How to Get the Facts Before Purchasing Dental Insurance (2024)

Affording the dentist is a big problem for many families. Dental insurance may be a great option to ensure that you and your family always have access to the dental treatment you need.

With the rising cost of going to the dentist, many people are struggling with the decision of whether or not to purchase dental insurance. Whether you are considering buying dental insurance through your employer or independently, be sure to investigate several different plans and ask questions about several factors, including network policies and coverage types. This information will help you choose the right dental insurance plan before signing on the dotted line.

Affordability and Yearly Maximum

The yearly maximum is the most money that the dental insurance plan will pay within one full year. The yearly maximum will automatically renew every year. If you have unused benefits, these will not roll over. Most dental insurance companies allow a yearly maximum of $1,000–$2,500.

In/Out of Network Dentists

Most independent dental insurance plans will only pay for your dental services if you go to a contracted and participating in-network dentist. Find out if you are required to go to a participating dentist or if you can choose your own. If the plan requires that you see an in-network dentist, ask for a list of the dentists in your area with whom they are contracted so you can decide if they have a dentist you would consider seeing.

If you wish to stay with your current dentist, some policies allow you to see an out-of-network dentist; however, the costs covered may be significantly lowered.

UCR (Usual, Customary, and Reasonable)

Almost all dental insurance companies use what is called a Usual, Customary, and Reasonable (UCR) fee guide. This means that they set their own price that they will allow for every dental procedure that they cover. This is not based on what a dentist actually charges but on what the dental insurance company is willing to cover. For example, your dentist may charge $78 for a dental cleaning, but your insurance company will only allow $58 because that is the UCR fee that they have set.

If you are on a policy that requires you to go to a participating provider, you should not be charged the difference between these two prices. A contracted dentist generally has an agreement with the insurance company to write off the difference in charges. If the policy allows you to go to a dentist or pediatric dentist of your choice, check the insurance company’s UCR fee guide against the fees that the dentist charges. You may be required to pay the difference out of your pocket, however, you cannot put a price tag on quality dental care.

Coverage Types

According to most dental insurance companies, dental procedures are broken down into three categories:

1. Preventive: Most insurance companies consider routine cleanings and examinations as preventive dental care, however, X-rays,sealants,and fluoride can be deemed as preventative or basic, depending upon the specific insurance carrier.
2. Basic or Restorative: Basic or restorative dental treatment usually consists of dentalfillings and simple extractions. Some insurance companies consider root canals basic, while others list them as major.
3. Major: Crowns, bridges, dentures,partials, surgical extractions, and dental implants are dental procedures that most dental insurance companies consider as major procedures.
   

Since all dental insurance carriers are different, it is important to clarify which dental procedures fall under each specific category. This is important because some insurance plans don’t cover major procedures, and others have waiting periods for certain procedures.

Orthodontic treatment is often considered a separate category. There can be age limits for coverage of certain procedures or dependents.

If you know that you will need major dental work that is not covered by a given plan, you should probably look elsewhere to find one that suits all of your needs.

Waiting Periods

A waiting period is the length of time an insurance company will make you wait after you are covered before they will pay for certain procedures. For instance, if you need a crown and the policy has a 12-month or longer waiting period, chances are you could have already paid for your crown while you have been paying your premiums and waiting.

Missing Tooth Clause and Replacement Period

Many dental insurance policies carry a “missing tooth clause” and/or a “replacement clause.”

A missing tooth clause protects the insurance company from paying for the replacement of a tooth that was missing before the policy was in effect. For example, if you lost a tooth before your coverage started and later decided that you would like to have a partial, bridge, or implant, the insurance company would not have to pay for that service if they have a missing tooth clause in the plan.

A replacement clause is similar, except that the insurance company won’t pay to replace procedures such as dentures, partials, or bridges until a specified time limit has passed.

Cosmetic Dentistry and Dental Insurance

Cosmetic dentistry is any type of procedure done for vanity purposes only.Teeth whiteningis very popular. While the effects are gorgeous, keep in mind that the vast majority of dental insurance companies won’t pay forcosmetic dentistry.

Comprehensive Coverage

Before deciding to purchase dental insurance, talk with your dentist regarding the extent of your treatment plan. This way, you can decide if you would be better off with or without dental insurance. A very important factor to remember regarding any dental insurance plan is that dental insurance isnot at allsimilar to medical insurance. The majority of dental insurance plans are designed with the purpose of only covering the basic dental care, around $1,000 to $2,500 (about the same amount that they covered 30 years ago) per year, and arenotintended to provide comprehensive coverage like that of medical insurance.

A Word From Verywell

To help finance your dental care, many dental offices are now offering interest-free payment plans because they understand that dental insurance only pays a small portion. Remember that dental insurance is very different from medical insurance, and be sure to talk to your dentist about the best option for you before embarking on any new treatment plans.

By Tammy Davenport
Tammy Davenport is a dental assistant with experience on the clinical and administrative side.