What does dental insurance cover?

(Photo courtesy of Angie's List member Debra A. of Spartanburg, S.C.)

(Photo courtesy of Angie's List member Debra A. of Spartanburg, S.C.)

You use your teeth every day for chewing, talking, smiling and a host of other activities, so keeping teeth healthy and strong is a necessity. Dental insurance plans can help defray the costs of treatment, but it can be tricky to navigate what's covered and what's not. In other words, how do you make the most of a dental plan?

Welcome the network

First, it's important to understand that most dentists operate under a preferred provider organization (PPO) agreement. This means the health insurance provider you deal with - through your work or a private provider of your choosing - has negotiated with certain dentists in your area and obtained lower rates for service. These dentists are "in your network" and can often bill your plan directly. You can choose to go outside of a PPO network but you will pay more (sometimes 100 percent of the cost) and will have to submit much of the paperwork on your own.

Some dental practices are also covered by health management organizations (HMOs), but these plans don't always adequately reimburse dentists, which may lead to dentists seeing patients very quickly and limiting treatment to bare essentials in an attempt to cover costs.

What dental insurance covers

Not all dental plans are created equal, but a standard employer-provided PPO should cover between 80 and 100 percent of the cost for treatments like regular checkups, cleanings, fluoride and sealants. More critical work such as root canals or fillings are covered at anywhere from 70 to 80 percent, while major work like crowns or dentures typically come in at 50 percent coverage.

You also need to bear in mind the cost you'll pay for each service. Dental plans come with a deductible each time you make a claim, which can range from $50 to $100. It's possible to lower the amount you pay per month by increasing the amount of your deductible and visiting the dentist only once per year, but you run the risk of a huge bill if you suddenly need treatment. In addition, most plans have a maximum payout each year, often between $1000 and $2000. This seems like a substantial amount until you consider the costs of treatment: A periodic oral examination costs less than $100 on average, but a crown can cost between $700 and $800, while fixing a molar costs at least $600. As a result, your plan can quickly cap out.

More expensive options

Dental insurance plans typically have "tiers" of coverage, starting with basic options meant to cover the average expenses associated with hygiene. Your employer (or you, if you're going to bear the entire cost of insurance) can opt for orthodontic coverage, which includes more expensive options like braces, casts and referrals to orthodontic specialists.

Generally speaking, cosmetic dental procedures are not covered under an insurance plan, especially one managed by an employer. If your dentist can make the case for medical necessity, it may be possible to have treatments such as dental veneers covered, but depending on the percentage and deductible, it may not be worth the cost.

Making the most of dental insurance

To make the most of your coverage, you want to roll as many services into a visit so you only have to pay a single deductible. Do this within reason, of course - a reputable dentist should be able to deal with most of your dental needs in a relatively short period of time, saving you money in the long run. In addition, make sure to check with your employer about how much you're paying per check for your insurance. In some cases, the amount deducted amounts to more than the total coverage offered, meaning you may want to opt out.

Dental discount plans are also an option as alternatives to traditional insurance. Instead of offering co-payment at a fixed price per month, discount plans have a much smaller monthly fee ($10-$20 per month) and give access to discounted services. If you need regular, costly treatments, you may want to consider this option. Make sure, however, that your plan has credible dentists on its list; some offer great deals but don't actually provide access to any services.

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