Understanding Dental Coverage

The best way to get the most out of your dental coverage is to understand its many features. For instance, most insurance companies have various plans befitting the needs and circumstances of different individuals. As well, dental benefits are calculated within a benefit period, which is typically one year (though possibly not a calendar year). There’s much to learn about dental coverage, so here are a few aspects to help you get a better idea of it, especially if there are any benefits left before the end of the year.

Maximums

Most dental plans have an annual maximum, which is the dollar amount a dental plan will pay toward the cost of dental care within a specific period, even if a patient’s costs exceed the limit. The patient is personally responsible for paying costs that exceed the annual maximum. A common annual maximum is $1000 or $1500 while some can go as high as $2000 or $3000. These totals can be individual or family maximums.

Deductibles

Most plans have a specific dollar deductible. The amount of dental expenses is the responsibility of the beneficiary before a third party can assume liability for payment of benefits. In other words, you personally have to pay a portion of your bill before your benefit plan will contribute to your costs. Each plan varies—for example, some apply the deductible to diagnostic or preventive treatments while others do not. The deductible may be a one-time charge, or it may vary depending on the program.

Coinsurance

Many plans have a coinsurance provision, meaning the benefit plan pays a predetermined percentage of the cost of your treatment. The part you pay is called coinsurance—this is paid even after your deductible has been reached. For example, you may pay 20 percent while your plan may cover 80 percent of the expenses.

Reimbursement

Many dental plans offer different classes of coverage. Each class provides a certain percentage of coverage and certain limitations and exclusions. Each plan may vary, so it’s best to go over your benefits carefully. For example, Class I may offer coverage at the highest percentage—at least 80-100 percent of the plan’s maximum allowance. Class II may cover only basic procedures like fillings, extractions, and periodontal treatment, with reimbursements usually ranging from 70-100 percent. Class III often reimburses at a lower percentage at 50 percent and may have a waiting period before services are covered.

Estimates

You may want to ask your dentist to complete and submit a request for a cost estimate. These are often referred to as pre-treatment estimates. This lets you know in advance what procedures are covered though it is not a guarantee of payment.

Exclusions

Exclusions are dental services that aren’t covered by your plan. Some dental plans are designed to help with expenses and may not cover every need, and these are referred to as limitations or exclusions. Some health groups restrict coverage for pre-existing dental conditions that are present before a patient enrolls in a plan, such as a missing tooth.