Understanding dental coverage
Here’s a quick overview of how most dental coverage works. Check your plan booklet or Policy 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.
Most dental plans work within a “benefit period” that is typically one year — but not necessarily a calendar year.
- If you have a Delta Dental PPOTM1 or Delta Dental Premier®1 plan (our fee-for-service, open network plans), you can visit any licensed dentist, but you’ll usually save the most when you visit a dentist in your plan’s network. Your network dentist will submit a claim after your visit and won’t bill you more than the approved amount.
There’s no balance billing when you visit a Delta Dental dentist because our dentists agree to contracted fees. You’ll only pay any applicable copayment or coinsurance for a covered service. Non-contracted dentists are under no obligation to limit their fees. Plus, when you visit a non-Delta Dental dentist, you may be responsible for paying your dentist the full amount for the service and submitting the claim to us after the visit.
- If you have a DeltaCare® USA2 plan (our prepaid, fixed copayment, closed network plan), you choose a network dentist when you enroll and visit that dentist to use your benefits.3 (You can change your dentist at any time.4) This dentist will refer you to a specialist when needed.5 When you visit your selected network dentist, you have predictable costs and you don’t have to worry about claim forms.6
Things to know
Similar to car insurance, this is the amount you pay before your benefit plan begins to pay the cost of your dental treatment. A deductible usually doesn’t apply to diagnostic and preventive treatment. Learn more about deductibles.
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. Depending on the specifics of the plans, your coverage may not total 100%. Learn more about dual coverage.
This is the most money a dental plan will pay for dental care within a benefit period. Once you reach the maximum amount, you’ll pay any costs for the remainder of the benefit period.
Generally, Delta Dental PPO and Delta Dental Premier plans have maximums and deductibles, but the DeltaCare USA plan does not. Learn more about maximums.
If you have a fee-for-service benefit plan, your plan pays a predetermined percentage of the treatment cost and you’re responsible for paying the balance. This part of your out-of-pocket costs is known as “coinsurance.” Delta Dental PPO and Delta Dental Premier plans have coinsurance.
Fee-for-service dental plans offer different categories of coverage, each tied to a certain percentage. For example:
- Diagnostic and preventive procedures, 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 root canals, are usually reimbursed at the lowest percentage (for example, 50%).
Procedures can fall under a different category depending on your plan. Please see your plan booklet or Policy for a complete description of benefits, limitations and exclusions.
If you have a closed network, prepaid, fixed copayment plan, you pay a set dollar amount for covered services, instead of a percentage. (Some services may have no copayment.) When you enroll, you’ll receive a list of covered services and their copayment amounts. These types of plans usually have no annual deductibles or maximums.
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 any applicable coinsurance/copayments, deductibles and dollar maximum limits might affect your share of the cost. While it’s not a guarantee of payment, a pre-treatment estimate can help you predict your out-of-pocket costs. Learn more about pre-treatment estimates.
Limitations and exclusions
Dental plans are intended to cover part of your dental expenses, so you may not be covered for 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.” To find out how any limitations or exclusions would affect your share of the cost for a treatment, review your plan booklet or Policy or obtain a pre-treatment estimate.
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
1 Delta Dental PPO and Delta Dental Premier are underwritten by Delta Dental Insurance Company in AL, DC, FL, GA, LA, MS, MT, NV, TX and UT and by not-for-profit dental service companies in these states: CA – Delta Dental of California; PA, MD – Delta Dental of Pennsylvania; NY – Delta Dental of New York, Inc.; DE – Delta Dental of Delaware, Inc.; WV – Delta Dental of West Virginia, Inc. In Texas, Delta Dental PPO provides a dental provider organization (DPO) plan.
2 DeltaCare USA is underwritten in these states by these entities: AL — Alpha Dental of Alabama, Inc.; AZ — Alpha Dental of Arizona, Inc.; CA — Delta Dental of California; AR, CO, IA, MA, ME, MI, MN, NC, ND, NE, NH, OK, OR, RI, SC, SD, VT, WA, WI, WY — Dentegra Insurance Company; AK, CT, DC, DE, FL, GA, KS, LA, MS, MT, TN, WV — Delta Dental Insurance Company; HI, ID, IL, IN, KY, MD, MO, NJ, OH, TX — Alpha Dental Programs, Inc.; NV — Alpha Dental of Nevada, Inc.; UT — Alpha Dental of Utah, Inc.; NM — Alpha Dental of New Mexico, Inc.; NY — Delta Dental of New York, Inc.; PA — Delta Dental of Pennsylvania; VA – Delta Dental of Virginia. Delta Dental Insurance Company acts as the DeltaCare USA administrator in all these states. These companies are financially responsible for their own products.
3 In WY, you don’t need to select a primary care dentist, but you must visit a DeltaCare USA dentist to receive benefits. In the following states, you can maximize your savings when you visit a DeltaCare USA dentist, although you may visit any licensed dentist and receive out-of-network coverage: AK, CT, LA, ME, MS, MT, NC, ND, NH, OK, SD, VT. Refer to your plan booklet for details about your out-of-network benefits.
4 Changes received by the 21st of the month will be effective the first day of the following month. Verify that the dentist is your selected DeltaCare USA primary care dentist before each appointment. In the following states, you can change your dentist any time without contacting Delta Dental: AK, CT, LA, ME, MS, MT, NC, ND, NH, OK, SD, VT, WY.
5 Most services not performed by your primary care dentist must be authorized by Delta Dental. In some states, specialty care benefits are only available for services performed by a DeltaCare USA specialist. Refer to your plan booklet or Policy for more information.
6 You may have to complete a claim form if you visit an out-of-network dentist, such as for limited emergency treatment or in the following states: AK, CT, LA, ME, MS, MT, NC, ND, NH, OK, SD, VT.