While dental insurance has some similarities to health insurance, it can be confusing at first because there are some differences in how it pays. You always need to refer to your own insurance plan for the specifics of your coverage, but here are some general hints for understanding dental insurance.
Understanding the Classes of Services
Dental care is characterized by the type of care you receive and divided into four classes:
- Class I is diagnostic and preventative care, cleanings, exams, and x-rays. Typically, the cost of these services is fully covered when you see an in-network dentist.
- Class II is restorative care, such as fillings or periodontal work. The typical reimbursement is 80%.
- Class III is usually considered major restorative care, crowns, bridges, or dentures. The coverage is usually 50%.
- Class IV, if you have it, is for orthodontia care, like braces. Not all plans cover orthodontia, and those that do often limit this care to their members under 19 years old.
What is the annual maximum?
Your annual maximum is the maximum amount the insurance will pay in any one calendar year. Typically, you will have an individual maximum and a family maximum. If the cost of your care exceeds this limit, the plan will no longer help defray those costs, and you will be responsible for paying them in full. Some plans come with a higher annual maximum to meet the rising costs of dental care, but the most common maximums are $1000 or $1500.
What if my dentist recommends care that my plan won’t pay for?
Your dentist has your best interests in mind for the best outcomes for your teeth. Your insurance is there to mitigate your costs, but it may not cover every treatment the dentist offers. In this case, you may have to look at alternate services, which might be less expensive services that correct the same condition. You could pay for the service out of pocket. You should always be aware of your plan’s limitations and exclusions before receiving service so that you aren’t surprised by a large bill.
Our family has two dental plans. Which one pays for our dental care?
Coordination of benefits between dental insurance plans is complex, so you will need to check the language of your individual plans. The most that will be covered by the combined plans is only 100% of your care. If you have dental insurance through your work, that is your primary insurance. If your spouse also covers you through their work, that would be your secondary insurance. For your children, if they are covered by both insurance companies, the primary insurance is generally decided by the birthday rule: whichever parent’s birthday comes first in the year is the primary.
My dentist is not on my plan. Can I still go to him?
You always have the choice of where you get treatment. The real question is how your insurance pays for an out of network provider. With a PPO type plan, you often have reduced benefits when you go to a provider not on the preferred list. It just depends on the language of your insurance policy.