How Does Dental Insurance Work? Understanding Dental Coverage

Getting a handle on your dental insurance is step #1 to guarantee you get the maximum benefit from your dental coverage.

We realize that some of the “fine print” and lots of the dental insurance language can be somewhat confusing, so we prepared the following guidelines to take the mystery out of your dental plan.

Here are 2 options to familiarize yourself with your current dental plan:

• Read and review the benefits booklet for the fully detailed outline of all that is included in your dental benefits.
• Register/sign in to your MySmile® account and click on “Coverage overview” for an easy-to-read overview of your plan's features and benefits.

These are 7 fundamentals of your dental insurance that you'll want to know and understand:

• Benefit period
• Co-payments/coinsurance
• Dental network
• Deductibles
• Maximums
• Reimbursement levels
• Waiting period

To help you better understand these fundamentals of your dental coverage, here's a brief explanation of each one:

Benefit Period
Essentially, a benefit period is the length of time during which the benefit is paid. Your dental coverage has both a plan “effective date” and an “end date,” and in most cases, the benefit period for your plan will be one year.

So, if your effective date on your plan is January 1, 2019, and the end date is December 31, 2019, you will no longer have coverage as of December 31, 2019, unless you renew your plan before the end date.

Co-Payments/Coinsurance
These two terms may sound similar, but they are not exactly the same. Both are fees that the patient is responsible to pay for a portion of their dental treatments.

• Some dental plans include a co-payment, which is usually a flat fee per visit / treatment, and does not generally count towards your deductible.
• Coinsurance is the amount (usually a percentage) the patient is responsible to pay for a specific dental treatment, after the insurance company has paid their portion. For example, if your plan specifies you have a 20% coinsurance for fillings or crowns, then your insurance will pay 80% of the cost billed by the dentist, and you will be billed the remaining 20% for those services.

Deductible
Similar to your home owner or auto insurance policies, the dental plan deductible is simply the amount that you must pay out of pocket, before the insurance policy pays for any treatments. Most dental plans do have annual deductibles, some are for each individual covered on the plan and some will be 1 deductible for all family members included in the plan.
Some plans do not have a deductible required for some of the basic preventative treatments and services such as annual check-ups, cleanings, x-rays, etc.

Review your specific dental plan coverage to determine what deductibles you are responsible for.

Maximum
Your dental plan probably mentions two types of maximums: annual and lifetime.

• The annual maximum is simply the maximum amount your plan will pay towards the cost of all your dental care within that benefit period, which is usually the calendar year. Many plans do not include the standard preventive and diagnostic treatments in the annual maximum, which means your plan pays for these benefits above and beyond whatever the annual maximum is.
• The lifetime maximum is the maximum dollar amount your plan will ever pay towards the cost of specific dental services. The most common dental services with lifetime maximums are orthodontic treatment and TMJ.

Since not all plans are created equal, and some will have an annual or lifetime maximum, while others will not. This is why it is essential to read and become familiar with your specific plan coverage and limits.

 

Reimbursement Level
Dental insurance plans generally cover different treatments and services at different percentages (a.k.a reimbursement levels). The various types of services are categorized into 3 main classes with different reimbursement levels for each class. There are also some exclusions or restrictions noted for each class as well.
Here are the 3 main classes, and the reimbursement levels that generally apply to each class*:

• Class I procedures are preventive and diagnostic. They are covered at the highest percentage (usually 100%). This enables patients to obtain the routine, preventative treatments to help avoid more costly, and complicated treatments down the road.
• Class II includes basic restorative procedures like root canals, fillings, and extractions. These services are reimbursed at a lower percentage than Class I services. For example, 70-80% reimbursement vs. 100% for Class I.
• Class III is for major restorative procedures such as inlays, on-lays, crowns, and dentures. These services are typically reimbursed at the lowest percentage and may have a waiting period before these services are covered by your plan.

*Note: As with all aspects of your dental insurance coverage, it is important to review your specific plan benefits to confirm these reimbursement levels.

 

Waiting Period
In some cases, a plan will require a waiting period prior to allowing coverage for a specific treatment. For example, suppose your plan has a 4 month waiting period for root canals. If your plan coverage began on January 1, then your waiting period ends on May 1. Anytime after May 1, you are eligible to use your benefits for this treatment.