An Essential Guide Of Dental Coverage And Exclusions

Description: What do you know about dental coverage? What is covered and what is not covered by your dental insurance? Follow the article for more information.


Dental Insurance has become an essential part of maintaining good oral health. Dental insurance makes sure you don’t have to overspend your hard-earned money on ridiculously expensive dental treatments. Since dental insurance emphasizes preventative care, you get benefits from performing regular cleanings or checkups.

What confuses many people, whether in possession of dental insurance or not, is the confusing vocabulary terms and types of coverages offered by dentists and different insurance companies. Among thousands of available options, it is not an easy task to pick the best and most suitable dental care plan for you and your family.

This article will mainly discuss typical dental insurance policies and the coverage they offer.

Dental Insurance Options

Dental Insurance is generally divided into 3 plans: HMO, PPO, and indemnity.
  • HMO, known as Health Maintenance Organization, offers a network of dentists from which you can choose. The plan will cover the cost of treatments accordingly if you go to see one of the in-network doctors. If you fail to do so, HMO plan will not cover for your treatment. 
  • PPO, knowns as Preferred Provider Organization, is a little bit more flexible than HMO. PPO allows you to seek help outside of their system. However, you have to pay additional out-of-pocket money if you don’t choose in-network dentists. 
  • Indemnity plans are the most flexible. They don’t have any network of dentists. Instead, indemnity plans allow you to see any doctor you wish to see and still receive the same amount of coverage. Of course, there comes a price with that freedom. Indemnity plans are often more expensive the PPO and HMO.

The coverage policy in the dental insurance

So what is included in a typical dental insurance policy?
  • Preventative procedures: Preventative care includes regular checkups, cleanings, and examinations. Some insurance plan will cover for some small procedures such as X-ray, dental sealants, and fluoride treatments. Generally, the cost of treatments will be fully covered.
  • Basic procedures: Insurance companies will cover a hefty part of the cost for basic procedures, including fillings, tooth extractions, and root canals.
  • Major procedures: You should thank your dental insurance companies since important dental treatments are often costly. Treatments for crowns, bridges, dentures, surgical extractions and dental implants cost a fortune. Fortunately, dental insurance plans will cover up to 50% of the cost for those treatments. 
Typically, insurance companies set maximum coverage that you can use for dental treatments within a year. This coverage stays the same every year. On average, the vast majority of insurance company set a budget of $1,000 for their clients. You are only allowed to spend up to $1,000 but no more.

Depending on the types of dental insurance plans, you can access the network of dentists provided by insurance companies. If you go to see one of the in-network dentists, you will have to pay almost nothing out of your pocket.

However, it doesn’t mean you can’t visit other dentists outside of the network. When you choose to go to a dentist who doesn’t belong to the network, you can ask for UCR rates of your insurance company. UCR stands for Usual Customary and Reasonable. For example, if you go to a dentist to do filing for $60, and your insurance company will only pay $45 for this procedure, then you have to pay $15 as a UCR rate.

Most insurance companies set up a waiting period for their clients. That means if you have a major procedure like a  crown treatment, you may have to pay for the crown yourself and wait at least 12 months to access the coverage.

Exclusions in dental insurance policies

No matter how much premiums you have paid, there are still exclusions in dental insurance policies. For example, your insurance company will not cover for any cosmetic dentistry. This is because cosmetic dentistry is quite expensive, and no insurance company wants to run in a debit for years and waits for your premiums pay for the treatment. So any costs for veneers or teeth whitening will not be covered in many cases. If you use a dental discount plan, you may get a discount for the cosmetic dentistry. However, there are some insurance policies agree to cover orthodontic procedures.

Any pre-existing conditions will not be covered as well. Which means if you have any dental problems prior to the time of getting the insurance, your insurance provider will not pay for the cost of treatment. Also during the waiting period of at least 12 months, you have to pay for any costs of major treatments yourself.

However, if your dental treatment is considered “medically necessary,” health insurance can also pay for the dental work. For example, if your teeth are damaged in an accident and you need immediate oral surgery, you need not worry about the treatment fee since the health insurance may pay for you.

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