses with a fixed monthly payment. Furthermore, many employers may pay a percentage of the monthly premium for each employee making the cost for the individual employee more affordable.

Obtaining dental insurance for yourself and your family will insure that you get regular and proper dental care. Failing to do this can result in medical problems which affect overall health and well being.