Dental Insurance – What You Need to Know

Dental insurance covers most of the costs associated with routine exams, cleanings, and X-rays. However, all plans have limits on how much they will pay in a year. These limits are called annual maximums.


Some insurers offer PPOs, which allow patients to choose their own dentist. Others offer DHMOs, which restrict patients to in-network dentists. These plans generally have lower premiums and deductibles.

Preventive care

Many dental plans have a deductible, copayment, or coinsurance. They also have a maximum annual benefit and an insurance premium. These can be paid by the employer, the plan member, or the third party payer. The insurance premium is usually a monthly amount and may be deducted from the employee’s paycheck.

Dental plans cover preventive care such as oral exams and cleanings (usually twice a year), x-rays, and tooth sealants for children. Most plans also cover basic procedures like fillings and extractions. Some even include orthodontia. Other coverage options may be available for periodontics, endodontics, or oral surgery.

Most dental insurance plans have a network of dentists and other providers that the insurance company has negotiated contracts with to provide services at discounted rates. These are called preferred provider organizations or PPOs. The insurance company can also negotiate with dentists outside of the network, but those fees will be higher.

Restorative care

With Dental insurance, you can receive restorative care to help you get back on your feet after an injury or illness. These services may include range of motion and positioning, assistance with ambulation, and psychosocial skills training. They are also designed to promote independence and improve your quality of life.

Dental plans come in a variety of shapes and sizes, from individual or family coverage to group options for businesses. Some are available on the Marketplace as part of a regular health plan, while others stand alone. Some have a waiting period, stated deductibles, co-payments, or annual maximums.

Dental insurance typically covers preventive procedures, such as routine cleanings and X-rays. It also covers some basic restorative work, such as fillings. However, some dental plans require a patient to pay for a portion of the treatment before the insurer will begin covering it. These types of dental plans are called fee-for-service or indemnity plans.

Emergency care

Fortunately, most dental insurance plans cover emergency care. However, deductibles, coinsurance and policy maximums still apply. Many dental offices pre-screen patients for insurance before services are rendered and help them understand what they will owe based on their plan. They may also offer payment plans to make a procedure more affordable for those without insurance or who have high deductibles and copays.

Depending on the severity of a dental issue, it may be necessary to visit the hospital for emergency care. ER doctors typically won’t be able to fix the problem, but they can treat secondary symptoms like pain and bleeding.

Many states provide dental coverage to Medicaid enrollees as part of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. While some state policies may include only oral screening, others cover dental treatments if they are determined to be medically necessary. Other resources for emergency care include community dental clinics, which can often be accessed for free or at a reduced cost.


Co-payments are a way for patients to share the cost of dental care with their insurance company. The amount of the co-payment depends on your insurance plan and your deductible. In general, dental plans with a higher monthly premium will include lower deductibles and co-payments.

In addition to the deductible, dental insurance policies often have limits on how often and for what treatments they will pay. For example, many insurance plans only pay for a dental exam and cleaning every 6 months or twice per calendar year. They may also limit coverage to a certain number of visits for specific procedures such as X-rays or fillings.

Dental insurance plans are categorized into categories according to their American Dental Association (ADA) code. Preventive services include exams and cleanings, X-rays, fluoride treatment, and sealants. Basic services cover fillings and non-surgical extractions. Major services are crowns, dentures, and implants.


Deductibles are the amount that you must pay before the insurance company starts paying for procedures. Once you have met the deductible, most dental plans only cover a percentage of the cost, called coinsurance.

The deductible is typically based on a calendar year or plan period. It is important to understand this before choosing a plan. Some services, such as diagnostic or preventive treatments, are automatically covered, and do not count toward your deductible.

Some dental insurance plans use a Preferred Provider Organization (PPO) or Dental Health Maintenance Organization (DHMO) network to reduce out-of-pocket costs. These networks usually have a list of dentists who agree to discount their rates for plan subscribers. The plan may also include a referral service for out-of-network treatment. However, these networks can restrict your choice of dentists and limit access to certain treatments. In addition, these plans often have a maximum annual or lifetime limit for coverage.


Co-insurance is a cost sharing arrangement between you and your insurance provider. This means that you will pay a percentage of the dental fees for covered procedures after your deductible is met. The percentage varies from plan to plan, but is usually higher with higher-priced plans.

Coinsurance is generally listed on your plan details along with a calendar year maximum, deductible, and annual maximum benefit. It is important to know these terms before you select a dental plan to avoid surprises when it comes time to schedule your annual visits.

Many insurance providers offer a network of dentists who have contracted to accept a reduced rate for their services as an in-network provider. This is often referred to as a Preferred Provider Organization or an Employer Table of Allowance plan. At Making You Smile, we are an in-network/participating provider with a variety of PPO, EPO, and employer table of allowance plans.