How does dental insurance work?

Key takeaways 

• From cleanings to crowns, dental insurance is about prevention and protection, helping to cover costs and maintain your overall health. 
• Since plans vary widely, understand the differences between PPOs, HMOs, indemnity plans, and discount plans to pick the one that best fits your lifestyle and budget. 
• Look at premiums, deductibles, and annual maximums to plan for expenses — and prioritize preventive care to avoid surprises. 

Dental care isn’t just about having a bright smile — it affects your heart, immune system, and overall wellness. But good oral health can get expensive without the right coverage. 

Standard health plans don’t cover dental, but the right dental insurance can. From cleanings to braces or surgery, dental insurance helps you avoid surprising costs.   

Dental insurance basics 

Dental insurance is designed to make oral care affordable. Unlike health insurance, which helps cover a wider range of medical needs, dental insurance focuses on preventive and routine care to avoid more significant health issues.  

How can you get dental insurance? 

Dental insurance is typically offered in three ways: 

• As part of an employer-sponsored health plan. 
• As part of a health plan you buy yourself, through a broker like eHealth. 
• As a stand-alone dental plan or “rider” (either through your employer or purchased yourself). 

How do payments work? 

Here’s how payment usually works: When you sign up for dental insurance, you may pay a premium — a monthly fee to maintain your coverage. Many plans may also require you to meet the deductible, which is what you pay out of pocket before insurance kicks in and begins to cover some of your costs.   

You may also have to pay a fixed amount for a specific service called a copayment or coinsurance, a percentage of the cost. Most dental plans may also have an annual maximum, or the capped amount a plan will pay in a year.  

How dental insurance pays for procedures 

Dental insurance has three categories, each having its own level of coverage: preventive, basic and major. The coverage can impact what you pay out of pocket, so it’s important to understand how your coverage breakdown works.  

Preventive services 

Preventive services such as cleanings, exams, and X-rays are often covered 100% by most dental insurance plans and aid in maintaining good oral health and being proactive at catching issues at an earlier stage. This level of service helps prevent more costly procedures later and is one less thing to worry about during those yearly cleanings! 

Basic services 

Basic services may include fillings, extractions, and periodontal care. They typically have a 70 to 80% coverage rate for these more common dental issues. 

Major services 

Procedures that fall into the “major service” category — crowns, bridges, dentures, root canals, and oral surgery — are often covered at about 50%. While this offers the least amount of coverage, having dental insurance still helps significantly reduce how much you may have to pay out of pocket for your services. 

Types of dental insurance plans 

No dental plan is made the same — you may have several different types of plans to pick from: 

Dental PPO 

A Dental Preferred Provider Organization (PPO) offers flexibility:  

• You can use both in-network and out-of-network dentists. If you love having options, this is a great choice!  
• Consideration: These plans offer greater flexibility but are more likely to have higher premiums for out-of-network care. 

Dental HMO 

Dental Health Maintenance Organization (HMO) plans require choosing a primary dentist within a network.  

• Affordable: Though the choice of provider is a bit more limited, these plans typically have lower premiums and more predictable costs. 
• Limitations: There may be fewer covered procedures than a dental PPO plan. One of the key features of HMO plans is the emphasis on preventive care like regular check-ups, cleanings, and X-rays at low or no additional cost to you. 

Indemnity dental insurance plans 

Indemnity dental insurance plans, often traditional or fee-for-service dental plans, are known for their flexibility and simple reimbursement model.   

• Freedom: Visit any dentist you choose without choosing from a network. After receiving dental services, you pay the dentist directly and then submit a claim to the insurance company for reimbursement. 
• Consideration: Indemnity dental insurance best suits those who want the freedom to visit any dentist and are comfortable with paying upfront and submitting claims for reimbursement. 

Dental discount plans 

Discount dental plans offer a way to save money without the structure of a standard insurance plan. These plans are not insurance. Instead, they operate as a membership program where you pay an annual or monthly fee for access to a network of dentists who have agreed to offer services at discounted rates.  

The discounts typically apply to routine cleanings, X-rays, fillings, crowns, and even more complex procedures like root canals and orthodontics. The specific discounts and services covered vary by plan and provider. There are no deductibles, no annual limits, and no paperwork to file for reimbursements.  

Key features of dental insurance plans 

Choosing the right dental insurance plan goes beyond checking that your current dentist is within your plan’s network. To meet your needs, you should consider many key factors. 

• Network coverage: Using a dentist within your network can help you save on unexpected bills and reduces your out-of-pocket costs. 
• Waiting periods: Some plans may require you to wait several months before receiving major treatments — that could be anywhere between 6-12 months. Preventative services, on the other hand, typically require no waiting period.  
• Annual maximums: This is the yearly cap on what your insurance will cover each year. A higher maximum can help with budgeting for major services. 
• Out-of-pocket costs: These are expenses like deductibles, copayments, and coinsurance that you are responsible for paying for the services you receive. The amount of coverage varies between plans, which can also affect your budget. 

Does dental insurance cover cosmetic treatments? 

Cosmetic treatments such as teeth whitening or veneers are considered elective and usually are not covered by insurance. However, if a procedure is considered medically necessary, such as repairing a broken tooth, your plan may provide some coverage. 

To know what your plan may or may not cover, always check with your insurer to avoid unexpected costs. There are also other exceptions to this, including orthodontic care, which may be covered for children under certain plans. 

Special considerations 

There are a few additional considerations to keep in mind when choosing the best dental plan. 

Dual coverage  

Dual coverage occurs when you’re covered by two different insurance plans such as your employer’s plan and a spouse’s plan. The two plans work together to help reduce your out-of-pocket costs. In most cases, one plan is primary, which pays first. The other plan, the secondary plan, covers a portion or all the remaining costs. It’s like splitting the check at a restaurant — everyone pays a share. 

Pre-treatment estimates 

Without a pre-treatment estimate you may feel blindsided by unexpected bills. By requesting an estimate, your dentist submits a treatment plan to your insurance provider prior to treatment. The insurance company then sends back an estimate with a breakdown of what you’ll pay out of pocket and what your insurance will cover. 

Choosing the right dental insurance plan 

When choosing the right dental plan, think about your needs and budget. Is your dentist included within your network? How might waiting periods impact your decision? 

Don’t worry! Licensed insurance brokers like eHealth make it easy to search for plans that put you first. You can start browsing dental insurance plans or finding healthcare plans that also include dental coverage. Before you begin your research, here are some tips to find the right plan: 

• Understand out-of-pocket costs: Look at deductibles, co-pays, coinsurance, and annual maximums. A lower premium plan might cost more overall if it has high out-of-pocket expenses. 
• Check the provider network: If you have a preferred dentist, make sure they are included in the plan’s network. A quick call to your provider or an online search could have the answer for you in no time. 
• Consider waiting periods: Many plans have waiting periods for certain types of coverage, especially for major dental work — so plan your dental appointments and procedures accordingly. 
• Assess your dental health needs: If you foresee needing major dental work, look for a plan with comprehensive coverage. If you only need preventive care, a basic plan may suffice. 
• Compare plans: Compare plans side by side and focus on total costs — not just premiums — to better budget. 

The big picture 

Having dental insurance helps bridge the gap between oral care and affordability. With a quality dental insurance policy, you can get coverage for anything from routine exams to root canals. Dental insurance is all about knowing what plan works best for you and how to reduce your out-of-pocket costs to take care of your health, starting from the mouth. With dental insurance, stay prepared for dental expenses and keep your smile healthy! 

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