Dental Insurance 101

Ok, so we all know that sometimes insurance can be complicated to understand.  It doesn’t have to be that way once you know what you are looking at.  Let’s go over the basics with some dental insurance 101 to help you get a better grasp of it.

There are a bazillion ways that dental plans are written up, so we are just going to look at a typical generic plan and focus on that (please read your plan carefully to check on all the specifics).

First off, you have a dental maximum amount of dollars to use per your dental year.  This year typically runs from January 1 to December 31.  Some plans run on a different schedule due to hire dates and things like that, so you may have one that runs July 1 through June 30.  Knowing these dates will allow you to better prepare yourself to figure out how much time you have left to use up your remaining amount of benefit dollars and when your new year starts over with a new maximum to use.  Once you hit this maximum amount of dollars, that’s it until a new year starts!  Each member of the family on the dental plan has a maximum amount to use.  So, if the plan has a $1,000 maximum, it means that you, your spouse and child each individually have $1,000 of dental benefits. The maximum generally includes all of your services including exams, cleanings and x-rays, along with other things like fillings, crowns, dentures and so forth.  We’ve heard some patients say that they thought cleanings and exams are separate from the maximum, but that would be unusual.

Next: Deductibles.  Just like your car insurance or health insurance, dental insurance generally has a deductible that you need to meet.  This deductible (we see them a lot as $25 or $50 amounts) has to be paid by you prior to your insurance paying for dental treatment.  Most likely, the deductible is waived for things like regular cleanings, x-rays and exams, which are considered preventive care.  It does, however, apply to what is considered basic and major services.  Basic services generally include fillings, root canals, and extractions and some extensive cleanings.  Major services are usually things like crowns, bridges, partials and dentures.

Let’s look at a break down to show you how the deductible works.  

Let’s say you have a $50 deductible and you need to have a filling done, which costs $150 (let’s sneak a maximum in here also).


Dental Maximum: $1,000
Deductible: $50 (applies to basic and major)

Preventive: 100%
Basic: 80%
Major: 50%

Ok, your insurance plan covers 80% of fillings after your $50 deductible is met.  Take that deductible off the top to start with and set it aside.

$150 (cost of filling)
-$50 (deductible)
$100 that your insurance will now pay 80% after deductible

80% of $100 is $80, which leaves you a 20% co-payment of  $20
Add that $20 co-payment to the deductible that you owe:

$50 deductible + $20 co-payment= $70 out-of-pocket cost to you

Now that your deductible is met, you should not have to meet it again until your new year of benefits starts over.

And, since your insurance will be paying $80, that will be $80 subtracted from the $1,000 maximum leaving $920 to use for the year.

There can be some tricky situations, as we all know happen when dealing with dental insurance.  Sometimes your insurance has something called a pre-existing condition, just like most health insurances.  This will prevent them from paying for certain things due to the initial occurrence happening prior to your coverage starting with that particular plan (confused yet?).  Maybe at one point in your life you had to have a tooth removed; let’s pretend when you were 31 years old.  Now, at 37 years old, you want something to replace that tooth, however you started a new job with different dental insurance and it has a pre-existing condition clause or what may be called a missing tooth clause.  The insurance will not pay for a bridge to replace that tooth because you had it removed prior to starting with this insurance plan.

Another issue might arise where you have a waiting period that needs to be met on a new insurance plan before you have any coverage at all.  Sometimes it will be a 3-month wait but there are times that you have to be covered under that dental plan for a year before they will cover anything major like a crown or partial denture.  Be aware of these things before you jump the gun.  It’s exciting to have dental insurance when you haven’t had it for a while, so although you may be raring to go to get dental treatment done, just make sure that a waiting period doesn’t prohibit you from moving ahead.

Szmanda Dental Center can find out from your insurance plan what your coverage is and any stipulations it might have.  We can also preauthorize proposed treatment prior to you having it completed so you can be aware of exactly what you will have to pay out-of-pocket.  Please talk with our fantastic front desk team for further information on your dental plan and to schedule an appointment.  We are here to help!

Information compiled from Staff at Szmanda Dental Center  © Szmanda Dental Center, S.C. 2013