How does dental insurance work?

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Dental insurance generally covers a portion of the cost of a range of dental services from routine preventive care to dental surgery. But if you've never purchased or used dental insurance benefits before, the terminology can get a bit confusing. What exactly is dental insurance? What are waiting periods and maximums? And most importantly, how does dental insurance work?

Dental insurance is a type of supplemental health insurance that can help you budget for the cost of maintaining your oral health. It typically covers a portion of the cost of dental procedures in three main categories: preventive care such as cleanings and x-rays, basic care such as fillings, and major care such as surgery or crowns. Coverage and costs vary depending upon the tier of plan you select and the company you purchase dental insurance from, among other factors.

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Practically all dental insurance involves waiting periods and annual maximums. These amounts can affect how much your dental insurance will pay for the cost of treatment. However, they may not apply to all types of dental treatment.

Dental insurance annual maximums behave a bit differently from other insurance maximums you may be familiar with. Maximums in health insurance typically designate an out-of-pocket maximum that the patient pays. For example, a health insurance plan with a $5,000 out-of-pocket maximum indicates that a policyholder will not have to pay more than $5,000 for covered treatment, even if bills far exceed that amount. Annual maximums in dental insurance are essentially the opposite. Dental insurance designates an annual maximum that a dental insurance company will pay. This may be for specific services, such as orthodontia, or for all dental treatment for a full year. For example, a dental insurance plan with a $2,000 annual maximum will pay out a maximum of $2,000 in dental benefits during a calendar year. Costs that exceed that maximum will be paid out-of-pocket by the policyholder.

Most dental insurance also involves a waiting period. A dental insurance waiting period is typically a designated time between the policy effective date and when benefits will start being paid. Waiting periods are usually tied to specific categories of treatment. For example, Guardian Direct® top-tier plans have a relatively short waiting period of six months for basic dental services. This means the dental insurance company will not pay benefits for basic treatment received until after those six months are up. On the other hand, all Guardian Direct plans have no waiting periods for preventative treatment such as cleanings and x-rays.

As you compare dental insurance plans, be sure to familiarize yourself with how each plan works in terms of annual maximums, waiting periods, and other policy details. Though dental insurance may seem a bit difficult to navigate at first, it’s easy to enroll in a plan and use your benefits.

Some dental insurance compare sites may be misleading

Before enrolling in a dental insurance plan, it’s a good idea to compare multiple plan and insurance company options.

Many dental insurance compare sites exist to help guide your search, but be sure to carefully review the comparison results. Many dental comparison websites may compare very different plans to one another, creating material inaccurate averages that really don’t offer an apples-to-apples comparison when taking into account factors outside of price. Some sites may group dental discount plans in with individual dental insurance plans though they are not the same thing at all.

While you certainly want to make sure your dental insurance plan offers affordable coverage for the price you pay and that your monthly premium is comfortably within your budget, price isn’t the only factor you should consider as you compare dental insurance plans. As you research different dental insurance plans and how they work, consider the following common factors:

  • Premium costs – Once you’ve requested a quote, be sure the monthly premium cost is well within your budget, so you don’t experience a lapse in coverage due to missing payments.

  • Out-of-pocket costs – Your premium cost isn’t the only cost you’ll have to budget for. Be sure you’re aware of any applicable deductibles or co-pays you may have to pay each visit. Beyond that, look carefully at the coverage provided by your plan as you’ll be responsible for paying any treatment costs your insurance company doesn’t fully cover.

  • Coverage – Most insurance companies offer more than one type of plan, varying when it comes to what procedures are covered and at what percentage. Be sure you’re satisfied with the level of coverage your plan provides, especially if you’re considering getting major dental work done.

  • Network size –Dental coverage doesn’t count for much if you can’t use your coverage. Look for an insurance provider with a large provider network, preferably with multiple dental providers near your home or office. Find a dentist in the Guardian Direct® network.

As you explore different dental insurance plan options, note that prices and policies typically vary from state to state or even zip code to zip code. An effective way to compare dental insurance plans is to request a quote directly from the carrier, then compare that across carriers or plans.

Where to buy dental insurance online

What dental procedures are covered by medical insurance

Dental insurance and medical insurance are two distinct types of health insurance that rarely overlap. Medical insurance typically does not cover dental care. Dental insurance, on the other hand, is designed to cover part of the cost of the prevention and treatment of oral care. It may include medically necessary oral procedures such as oral surgery as well as non-medically necessary oral procedures intended to help prevent oral disease, such as fillings, cleanings, x-rays, and more.

However, dental insurance and medical insurance do occasionally overlap. Medical insurance may cover dental procedures that are deemed medically necessary, such as surgery, treatment for a traumatic injury to the jaw or face, or treatment for an abscessed tooth . Some dental insurance may also cover major care, which could also include surgery, injury care, or treatment for an abscessed tooth¹. Medical insurance typically does not cover routine dental care or any other treatment that is not deemed medically necessary.

Note that insurance coverage varies depending on your plan and insurance carrier, among other factors – consult your policy for exact details on what procedures are covered by your insurance plan.

Self-pay, individual dental insurance

Now that you know a little more about how using dental insurance works - what’s enrolling in a dental insurance policy like? Many Americans receive dental benefits through a group plan offered by their full-time employer. But unemployed individuals, part-time workers, freelancers, independent contractors, and people who simply aren’t satisfied with the plan offered by their employer can still obtain affordable dental insurance through self-pay, individual dental insurance.

Also known as individual or direct dental insurance, self-pay dental insurance is a direct-to-consumer, individual policy rather than a group policy offered by some employers or insurance carriers. It behaves roughly the same, with monthly premiums, deductibles, co-pays, etc. However, in a self-pay plan, you are responsible for making annual or monthly premium payments as well as for any out-of-pocket costs not covered by your plan. You’ll typically enjoy the flexibility to choose the plan that may work best for your family’s needs and changes or end your coverage at any time you choose rather than having to find a new job to get different dental benefits. Self-pay dental insurance can help cover just yourself or your entire family.

How to get a dental insurance policy & related insights

Once you’re clear on what sort of dental insurance plan you’re looking for and how dental insurance works, it’s time to start shopping for coverage.

Nowadays, you can purchase affordable dental insurance online 24/7 directly from an insurance provider. With Guardian Direct®, you can get a dental insurance quote within seconds, with guaranteed acceptance and instant approval. Depending on selected payment method, coverage begins on the first of the month following enrollment.

Simply input some basic information about who needs coverage and what sort of coverage you’re looking for to receive a quote for Guardian Direct dental coverage. Once you’ve compared plan options and settled on a plan, you can enroll and start using your benefits as soon as coverage kicks in.

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Sources

  1. https://www.dentistryiq.com/front-office/insurance-coding-and-tips/article/16352593/what-makes-it-medical-a-basic-guide-to-medical-vs-dental-procedures, 2021, last accessed July 2021

Brought to you by The Guardian Life Insurance Company of America (Guardian), New York, NY. Material discussed is meant for general illustration and/or informational purposes only and it is not to be construed as tax, legal, investment or medical advice.(exp.10/23)

2021-125316