Reviewed by Thomas J. Catalano
Fact checked by Vikki Velasquez
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Dental insurance can be expensive, and many Americans consider it an unnecessary cost. But the cost of dental care can be even more exorbitant, and the lack of care can have serious consequences. Here we discuss the types of dental insurance policies, and whether or not it’s worth the cost.
Key Takeaways
- Dental insurance plans typically cover three types of care: basic, preventive, and major.
- Most plans pay 100% of preventive care, but only a portion of the cost of major care.
- Preferred provider organizations (PPOs) give you the widest choice of providers, but you will pay more if you go out of network.
- Dental HMO plans are more affordable, but they give fewer choices.
- Some Medicaid or Medicare Advantage programs may also help provide dental care.
What Is Dental Insurance?
Dental insurance is the oral version of health insurance. Instead of paying full price for each visit, you pay a steady monthly rate, and your insurance plan pays for some or all of your care. You’ll pay a premium for your policy, as well as deductibles, copays, and coinsurance.
Dental plans cover three types of care: basic, preventive, and major. Up to 100% of preventive care is often covered, but coverage may drop to 50% for major dental work. Basic care falls in the middle at about 80%.
Major care includes treatment such as crowns, dentures, and implants. Basic care covers extractions, root canals, and fillings. Preventive care aims to make sure you don’t need any of these treatments through regular check-ins and cleanings with your dentist.
Types of Dental Insurance Plans
“In general, there are two types of plans, PPO plans and DHMO plans,” according to Dr. Sandip Sachar, a practitioner of cosmetic and general dentistry in New York City for more than 20 years.
“There are also variations within these two types,” Dr. Sachar adds. “PPO plans generally allow you to pick which dentist to go to, whereas DHMO plans only allow you to go to a participating provider.”
Preferred Provider Organization plans (PPOs)
Preferred provider organization plans (PPOs) contract with dentists who provide discounted fees that are passed on to the insured. You’re not obligated to use these providers, but you’ll pay more if you go out of network.
The plan provider pays the dentist after the work is completed. You won’t have to contribute to the cost if it exceeds the contracted amount. This is the most common type of dental insurance plan.
“I recommend purchasing a PPO plan,” Sachar says, “but always inquire if it’s a usual and customary fee schedule, not an in-network fee schedule. This ensures that you can go to any dentist that you like and the insurance will pay a majority of the fees so you don’t have to.” Sachar defines a fee schedule as an allowed amount that dictates how much the insurer will pay for each procedure.
Dental Health Maintenance Organization Plans (DHMOs)
Dental health maintenance organization plans (DHMOs) operate similarly. The plan provider contracts with a network of dentists. You’re generally restricted to obtaining care from these dentists, unless your policy includes a point-of-service provision that allows you to opt out of network coverage. Your insurance coverage will be reduced if you take this option.
“Sometimes having a DHMO plan is better than having no plan at all for patients who can’t afford PPO insurance or who don’t want to pay more for insurance,” according to Sachar.
Important
Some employers contribute to dental coverage costs for employees, but about 20% of employees have to pay the entire premium.
Coverage and Benefits
Some coverages can depend on how long the insured has held the policy. Preventative and restorative care are commonly covered in the first year, as are root canals, extractions, and minor surgeries. Coverage for orthodontics, periodontics, and dentures typically isn’t available until after the first year.
PPOs often cap the amount of coverage they’ll pay in a given year and this can be as little as $1,500.
Most insurers cover 100% of preventative care services but major procedures are only covered up to 50% of the cost and will require that you make copayments.
68 million
The number of Americans without health insurance in 2023, according to the CareQuest Institute for Oral Health.
How Much Will This Cost You?
How much you’ll pay for dental insurance depends on a series of interlocking factors and current trends.
“There’s been a large change over the past 20 years,” Sachar says. “Insurances pass many more costs on to the patient. This includes higher deductibles and coinsurances. They’ve also lowered their fee schedules, the amount they allow for each procedure.”
Premiums
You’ll have to pay an insurance premium for your coverage. A single individual might pay from $17 to $96 a month. This could increase to $50 to $150 a month for family coverage but it can depend on where you live and your age. You might be able to agree to a higher deductible or coinsurance and your premium will drop a bit in return.
Deductibles
Dental plans almost always require that you pay a deductible. You must personally make a payment to your care provider for a portion of their services and your dental insurance will pay the balance.
Deductibles are capped at a certain figure and these are usually annual amounts. They reset at the end of the year. You don’t get to roll over any unused deductible amounts into the next calendar year. Money Magazine puts the average deductible at just about $50 per person per year.
Coinsurance
Coinsurance provisions require that you continue to pay for a portion of your care even after you’ve paid your deductible. Deductibles and copays will typically cost you more if you go out of network for care.
Warning
An insurer could require you to pay both a deductible and coinsurance for dental services. Look into their terms for these provisions when you’re looking for a plan.
Annual Maximums
“This is the most the insurer will pay per calendar year,” Sachar explains. “Insurance no longer pays and you’ll have to pay any balance when you’ve met the annual maximum.”
You would have to come $1,000 out of pocket if your insurer’s maximum is $1,500 and your care costs $2,500.
Common Exclusions and Limitations
Now some more bad news: Most dental insurance policies exclude or limit certain treatments. Orthodontics may not be covered at all on some policies. The National Association of Dental Plans indicates that you must usually purchase an additional rider if you want this type of coverage.
You can most likely forget about cosmetic procedures such as teeth whitening, at least if you don’t want to pay the entire cost on your own. Most policies don’t cover this work.
Pre-existing conditions are typically excluded as well: any ailment or problem that already existed at the time you purchased your policy.
Government Programs for Dental Coverage
Some government programs stand by ready to assist with these expenses.
Individuals over age 65 can get coverage as a supplemental benefit if they sign up for a Medicare Advantage plan, often at no additional cost or for a minimal additional premium. Out-of-pocket costs for deductibles and copays can reportedly be significant, however, particularly for those who need serious care.
Original Medicare doesn’t cover routine dental work but it does cover treatments it calls “medically necessary.” This includes care associated with dialysis treatment for end-stage renal disease beginning in 2025.
The Affordable Care Act also enhanced dental benefits for children beginning in 2014. The ACA caps out-of-pocket expenses at $350 per year for one child or $700 annually for family coverage. Medicaid also provides for top-notch dental care for children.
The Children’s Health Insurance Program (CHIP) added a provision in 2009 that permits families to purchase only dental insurance for their children if they have family health insurance coverage but no dental coverage.
The Bottom Line
Dental insurance can be a hot topic of debate. Is it necessary? Is it worth it, what with all the extra associated expenses? Numerous types of out-of-pocket costs can apply and some types of work might not be covered at all.
Whether you should buy dental insurance is a personal decision with no one-size-fits-all answer.
“The best advice I give when asked about dental insurance is to always read the fine print,” Sachar says. “Do your best to try to understand how the insurance works. Ask about what’s covered and what’s excluded.”