Most people get their dental insurance through their employer, who will choose it depending on what they expect the dental needs of their employees are. However, if you are self-employed, not working, or your employer doesn’t offer dental insurance, you can sign up for dental insurance as an individual. Whether you’re buying dental insurance for yourself or you’re the person at a company who’s in charge of this task, it’s important to understand some basics about how dental insurance works so you can choose the best plan.

Some may be surprised to hear this, but dental insurance doesn’t really resemble insurance in the traditional sense (a payment to cover the cost of a loss). Most plans operate more like a cost-savings membership than an insurance plan. While your auto insurance will pay to repair your car if you have an accident, if one of your tooth gets damaged, your dental insurance will not pay for all of it. The cost of repairing the tooth will be split between you and the insurance company, and the portion you pay is determined by the plan you chose.

Many dental insurance plans include coverage for some services but not others. For example one plan may cover tooth sealants but not braces, compared to another that covers braces but not sealants. The fact that a dental plan doesn’t cover a certain service doesn’t mean that this treatment isn’t necessary or that you should hesitate to get a treatment that your dentist has recommended.

Some dental plans will also offer an alternate lower cost version of a treatment for a given dental program. For example, if you need a crown, your dental insurance may suggest a lower cost amalgam (metal) crown instead of a composite (tooth-colored) crown. This doesn’t mean that the composite option is “extra” or less recommended, it simply means that the insurance company is trying to reduce how much they have to pay. You should always select the treatment that is both recommended by your dentist and fits your goals for the outcome of treatment. For example, if you’d rather have a composite crown that looks like a natural tooth than a metal one that stands out, you should get the composite, even though the insurance company will not help you pay for as much of it.

It’s a good idea to try to find a plan that emphasizes preventive care by paying to cover these services at 100%. That means that routine preventive care such as teeth cleanings, exams and x-rays won’t cost you anything out-of-pocket. Preventive care will help save you money in the long run. Problems can be prevented entirely (e.g. removing tartar from teeth to prevent decay) or caught earlier when they’re easier and cheaper to treat (e.g. filling a cavity when it’s still really small).

There are three major types of dental insurance plans, and it can be helpful to know the differences.

Preferred Provider Organization

With a Preferred Provider Organizations (PPO) plan, patients select a dentist from a list of participating providers. These dentists have contracted with the insurance company to offer a discount on their fees. While most PPO plans allow patients to go to a dentist who is not a preferred provider, these patients will usually pay a slightly higher co-pay at a non-participating dentist (for example: 80% coverage on a crown procedure at a non-provider vs. 90% at a contracted provider).

Dental Health Maintenance Organization

A DHMO plan (sometimes just called an HMO) contracts with dentists & pays them a fixed amount (usually monthly) per family or individual enrolled in the plan, regardless of whether they go to the dentist or get treatments. In exchange, the dentist doesn’t charge the patients for certain types of treatment. In theory, these plans are designed to reward dentists who keep patients in good dental health, because it reduces costs for everyone. However, the result is often a more limited choice of which dentists you can go to.

Direct Reimbursement

Direct Reimbursement plans do exactly what their name implies: the insurance company reimburses patients for the dollars spent on dental care. The biggest benefit of this is that patients get total freedom to choose a dentist, because the dentist is removed from the insurance equation. However, it does mean that the patient will have to pay the whole cost of their payment up front, then wait for a check to be sent after they file a claim. If paying for treatment out-of-pocket immediately is a hardship for a patient, many dentists now offer payment plans or financing to help spread the cost of treatment out over time.

If you have dental insurance, your insurance company provides you with certain dental benefits each year. In case you’re not very familiar with insurance vocabulary, you can think of an insurance benefit as a dental service that the insurance company pays all or most of the cost of. Most dental plans cover the most common preventive services at 100%, meaning the insurance company pays 100% of the cost & you pay nothing.  But you should know, if you don’t use these benefits each year, they’re gone forever!

Why does it matter whether you use your benefits each year? For one thing, these benefits are provided as a way to help keep you healthy. That’s why preventive & diagnostic services such as exams & x-rays are usually covered at 100% by the insurance company. Even your free cleanings are a great opportunity for the dental hygienist or the dentist to detect potential problems. Think of it as an incentive to get your teeth checked out by the dentist twice per year.

The other advantage of using up your preventive benefits each year is that it can save you money. The healthier you stay & the earlier problems can be uncovered, the less both you & the insurance company will have to pay for more complex care in the future. For example, a cavity that is caught when it’s relatively small & minor will just result in a filling. A big cavity that has gone undetected for a long time until it started causing problems might result in a crown instead, which is a longer, more complex, & more expensive procedure.

Another reason to use up your dental benefits is if you encounter the need for more than one relatively major dental procedure in a single year. If you’ve been told you need a crown, rather than put off the treatment, if you get it done right away you’ll hit your deductible, the minimum you have to pay out-of-pocket before the insurance company starts helping pay for the cost of your care. But say a few months later you end up needing a root canal on a different tooth. If both treatments fall in the same calendar year, you only pay your deductible once. But if the two treatments fall in two different calendar years, you’ll pay your deductible each time. You’ll save money by completing your dental treatment sooner rather than later & using up your dental benefits!

We know dental insurance (or any insurance for that matter) can be confusing. If you have questions about your coverage, we will do our best to answer them. Our staff is trained to make the most of your dental benefits.