What Is Dental Insurance?
Dental insurance is insurance that covers dental health and care. Because dental health, also called oral health, is important to your overall health, you may want to get dental insurance to help you pay for the cost of your dental care. You can purchase dental insurance as part of a medical insurance health plan or as a separate policy through a dental insurer, the Health Insurance Marketplace, or a private insurance broker.
Dental Insurance vs. Dental Benefits
When shopping for insurance, you may see the term "dental benefits," which is different from dental insurance.
A benefits plan covers some things in full, but other things only partially, and others not at all. It’s meant to be helpful, but it’s not a catch-all.
If you have dental benefits, do you know what’s in the fine print and what type of plan is best for you?
Many Americans (79%) have dental benefits, the National Association of Dental Plans (NADP) says. Most people have private coverage, usually from an employer or group program. Large employers are more likely to offer dental benefits than small employers, and high-wage workers are more likely to receive them than low-wage workers. Medicare doesn’t cover dental care, and most state Medicaid programs cover dental care only for children.
To make the most of your benefits, you need to know these things. When you shop for dental coverage, make sure you understand what type of plan you are choosing, and what it covers.
Dental Insurance Categories
Although the features of plans may differ, the most common dental insurance offerings can be grouped into the following categories:
Direct reimbursement programs
Direct reimbursement programs pay you a predetermined percentage of the total amount you spend on dental care, regardless of the treatment category. This method typically doesn't exclude coverage based on the type of treatment needed and allows you to go to the dentist of your choice. And it encourages you to work with your dentist toward healthy and economically sound solutions.
"Usual, customary, and reasonable" (UCR) programs
UCR programs usually allow you to go to the dentist of your choice. These plans pay a set percentage of the dentist's fee or the plan administrator's "reasonable" or "customary" fee limit, whichever is less. These limits are the result of a contract between the plan purchaser and the third-party payer. Although these limits are called "customary," they may or may not accurately reflect the fees that local dentists charge. There is a wide fluctuation and lack of government regulation on how a plan determines its "customary" fee level.
Table or schedule of allowance programs
These programs provide a list of covered services with an assigned dollar amount. That amount represents just how much the plan will pay for services that are covered, regardless of the fee charged by the dentist. The difference between the allowed charge and the dentist's fee is billed to you. This is called balance billing.
Capitation programs pay contracted dentists a fixed amount (usually every month) for each enrolled family or patient. In return, these dentists agree to provide specific types of treatment to you at no charge. (For some treatments, you may need to make a co-payment.) The capitation premium that is paid may differ greatly from the amount the plan provides for the patient's actual dental care.
Dental Insurance Plans
Dental insurance plans are similar in some ways to health insurance plans, but different in other ways. You’ll generally have the following options:
As with a health insurance PPO, these plans come with a list of dentists and other oral health care providers that accept the plan. These are referred to as in-network providers. Going to an in-network provider offers you the lowest out-of-pocket cost. You may have the option of going out of network, but your out-of-pocket costs will be higher than the costs incurred using an in-network provider.
Dental health maintenance organization (DHMO)
Like a health insurance HMO, DHMO plans provide a network of dentists that accept the plan for a set co-pay, or no fee at all. However, you may not be able to see an out-of-network dentist. If you do, you may have to pay the full amount on your own.
Discount or referral dental plan
A discount or referral dental plan offers you a discount on dental services from a select group of dentists. Unlike health insurance, this type of plan doesn’t pay anything for your care. Rather, the dentists who participate agree to give you a discount for the care you receive. These plans are also called access plans or savings plans.
Private dental insurance
Private dental insurance is insurance you purchase on your own, and not through an employer. You can purchase private dental insurance directly through a dental insurer, HealthCare.gov, or an insurance broker.
Dental Insurance for Seniors and Low-Income Residents
Once you reach age 65, or if you meet certain low-income and resource requirements, you may qualify for government-funded health insurance plans. Here’s how those plans handle dental coverage:
Medicare is health insurance for people aged 65 and older. You may also be eligible for Medicare if you have a disability, amyotrophic lateral sclerosis, or end-stage renal disease. Medicare is funded by payroll taxes paid by most employees, employers, and people who are self-employed as well as by funds authorized by Congress. Most people don’t pay any monthly premium for Medicare Part A, or hospital insurance benefits. For Medicare Part B, or medical insurance benefits, you will pay a standard monthly premium.
Medicare usually doesn't cover dental services such as routine cleanings, fillings, or tooth extractions. It also doesn’t cover items such as dentures. You pay 100% of non-covered dental services. Medicare may cover certain dental procedures that require you to be admitted to a hospital as an inpatient, either due to the severity of the dental procedure or because you have an underlying medical condition. Medicare may also cover specific inpatient and outpatient dental services related to covered medical conditions or the success of medical treatments. You will still be responsible for paying the Medicare Part-A deductible and co-pays for your hospital stay. For Part B-covered dental services, you pay 20% of the Medicare-approved amount after you meet the Part B deductible. You’ll also pay a facility co-payment for covered dental services you receive in a dentist’s office or another outpatient setting.
Medicare Advantage Plans (Part C)
Medicare Advantage Plans provide all your Medicare Part A and B benefits and other benefits not covered under Medicare. Depending on the plan you choose, it may cover dental services, such as routine checkups or cleanings. Your monthly premiums, deductibles, coinsurance, and co-payments vary based on which plan you join. Once you pay the plan’s yearly out-of-pocket limit, it pays 100% for covered health services for the rest of the year.
Medicare supplement insurance
Also called Medigap, Medicare supplement insurance is extra insurance that helps you pay your out-of-pocket costs associated with Original Medicare. You can buy a Medigap policy from a private insurance company. Because all Medigap policies are standardized, they offer the same basic benefits no matter where you live or from which insurance company you buy the policy. Price is the only difference between the 10 different types of plans offered by most states. Medigap policies generally don’t cover dental care.
Some people with limited income and resources may qualify for Medicaid, a joint federal and state program that helps cover medical costs generally not covered by Medicare. Each state sets its own rules to determine who is eligible for Medicaid. Under Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, states are required to cover dental services for people enrolled under the age of 21. Most states provide emergency dental services for adults in their Medicaid programs, but less than half of the states provide comprehensive dental care.
Other Medicare health plans
There are three other Medicare health plans that can help you lower costs. Each has its own eligibility and requirements.
- Medicare-Medicaid plans. Only available in some states, these plans help coordinate your Medicare and Medicaid benefits.
- Special Needs Plans (SNP). You may qualify if you have both Medicare and Medicaid, have a chronic or disabling condition, and need long-term care. SNPs are not available in every state. Some SNPs may cover dental care benefits.
- Program of All-Inclusive Care for the Elderly (PACE). If you join PACE, a team of health care professionals will coordinate your care. PACE covers all Medicare- and Medicaid-covered care and services, and anything your health care team decides you need to improve or maintain your health, including dental care. To be eligible for PACE, you must be at least 55 years old, be certified by your state as needing nursing-home level of care, and live in a service area of a PACE organization.
Understanding Dental Insurance Plans
In-network and out-of-network dentists
You'll be given a list of dentists who participate in your dental insurance plan. These are known as in-network providers. Most dental insurance plans will only pay for care if you go to a contracted and participating in-network dentist, orthodontist, or other oral health care specialist. Going to an in-network provider often results in the lowest out-of-pocket costs for you.
Most PPOs allow you to see dentists who don't participate in your plan. These are known as out-of-network providers. Even though a PPO allows you to see out-of-network providers, the plan will pay a much lower percentage of the cost than it does for seeing an in-network provider. Your out-of-pocket costs will be higher when seeing out-of-network providers.
When it comes to HMOs, these plans usually don't allow you to see out-of-network providers. They won't pay for any dental care that isn't provided by an in-network provider. When you have an HMO dental plan and see an out-of-network provider, the entire cost of dental care you receive falls on you.
Medicare and Medicaid plans also have a list of dentists and other oral health providers who accept these plans. You can look up and compare providers in your area at Medicare.gov.
Predetermination of costs
Some dental insurance plans encourage you or your dentist to submit a treatment proposal to the plan administrator before receiving any care or treatment. The administrator may determine your eligibility, the eligibility period, services covered, your co-payment, and the maximum limitation. This is called predetermination. Some plans require predetermination for treatment over a specified dollar amount. This is also known as preauthorization, precertification, pretreatment review, or prior authorization.
Annual benefits limitations
To help contain costs, your dental insurance plan may limit benefits by the number of procedures or dollar amount in a given year. In most cases, especially if you've been getting regular preventive care, these limitations allow for adequate coverage. By knowing what and how much the plan allows, you and your dentist can plan treatment that will minimize out-of-pocket expenses while maximizing compensation offered by your benefits plan.
Peer review for dispute resolution
Many dental insurance plans have a peer review mechanism through which disputes among third parties, patients, and dentists can be resolved, eliminating many costly court cases. Peer review aims to ensure fairness, individual case consideration, and a thorough examination of records, treatment procedures, and results. Most disputes can be resolved satisfactorily for all parties.
Full coverage dental insurance
Full coverage dental insurance, also called comprehensive dental insurance, means the plan covers some portion of these categories of dental care:
- Preventive care :Dental experts recommend you get regular cleanings and checkups once every 6 months to maintain your oral health. Preventive care includes regular exams, cleanings, fluoride rinses, and oral cancer screenings. X-rays are also part of preventive care. These services help prevent dental issues from developing and catch issues early before they get worse.
- Basic or restorative care: This includes simple fillings, crowns, and tooth extractions to help treat cavities, gingivitis, or other oral infections. Most dental plans usually cover any X-rays needed to complete these procedures.
- Major dental care: Some restorative care involves more complex invasive procedures that may require the use of anesthesia or oral surgery. Major dental care may cover:
- Endodontics or root canals.
- Periodontics, the care of the structures that support and surround the tooth. This includes scaling, root planing, and managing acute infections or lesions.
- Prosthodontics, such as dentures and bridges.
- Oral surgery, such as removing impacted wisdom teeth, tissue biopsy, and draining minor oral infections.
- Some full-coverage dental insurance may even cover dental implants.
- Orthodontic care: Some full-coverage dental plans cover orthodontia, such as braces, retainers, or aligners, but usually only for children.
You’re usually covered for two preventive visits per year. If you get an individual policy, periodontics and prosthodontics may not be available in the first year of coverage.
Most plans follow the 100-80-50 coverage structure. That means they cover preventive care at 100%, basic procedures at 80%, and major procedures at 50%, or a larger co-payment. But a dental plan may choose not to cover some procedures, such as sealants, at all.
Does dental insurance cover braces?
A common question many people have about dental insurance is whether it covers braces and other types of teeth straightening. Coverage for orthodontics, such as bracers, retainers, and aligners, often requires a rider, in which you pay an additional fee, for any kind of policy. If you have crooked teeth or a misaligned bite, read the fine print on whether your plan covers orthodontia. Most full-coverage dental plans cover orthodontics only for children.
Limitations of Dental Insurance Plans
Dental insurance plans have limits on how much they pay during a plan year. That’s true even of full-coverage dental plans.
Every plan also has a cap on what it will pay during a plan year. For many, that cap is quite low. This is the annual maximum your plan will pay. You have to pay all expenses that go beyond that amount.
About half of dental PPOs offer annual maximums of less than $1,500. If that’s your plan, you would need to pay for all expenses above $1,500. If you need a crown, a root canal, or oral surgery, you can reach the maximum quickly. There’s generally a separate lifetime maximum for orthodontics costs.
Some plans may exclude certain services or treatments to lower their costs. You need to know what specific services the plan covers and excludes.
There are also certain limitations and exclusions in most dental insurance plans that are designed to keep dentistry's costs from going up without costing you more. All plans exclude experimental procedures and services not performed by or under the supervision of a dentist, but there may be some less obvious exclusions. Sometimes, dental coverage and medical health insurance may overlap. Read and understand the conditions of your dental insurance plan. Exclusions in your dental plan may be covered by your medical insurance.
Dental Insurance and Timing
Along with knowing what types of care your plan covers, you should know when coverage for each type of care begins, and how often you can receive that type of care.
Dental insurance waiting period
With most dental plans, you can often begin receiving preventive care right away. But you may have a waiting period before the plan will begin covering certain types of care.
Usually, only preventive care, restorative care, root canals, and some oral surgery will be covered in a policy’s initial year. Depending on the plan and what dental care you need, you may need to wait 3-6 months or up to a year before the plan will pay for restorative or major dental care. You may need to hold the policy longer than a year before it will cover periodontics or prosthodontics. The orthodontics rider will have its own waiting period.
Dental care frequency
Experts generally encourage adults to see their dentists twice a year. Dental benefits policies support this, although the wording varies. It may be that your policy will pay for a preventive visit every 6 months (but not closer together), twice per calendar year, or twice in 12 months. Get to know your policy so you understand how it works. That will help you schedule your appointments.
There are usually time limits on other services as well, such as X-rays, fillings on the same tooth, crowns and bridges on the same tooth, or fluoride treatments for children. For instance, your policy may pay for a full series of X-rays only once every 3 years.
Dental Insurance and Preexisting Conditions
You may not be able to find a dental plan that covers conditions that existed before you enrolled. If that’s the case, you will have to pay any ongoing treatment costs out of pocket.
What to Do Before a Dental Procedure
Before getting any dental procedure, read your dental policy closely to see whether your procedure is covered. Call your insurance company if you have questions.
If you need a major procedure, you can ask your dentist to submit a pretreatment estimate. This will help you know what you’ll likely owe after any coinsurance, deductible, and policy maximum.
Confirm with your dentist and insurance company whether you need any preauthorization for the dental procedure, and if your dentist has received it. The preauthorization will determine whether your dental procedure is covered by your plan and how much your plan will pay for it. A preauthorization can also confirm whether you meet the timing requirements for the procedure. Many plans won’t cover certain dental procedures unless your dentist receives preauthorization.
It’s also smart to understand how your dental plan handles emergencies. Many have provisions for urgent care or after-hours care, but you may owe a deductible, a co-pay, or a larger percentage of costs.
What to Consider Before Buying Dental Insurance
If your employer offers dental coverage, that’s an easy choice. It tends to be cheaper than getting a policy on your own. If you’re shopping for your own plan and you already have a dentist, your dentist may be able to recommend a plan based on your dental history. They can also tell you in which dental plans they serve as an in-network provider.
As you compare plans, try to find out the following things:
- Whether your dentist and any specialists you may need are in-network
- Total costs for the plan each year, including premiums, co-pays, and deductibles
- Annual maximum
- Out-of-pocket limit, if any
- Limitations on preexisting conditions
- Coverage for braces, if needed or anticipated
- Emergency treatment coverage, including treatment if you’re away from home
- Whether you can choose your own dentist
- Who controls treatment decisions -- you and your dentist, or the dental plan
- Whether the plan covers diagnostic, preventive, and emergency services, and how much
- What routine treatment is covered
- What major dental care is covered
- Whether you can see the dentist when you need to and schedule appointment times convenient for you
- Who is eligible for coverage under the plan, and when coverage goes into effect
You should insist on regular reviews of premium levels to make sure that UCR or table of allowances payment schedules are equitable. This analysis can help optimize your benefit levels, making sure that every dollar you spend is used wisely.
If you are covered under two dental benefits plans, tell the administrator or carrier of your primary plan about your dual coverage status. In some cases, you may be assured full coverage, where plan benefits overlap and you receive a benefit from one plan where the other plan lists an exclusion.
It may be best to choose a plan with dollar or service limitations, rather than one that excludes categories of service. By doing so, you can get the care that's best for you and work with the dentist to develop treatment plans that give the most and highest-quality care.
Your dentist can’t answer specific questions about your dental insurance plan or predict what level of coverage for a particular procedure will be. The extent of coverage for each plan varies according to the contracts negotiated. If you have questions about coverage, contact your employer's benefits department, your insurance plan, or the third-party payer of your health plan.
Like health insurance, there’s no one-size-fits-all approach to choosing dental insurance. Understanding what types of plans and coverage are available can help you make the right decision for you and your dental care. Be sure to review any dental insurance you currently have to make sure it provides the dental care you need at a price you can afford.
Dental Insurance FAQs
What expenses does dental insurance cover?
What your dental insurance will cover depends on the type of plan you choose and the timing of dental care and procedures. As with any health insurance, you will need to pay monthly premiums to receive care.
What is the most common dental insurance in Florida?
PPO plans are the most popular type of dental plan in Florida. According to NADP, PPOs account for more than 80% of Florida dental plans.
Does Covered California have dental plans?
All Covered California health plans include dental care for children at no cost, including preventative care and diagnostic services. You will still pay part of the cost for other dental care services for children. Adults can add dental coverage to a Covered California health plan for an additional cost.
What is the best dental insurance that covers implants?
Dental implants can be expensive, with the cost of a single tooth implant ranging from $3,100 to $5,000. Coverage for implants depends on the plan you choose. If you are considering implants, be sure to read the plan details before choosing an insurance company and plan accordingly to see how much coverage they provide and when they provide it. Even if they offer implant coverage, they may cap how much they will pay each year, often at $1,500. These companies appear on independent rankings (in no particular order) of best dental insurance companies for implants in 2024:
- Cigna Dental
- Delta Dental
- Denali Dental
- Spirit Dental & Vision