Understanding Dental Coverage
Here’s a quick overview of how most dental coverage works. Be sure to look at your plan booklet for the specifics of your coverage.
- We offer a variety of benefit plans, each with different features. So while you may have 100% coverage or no copayments for checkups and cleanings, your friend who also has a Delta Dental plan may not.
- If you have a Delta Dental PPOTM or Delta Dental Premier® plan (our fee-for-service open network plan), you can visit any licensed dentist, but you will usually save the most when you visit a dentist in your plan’s network. Your dentist will submit a claim after your visit and will not bill you more than the approved amount. If you visit a non-Delta Dental dentist, you may be responsible for paying your dentist the full amount and submitting the claim to us after the visit.
- If you have a DeltaCare® USA plan (our DHMO-type closed network plan), you select a primary care dentist from our network whom you visit for your care. This dentist will refer you to a specialist if needed. When you visit your dentist, you have predictable costs and you don’t have to worry about claim forms.
- You might have benefits from more than one dental plan, which is called dual coverage. In this situation, the total amount paid by both plans can’t exceed 100% of your dental expenses. And in some cases, depending on the specifics of the plans, your coverage may not total 100%.
- Most dental plans work within a “benefit period” that is typically one year — but not necessarily a calendar year.
Things to Know
Similar to car insurance, this is the amount you have to pay before your benefit plan begins to pay the cost of your dental treatment.
This is the most money a dental plan will pay for dental care within a benefit period. Once you reach the maximum amount, you will be responsible for paying any costs for the remainder of the benefit period.
If you have a fee-for-service benefit plan, the plan pays a percentage of the treatment cost, and you are responsible for paying the balance. What you pay is called coinsurance, and it is part of your out-of-pocket cost after your deductible is reached.
Fee-for-service dental plans offer different categories of coverage, each tied to a certain percentage. For example:
Procedures that are diagnostic and preventive (such as cleanings and checkups) are typically covered at the highest percentage (for example, 80 to 100% of the plan’s contract allowance). This gives you a financial incentive to get regular checkups and cleanings to prevent the need for more extensive procedures.
Basic procedures (such as fillings and gum treatment) are usually reimbursed at a slightly lower percentage (for example, 70 to 80%).
Major procedures (such as crowns and fillings) are usually reimbursed at a lower percentage (for example, 50%).
If you have a DHMO-type plan, you pay a fixed dollar amount for certain covered services (some services may have no copayment), instead of a percentage. When you enroll, you receive a list of covered services and their copayment amounts. These types of plans usually have no annual deductibles and no maximum amounts for covered benefits.
If your dental care is extensive and you want to plan ahead for the cost, you can ask your dentist to submit a pre-treatment estimate. This estimate includes an overview of services covered by your dental plan and how coinsurance, deductibles and dollar maximum limits might affect your share of the cost. While it is not a guarantee of payment, a pre-treatment estimate can help you predict your out-of-pocket costs.
Limitations and Exclusions
Dental plans are intended to cover part of your dental expenses, so coverage may not extend to your every dental need. A typical plan has limitations such as the number of times you can receive a cleaning each year. In addition, some procedures may be not be covered under your plan, which is referred to as an exclusion. Review your plan booklet and obtain a pre-treatment estimate to see how any limitations or exclusions would affect your share of the cost.
In addition, a procedure covered under your plan might be limited or denied based on a clinical review by one of our licensed dental consultants. These decisions are based on the standard of care all dentists are required to follow. You may obtain a copy of these guidelines by sending a written request for the following benefit categories:
- Basic benefits
- Crowns, inlays, onlays and cast restoration benefits
- Prosthodontic benefits such as fixed or removable appliances