How Does Dental Insurance Work?

Trying to understand your dental insurance — and what’s covered — can seem like a word problem from one of your high school math classes. But when you understand how dental insurance works, it can take the guesswork out of making your oral health care as affordable as possible.



In-Network vs. Out-of-Network


Dental insurance companies prefer their enrolled members to see “in-network” providers. An in-network dentist is one who has signed a contractual agreement to provide services at specific fees to its members. Out-of-network dentists do not have contractual agreements but may not charge much more than an in-network provider. If your insurance plan is a PPO and allows you to see out-of-network dentists, they may pay a slightly lower amount toward your care compared to an in-network dentist’s office.


Dental Insurance Deductibles


Deductibles are the flat fees that patients have to pay out of pocket before their dental insurance benefits kick in. Typically, you don’t have to pay a deductible on preventative services like checkups and cleanings. But if you have active oral disease and need a filling or crown, you’ll have to pay the deductible first. Each policy has its own requirements, but it’s not uncommon for deductibles to be as little as $50 for some people.


Annual Allowables


The term “annual allowable” is the max dollar amount (or allowance) that your insurance policy will cover each year. Let’s say that your annual allowable is $1,500. Once you’ve utilized benefits to pay for fillings or crowns and the allowable runs out, it doesn’t cover anything else.


Annual allowables usually re-set on January 1st of each year. If you’ve used all of your benefits, all you have to do is wait until the rollover to access an allowance again. That may not be that all of a big deal if it’s already later in the year, but if you’re early on in the calendar year and have already used your allowable with more treatment to go, it could leave you paying for the rest of it out of pocket. Work with your dentist to prioritize which therapies are most important and start with those first.


If you don’t use your benefits by the time the year is over, they expire. You’re essentially “losing” money if you aren’t tapping into the coverage you’re entitled to. Don’t avoid your dental checkups and definitely don’t put off your dental fillings if you have active tooth decay. Those unused allowables won’t roll into or add to next year’s allowance.



Category of Dental Treatment


Your dental insurance plan will cover a certain percentage of certain treatments, depending on what type of category they fall under. The common categories are Preventative, Restorative, and Major.


Preventative care includes your regular dental cleanings, sealants, and sometimes even mouthguards. Each policy is different, but most of them allow your preventative care services to be rendered every six months or on another set schedule.


Restorative treatments include basic dental work like dental fillings. Fillings are a necessary procedure for treating tooth decay and are less-invasive than more major therapies.


Major dental treatment usually refers to complex restorations like dental crowns, bridges, dental implants, extractions, and oral surgery.



Tiers of Dental Insurance Coverage


Now that you understand the varying categories of dental treatment, it’s important to note that each category falls into a different tier of coverage. Preventative dentistry receives the most coverage, leaving you with little to nothing out of pocket and usually no deductibles. Your insurance plan is naturally “encouraging” you to take a prevention-based role in your oral health.


Once you do require treatment to repair a tooth, the next tier of coverage is “basic”, which is your standard restorative fillings and similar work. Depending on your insurance company’s specifications, your “basic” treatment is covered at a lower percentage, like 75-80%. You’ll be responsible for paying for the portion that isn’t covered by your plan.


Major treatments are covered at an even lower rate. 50% coverage is fairly common. You pay for half, your insurance policy pays for the other half. Sadly by this point, a lot of people try to avoid getting treatment because they’re paying for more than they want to. But delaying care can compound your oral health needs and lead to even more complications in the future.



Preventative Dental Insurance Benefits


By nature, dental insurance is meant to be used for preventative services. Each time you book a routine six-month checkup, you’re receiving preventative care. These visits include exams, prophylactic dental cleanings, periodontal screenings, oral cancer screenings, and diagnostic X-rays. These routine services help you keep your smile healthy and also pinpoint concerns while they’re smaller and easier to treat. Some can even be reversed if treated early enough.


To encourage patients to maintain a preventative care plan, your dental insurance will probably cover all preventative services at or close to 100%. When you keep up with routine checkups and hygiene recommendations, you’re less likely to need major restorative or emergency treatments. It’s a win-win financially for yourself as well as your dental insurance company.



Child vs. Adult Dental Insurance 


Adults and children aren’t covered by dental insurance the same, either. Pediatric dental benefits typically extend up until around 14 years of age (check with your carrier to make sure.) Once a child hits the next birthday, their services have to be categorized as an adult treatment.


Why does any of that matter? Because some types of preventative services — like dental sealants or fluoride treatment — might only be covered at certain ages. Even though dental sealants effectively prevent cavities, most insurance plans will only pay for them if they’re placed on children (not adults.) The same can be said for fluoride in some cases. Fortunately, both of these services are still fairly affordable, so you can consider getting them as an adult as long as you’re prepared to pay a small amount out of pocket.



Missing Tooth Clauses


Some dental insurance plans have what’s called a “missing tooth clause.” Essentially, this unique clause means that your insurance plan doesn’t have to pay to replace a tooth — like with a dental implant or bridge — if you were already missing the tooth before you became enrolled in their coverage. On the other hand, if you didn’t have the tooth fall out or extracted until you’d been on their plan for a while, the missing tooth clause wouldn’t apply.


Not every dental insurance policy has a missing tooth clause, so be sure to talk to your HR department or our Raleigh dentist if you have questions about treatment recommendations. Having all of the information ahead of time will prevent you from any unexpected surprises (like unpaid claims and added bills) before you book a treatment.



Waiting Periods


A waiting period is something that dental insurance may require if you’re new to the policy. For instance, there might be a six-month or 12-month waiting period if you just got the insurance plan but want to use it on something like a dental crown. If you were to get the crown before the waiting period had elapsed, you would be paying for it out of your own pocket. The bad thing about waiting periods is that sometimes people sign up for insurance to plan on immediately using it for major dental work not realizing that “waiting periods” are even a thing. In the end, it’s dangerous to delay major dental work, because it can jeopardize the integrity and health of your tooth in the future.



Finding the Best Dental Insurance Coverage


Are you considering switching your dental insurance company, buying an independent plan, or trying to convince your employer’s HR department to adjust the program you’re enrolled in? A lot of people ask us, “What’s the best dental insurance?” But the answer really varies. Some plans — even under the same carriers such as Aetna, Cigna, or BlueCross BlueShield — have varying levels of coverage. The “best one” often depends on what you personally want your deductible to be and the tiers of coverage you need.


Here’s the cold, hard truth. A lot of dental insurance benefits haven’t adjusted to the cost of inflation alongside medical policies. While it’s common for your health insurance to cover huge procedures, surgeries, or hospitalizations, dental insurance is different. Most policies have a cap amount (annual allowable) that’s barely budged since the late 1970s and early 1980s. We’re not kidding. If for some reason you’re going without insurance, it might mathematically work in your favor to use a Flex Spending Account/Health Savings Account or pay out of pocket for the care you need before buying into a monthly premium.


Raleigh Dentist That Takes My Insurance


Raleigh Dental Arts works with both in-network and out-of-network patients and their families. When you call our office, be sure to have a copy of your insurance information on hand. Our patient coordinators can let you know what to expect and run your information prior to any treatment being rendered.


Don’t have dental insurance, or maybe you don’t have the coverage you wish you did? We also offer flexible payment plans that can be used to finance your treatments on an affordable monthly basis. Just ask!


Call Raleigh Dental Arts today to reserve your first appointment. 


Tarun Agarwal

Dr. Tarun Agarwal, DDS is considered one of the top dentists in the country. He is a recognized speaker, author, and dental leader. He has been featured on CBS, NBC, ABC, FOX, and News 14 Carolina. Dr. Agarwal has been awarded '40 under 40' Business Leaders by the Triangle Business Journal. He is regularly invited to teach other dentists around the world and recently built a training center within the practice dedicated to sharing his expertise. Most importantly he is a loving husband and dedicated father of three wonderful children. His biggest accolade was being voted 'Best Dad in the World' by 2 of his 3 kids.