Key takeaways:
Dental insurance covers three main types of care: preventative, basic, and major.
Dental insurance coverage varies based on your plan and provider.
Expect to pay out-of-pocket dental expenses, such as premiums, deductibles, coinsurance, and copays. You’ll also have to pay any amount over the annual maximum.
Imagine cracking your tooth on a piece of hard candy or finding out you need a root canal. If you have dental insurance, you can expect some help with the costs, but you’ll likely have to pay a portion of the bill. Whether a service is fully or partially covered — or not covered at all — depends on the procedure and your dental insurance plan.
What does dental insurance cover?
Dental insurance helps pay expenses associated with dental care. Health insurance does not cover dental care. That’s why you need a separate plan.
The type of service you need will determine if your insurance plan will cover 100%, 80%, or 50% of the cost. Dental insurance usually covers three types of services:
Diagnostic and preventative: Class I (also called group I or type A) services prevent tooth decay and gum disease. Traditional dental plans often pay 100% of the costs for diagnostic and preventative services.
Basic: Class II (group II or type B) services address the effects of normal wear and tear and aging on teeth. Traditional dental plans usually pay 80% of the costs of basic services.
Major: Class III (group III or type C) services repair teeth through complex procedures. Traditional plans tend to pay 50% of the costs of major services.
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Some dental insurance plans also cover orthodontia. These services correct the alignment and positioning of your teeth and jaw. If you have orthodontia coverage, verify whether it’s for a percentage of the total fees or capped at a specific dollar amount.
What dental expenses are usually covered by insurance?
The best way to know which dental expenses your insurance covers is to read your plan and contact your provider with questions. Most plans cover the services in the table below in some capacity.
| Preventative | Basic | Major |
|---|---|---|
| Oral exams | Amalgam fillings | Bridges |
| Teeth cleanings | Composite fillings (some) | Crowns |
| Bitewing X-rays | Sedative fillings | Complete dentures |
| Periapical X-rays | Extractions | Removable partial dentures |
| Panorex/full-mouth X-rays | Root canals | Denture relines and rebases |
| Fluoride treatment | Root planing | Denture repair |
| Space maintainers (kids) | Tooth extractions | Oral surgery |
| Sealants | Periodontal scaling | Implants |
If your insurance covers orthodontia, read the fine print. You may need to prove your treatment is medically necessary to get coverage. Most plans won’t pay for cosmetic dentistry.
Orthodontia services typically include some combination of:
Clear braces
Retainers
Types of dental care plans
Dental plans vary — and so do their requirements. Your coverage may include in-network dental providers, maximum charge limits, or set fees for specific services.
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The American Dental Association lists eight types of dental plans:
Indemnity plans: A policyholder typically chooses their dentist and the insurance company pays a percentage of the charges (up to the maximum allowance) based on the procedure performed.
Preferred provider organizations (PPOs): A traditional indemnity plan is paired with contracted dentists who deliver specified services for set fees.
Dental health maintenance organizations (DHMOs): The insurance company prepays contracted dentists a specific amount for a policyholder’s care every month. The dentists provide specific services at no cost or a reduced cost to the policyholder.
Direct reimbursement (DR) plans: With these self-funded plans, the insurance company may pay dentists directly or reimburse policyholders who pay for services.
Point of service (POS) plans: With this type of dental plan, a policyholder can be reimbursed for out-of-network treatment. However, the benefits may be lower than with an in-network provider.
Discount or referral plans: Contracted dentists agree to reduce their fees for patients enrolled in the plan.
Exclusive provider organizations (EPOs): A policyholder can only see dentists participating in the plan if they want to get reimbursed.
Table or schedule of allowances plans: These indemnity plans pay a certain amount for each procedure. A policyholder must pay the difference between the dentist’s charges and the insurance payment.
Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP) also provide dental benefits. For example, Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit provides reimbursement for medically necessary dental services for children.
Because of the Affordable Care Act, health insurance marketplaces must offer dental plans for children. The law doesn’t require adults to be offered dental coverage, but some state marketplaces may provide plan options.
What dental expenses do you pay out of pocket?
When you receive dental services beyond preventative care, you’ll likely have to pay a share of the expenses. These charges are called your out-of-pocket costs and can include:
Premiums: This is the amount you pay every month for dental insurance. Monthly premiums for DHMO plans are generally cheaper than those for PPO dental plans, because DHMOs have contracted rates with a select group of dentists.
Deductibles: After you pay a set yearly amount for services, your dental insurance plan starts paying some of the costs. For example, if your deductible is $75, your dental plan will kick in after you’ve paid that much out of pocket for qualified dental care expenses.
Coinsurance: You share a percentage of expenses with your dental insurance provider after you meet your deductible. If your dental plan covers 80% of the cost of a service, you will pay the remaining 20% of the cost out of pocket. Your coinsurance amount depends on the total charges for the service and the type of service.
Copays: Typically, you pay a predetermined amount at the time of service. The amount of a copay depends on your plan and the type of service. If your copay for a deep cleaning is $20, you’ll have to pay this amount before receiving the service.
Charges above the annual maximum: The annual maximum is the most your dental plan will pay for services in a 12-month period. Once you reach your annual maximum, you must pay 100% of your dental expenses. Annual maximums typically range from $1,000 to $2,000.
If you have a health savings account (HSA) or a flexible savings account (FSA) and you have reached your annual maximum, you could use those funds to help pay for out-of-pocket dental costs.
What benefits do I get from my dental insurance?
If you have dental insurance through work, your employer probably subsidizes your monthly premiums and negotiates lower rates with in-network dentists. This assistance reduces how much you have to pay out of pocket.
If you currently don’t have dental insurance, here are some benefits that may make the cost worth it:
Preventive services such as cleanings and X-rays are usually fully covered.
You may not have to pay full price for major dental services like crowns and implants.
You can receive discounts on services by seeing an in-network dentist.
And, when you pay for dental insurance, you won’t want to waste it. Having coverage motivates you to go for regular checkups, which can prevent serious and costly issues later on.
Does dental insurance cover preexisting conditions?
Dental insurance generally doesn’t cover preexisting conditions. If you find a dental insurance plan that does cover them, your insurance may require you to be enrolled in the plan for a certain period of time before they start covering costs.
How do I find an in-network dentist?
Contact your dental insurance company by phone or email for a list of in-network dentists. You could also search your provider’s website for the kind of insurance they accept.
The bottom line
With dental insurance, preventative care is generally free, but you can expect to pay for portions of basic and major services. Your insurance provider should lay out all the details of your dental coverage in your plan. Read up on your benefits or reach out to your insurance company directly to learn what’s covered and what you’ll pay out of pocket.
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References
American Dental Association. (n.d.). Choosing a dental plan under the Affordable Care Act (ACA).
American Dental Association. (n.d.). Types of dental plans.
American Dental Association. (n.d.). Typical dental plan benefits and limitations.
American Dental Association. (2022). Dental benefits: An introduction.
Delta Dental. (n.d.). What is a dental insurance annual maximum?
Medicaid.gov. (n.d.). Early and periodic screening, diagnostic, and treatment.
National Association of Dental Plans. (2016). Glossary of dental insurance and dental care terms.
Rosato, D. (2019). Think twice before buying private dental insurance. Consumer Reports.
