Understanding Dental Insurance - Part 1 (Preventative)

Dental Insurance can be one of the most complicated and misunderstood things that patient deal with. It is very common for dental insurance to be administered by a separate company from health and vision, and everyday we receive health insurance cards instead of dental. For many patients, dental carriers don’t send a physical card in the mail and it is typically buried in an email. Most dental offices are experts on helping patients track down their dental plans and can often find it based on an employer.

Health Insurance

What Is Typically Covered Under A Dental Insurance Plan?

Most dental plans can be broken down into three categories: preventative, basic and major. These facets are often covered at 100%, 80% and 50% respectively. Another common feature is a yearly deductible and individual maximum. Deductibles tend to range from $25 - $100 and are frequently applied only to basic and major services. It is less common for a deductible to be applied to preventative services, but it can sometimes occur. Yearly maximums average around $1,000, but in some instances can be as low as $500 and as high as $3,000 or more. 

What Are Preventative Services 

Most dental plans cover preventative services at 100% with no deductible. A common misconception is that since it is covered at 100% it isn’t taken from the yearly max. Although preventative services are more often than not fully covered, they are subtracted from the plan’s annual maximum. For instance, if a comprehensive exam, cleaning and x-rays cost $200 and the annual plan maximum was $1,500, the patient would have $1,300 remaining for the plan year. Preventative services cover routine maintenance and exams which commonly encompass:

  • Cleanings provided by a dental hygienist
  • X-rays that allow a dentist to see in between teeth and other dental concerns such as impacted wisdom teeth or oral cancer. Various x-rays can be used to diagnose and refer patients to the appropriate specialist if needed:
    • Bitewing - used to see in between posterior teeth and covered once per year
    • Occlusal x-rays - shows anterior teeth and may or may not be covered
    • Periapical - displays the root of teeth and may fall under preventative, basic or not covered
    • Panoramic - Often associated with viewing wisdom teeth and typically covered once every 3-5 years. Also valuable in spotting tumors, supernumerary teeth, permanent teeth that have not erupted and other potential anomalies in the upper and lower jaws.
    • Full mouth series - a combination of bitewing and periapical x-rays that provides a comprehensive series of images of individual teeth. May or may not be covered and typically only covered every 3-5 years
  • Exams where a dentist evaluates a patient for potential areas of concern or provides a treatment plan for dental needs.
  • Fluoride on younger patients, typically 18 and under
  • Sealants placed in the grooves of posterior teeth to prevent cavities from forming. There are dental limitations on sealants, which are typically allowed on kids under sixteen years old on permanent molars.

Why Are Preventative Services Covered At 100%?

Preventative or routine services help reduce expensive dental claims. Having regular dental cleaning removes plaque and tarter, lowering the risk of cavities forming. At routine visits, a dentist could potentially find spots of demineralization. These spots are not yet cavities, but are weakened areas in teeth where decay is likely to form. Prescription toothpaste containing high levels of fluoride can help the enamel remineralize and prevent a cavity, potentially eliminating the need for an additional dental claim. In the event a dentist finds a cavity on a patient who visits every 6 month, the cavity is typically very small and less expensive to fix.

Patients that don’t use their preventive dental coverage, often wait for a dental problem to occur and this leads to more expensive dental claims for procedures like extractions, crowns, bridges, implants and more. These patients often have to travel between a specialist and general dentist and use up their yearly maximum. They also hold off proceeding with dental treatment until their insurance resets in the following year and then max out their insurance again. Dental insurance companies prefer to avoid this situation and prefer their clients to visit the dentist every six month to avoid maxing their dental plans yearly.

To learn more about our practice visit Biltmore Avenue Family Dentistry's Home Page or Contact US for questions. If you enjoyed this article, we invite you to peruse our other Blogs and check out our last article “WHAT IS A FAMILY DENTIST?”.