Dental plans are designed to share costs between the insurer and the insured. Most plans cover 50 percent or more of the cost of dental services, but they rarely cover all. Coverage varies widely, and you should know what you’re getting before you buy. Don't be surprised to find that your insurer does not cover certain procedures excluded in the fine print of the plan. Here are 6 key things to know about dental insurance that will help you choose the right plan for your needs.
1. You Might Not Get Back Everything You Pay
Just because you have a dental plan, it doesn’t mean that it will cover the entire fee. For instance, cleanings and X-rays are often fully covered, while major work, such root canals or crowns, are not.
Dental plans are unique because insurers categorize procedures into "classes" of service based on their complexity and cost. This determines the reimbursement rate, but some plans use an amount other than your dentist's fees to calculate how much you get back.
Some insurers set an arbitrary "customary" fee limit. You are then paid a percentage of this fee or a percentage of your dentist’s fee, whichever is lower. As a result, what ends up back in your pocket varies widely between providers. Some use straight percentages by class of service, while others do not, so it pays to shop around.
2. There Are Limits on Treatments and Coverage Varies
High coverage usually means you pay more every month but pay less when you use dental services. However, some policies include a deductible for particular services, while others do not. Most plans have limitations on the number of office visits, consultations, X-rays, and other treatments they cover. For instance, one plan might cover one cleaning per year, while another covers two.
Moreover, there may be a wait period before you can get major work done too. Many plans only cover exams, cleanings, and X-rays for the first six months, but some go for as long as a year.
Plans are often tailored to age groups as well. Coverage for children isn’t necessarily identical to coverage for adults. Be sure to read the fine print to make sure the plan applies to you and your family, and that the rate is appropriate to the benefits you receive.
3. Even If Your Dentist Recommends It, Your Insurer Might Not Cover It
Inexpensive dental plans are often inexpensive for a reason. They may not allow all treatment options, even if they are the best thing for your teeth. For instance, your dentist may tell you your tooth is in bad shape and recommend a crown, but your insurer wonly covers fillings. A common complaint with many plans is that they do not cover white fillings. Instead insurers insist patients put up with amalgam fillings even though they don’t want them. Many insurers will not cover preventative measures, such as sealants either. When you purchase a dental plan, the least expensive option isn’t always the best option. Read the fine print, and be certain the insurer covers the procedures you may need.
4. The Sky Is Not the Limit
Most dental plans have an annual maximum for care over the plan year, which isn’t necessarily the same as the calendar year. Most are sufficient for routine care, such as an annual x-ray, cleaning and checkup. However, when you need complex or extensive dental care, it is easy to reach your maximum quickly. This is also a problem if you have children in the household who need braces or other corrective devices as they grow.
When looking for a policy, do a bit of homework to estimate possible costs and shop for the best rate for a plan that meets your needs. Dental care costs are high, but maximum levels of reimbursement don’t necessarily match costs.
5. You May Have to See a Preferred Dentist
Some insurers suggest you choose from a list of the dental plan’s preferred dentists. These dentists are on the insurer’s list because they offer their services at a lower rate. The dentists benefit from the plan’s network and the insurer cuts costs. While they cannot force you to use their network of dentists, they can adjust reimbursement rates if you choose another dentist. This means less money in your pocket even though you pay for dental coverage. Opt for a plan that lets you choose your own dentist to avoid this problem.
6. A Pre-existing Condition Might Preclude Coverage
You’ve likely heard this term in the context of health insurance, but it applies to some dental plans too. Just as with medical insurance, a dental plan may not cover conditions a person had before enrolling in the plan. Clauses may exclude payment if you have bridge work, crowns of dentures under five years old, or if you have partially completed dental work that you need to have finished.
Dental insurance is complex, but with a little due diligence you can find a plan that suits your needs and meets your budget. Check the items mentioned above and always read the fine print so you can keep smiling for years to come.