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A comprehensive guide to dental insurance

man brushing his teethYou may not think of dental insurance often, but you might be glad you have it the next time you go to your dentist’s office and you don’t have to pay a large bill. 

We’re answering all your commonly asked questions about dental insurance below, including:

How does dental insurance work?

Dental insurance is a type of protection you can purchase to help with the costs of dental care. Like medical insurance, dental insurance can be obtained as a group plan through your employer as part of your workplace benefits package or voluntary benefit, through an insurance broker, through the Affordable Care Act (ACA) marketplace, or directly online from companies like Guardian Direct.

Taking care of your teeth and maintaining good oral and overall health can be expensive. Dental insurance generally covers a portion of the cost of a range of dental services from routine preventive care to dental surgery. Dental insurance also typically includes negotiated rates with a network of dentists, further helping reduce the cost of dental services.

Dental care is generally grouped into three main categories: preventive, basic, and major. Many dental insurance plans cover preventive care, basic procedures, and major services. However, coverage and costs can vary depending upon the plan level you select.

There is no standard classification among insurance companies for what services are considered preventive, basic, or major and insurance coverage varies. When comparing dental insurance policies, it’s important to compare what services each insurance company classifies as preventive, basic, or major and what their coverages are for those classifications. Preventive, basic, and major treatment, generally includes the following:

Preventive care

  • Oral exams
  • Cleanings 
  • X-rays

Basic services

  • Fillings
  • Simple extractions

Major services

  • Crowns
  • Complex extractions
  • Oral surgery
  • Implants

Without a group or individual dental insurance policy, you must pay all the fees charged to you by dentists out of your own pocket. 

what dental insurance cover graphic

Types of dental insurance

There are two major types of dental insurance: Dental Preferred Provider Organization (DPPOs) and Dental Health Maintenance Organizations (DHMOs). From co-pays to annual maximums to your network of dentists, each plan offers its own unique advantages for cost and coverage options to help suit your needs.

In addition to DPPOs and DHMOs, you may also have a choice of joining a dental discount plan, which is not insurance but typically provides members with dental care at lower fees1. Medicaid also provides a limited amount of coverage for dental care if you meet certain eligibility requirements as set by your state. 

DPPOs

In a DPPO (or PPO), dentists and an insurance company have an agreement to provide services to subscribed clients at reduced rates.  The insurance company pays a percentage of dentist's charges by category of service (e.g. preventive, basic, and major). You as the insured would them be responsible for paying the remainder of the dentist's charges.

Unlike a DHMO, a PPO has a much wider network of dentists you can visit and is more likely to offer reimbursement for services from an out-of-network dentist. However, PPO members are incentivized to visit an in-network dentist because they have reduced contracted rates and you wouldn’t need to submit any claim forms. An in-network dentist submits all dental claim forms directly to your insurance company on your behalf.

If you choose an out-of-network dentist, you may be charged their regular rates for services, which will likely be higher than the in-network contracted rates. Your insurance will only pay a standard amount, calculated according to the requirements of your state. You will be responsible for the difference.

Some DPPO plans have no waiting periods (time period following your coverage start date during which no benefits are paid) for preventive care, such as cleanings, exams, and X-rays. Basic services, such as fillings and simple extractions, and major dental work, such as root canals, crowns, implants, and kids’ braces, may have waiting periods of six to 12 months, depending on your state.

dentist examining x-rays of teeth

DHMOs

In a DHMO, dentists contracting with an insurance company agree to accept an insurance fee schedule and give their patients a reduced cost for services as an in-network dentist. You are required to choose a primary care dentist from the DHMO’s network of dentists, which will likely be smaller than a PPO’s network. If you do not choose a primary care dentist, a dentist in your area will be assigned to you. All care must be provided or arranged by your primary care dentist. There is no out-of-network coverage.

DHMO plans like Guardian Direct’s pay the difference between the total cost of dental services and your office visit charge plus the copay. You pay a small office visit charge plus a copay amount associated with each type of covered treatment. 

With a DHMO program, you know exactly what you will be responsible for paying before you visit the dentist. There are no claim forms to submit, no waiting periods, no deductibles, and no caps on maximum annual payouts.

Dental discount plans vs. dental insurance

a woman choosing a dental insurance planDental discount plans are not insurance. You typically pay an annual fee to join the discount plan and you also pay the dentist directly the entire cost of services provided by the dentist at a discounted rate negotiated between the dentist who participates in the discount plan and the referring company. Discounts can range between 10% to 60%2 of the normal cost depending on the service provided. You will pay full price if the dentist you go to does not participate in the discount plan.

Many dental insurance plans will cover 100% of two preventive care visits a year, including routine cleanings, exams, X-rays, topical fluoride, and sealants. Dental insurance can also help lower your cost of procedures like fillings, extractions, crowns, and root canals through negotiated rates with a network of dentists and also by covering a percentage of the cost of dental care. 

Many dental insurance companies allow you to choose a dentist participating in your insurance network. Some discount networks include thousands of dentists while others include less than 200.

Waiting periods with dental insurance vary depending on the type of dental procedure. There are typically no waiting periods for preventive care, but there can be for other types of dental services. Depending on the service, there may be no waiting periods with dental discount plans.

When it comes to basic and major dental services, overall, you may pay less with dental insurance coverage over a discount dental plan. Although your monthly premiums for a dental insurance policy may be higher than your discount dental plan annual fees, insurance plans may sometimes cover 100% of dental visits and procedures (up to a stated maximum, and after your deductible if there is one). If you have any expensive procedures ahead, you’ll likely pay a lot more out-of-pocket with a dental discount plan.

Medicaid

While Medicaid guidelines require states to provide some level of dental care for children, states are not required to provide dental benefits to adults. Each state decides whether to provide those and, if so, which dental services they will cover.3

Many states limit coverage to only tooth extractions or to specific demographics. Many states provide only emergency dental services for adult patients. Medicaid does not set a minimum requirement for the dental coverage states provide to adults as they do for children. Contact your state’s Medicaid office for specific information about adult dental coverage.

Is dental insurance worth it?

why dental insurance is worth it for AmericansTaking care of your teeth and maintaining good oral and overall health can become expensive. Dental insurance helps pay for preventive care like cleanings and X-rays, that can keep you healthy, but it also helps pay for more extensive, costly, and often unexpected expenses, such as fillings, crowns, and root canals. 

Americans with dental benefits are more likely to go to the dentist, take their children to the dentist, receive restorative care and experience greater overall health. Conversely, if you don’t have dental insurance, you are more likely to have extractions and dentures and less likely to have restorative care or receive treatment for gum disease. People without dental benefits report higher incidences of other illness, including heart disease, osteoporosis, and diabetes.4

And, if you have young children, regular visits to a dentist can be an important part of your child’s lifelong oral health. Tooth decay is the most common childhood disease of children aged six to 11 years and adolescents aged 12 to 19 years5—often causing pain that impacts a child’s sleeping or eating habits, and it may lead to school absences. Dental insurance helps make taking care of a child’s oral health more affordable.

childhood tooth decay symptoms

Dental insurance for seniors

Some seniors may think that as they get older their teeth become less important so they don’t need dental insurance. The opposite is true. In fact, adults over 65 are more likely to have tooth decay, gum disease, tooth loss, and oral cancer.6

Paying for dental care can also be an issue. Almost 60 million people in the U.S. rely on Medicare for their health insurance.7 But traditional Medicare does not cover dental or vision care. Individual dental insurance can supplement your Medicare coverage and help you pay for preventive care, as well as major dental services.


How much is dental insurance?

How much you can expect to pay for dental insurance depends on a variety of factors including your policy type (PPO vs. DHMO), whether your dentist is in or out of network, the type of services you are looking for, deductibles, and your plan’s maximum payouts. If you have a family or think you may need major dental work over the next two to three years, including fillings, crowns, implants, or braces, higher-tier plans provide more coverage for those procedures but may have higher costs.

Premiums

a dentist in her officeAn insurance premium is the amount of money you pay either monthly or annually for the policy to stay in effect and for the insurance company to honor claims you or your dentist may make. 

The amount of your premium depends on the type of insurance you buy and the extent of the coverage the plan provides. Plans that cover only preventive services may have less expensive premiums than those providing full coverage for all dental services.

Features of the plan also affect the cost of dental insurance premiums. Plans with a high deductible, say for example $500 per year, are likely to cost less than plans with only a $50 annual deductible. Generally, plans that pay a higher fee-per-service or a high percentage of fees charged cost more than ones paying out at a lower rate. The amount of the annual maximum benefit also influences the monthly premium amounts.

Deductibles

A deductible is the amount that you must pay from your own pocket before the insurance plan begins to pay out benefits for your dental treatment. 

As with medical insurance, the higher the deductible, the lower the cost of the insurance. Depending on the plan, some services, such as diagnostic and preventive, might not require a deductible. 

Copayments

Commonly called copays, these are fixed amounts that you must pay at each dental appointment, regardless of what services you received. Like deductibles, the amount of copay varies with each policy. Higher copays usually mean lower premiums. This is a cost for dental insurance policies often overlooked when figuring up the overall costs of purchasing a dental plan.


What does dental insurance cover?

dental x-ray

Dental insurance generally covers a portion of the cost of range of dental services from routine preventive care to dental surgery, including oral exams, cleanings, X-rays, fillings, extractions, oral surgery, root canals, and crowns.

While no two dental insurance plans are exactly alike, dental insurance may cover all or part of these service categories:

  • Preventive services including examinations, x-rays, cleanings, fluoride treatments, and sealants
  • Basic services including fillings and root canals
  • Major services such as crowns, bridges, and dentures

In addition to these commonly covered services, some plans may include coverage for braces and implants.

Are there restrictions on what dental insurance covers?

Dental insurance policies often have built-in restrictions on coverage. It is good to know before purchasing a policy or joining a group plan what those restrictions are and whether they will affect your ability to get the coverage you need.

Annual maximums

The cap on the amount the insurance will pay in a calendar year is one of the most common restrictions of dental insurance coverage. Any fees above the annual maximum must be paid out of the patient's pocket. Once the insurance company has paid out the annual maximum, any additional charges by the dentist are the responsibility of the patient.

A typical dental insurance plan usually has a maximum amount of coverage that you may be entitled to each calendar year. Wise planning can help manage these limits, for example,  If you need extensive dental work, you might want to plan to have part of it completed in November or December of one calendar year and wait to have the rest done until January of the next calendar year. 

Waiting periods

Many policies have waiting periods before paying any claims. Be sure to ask about this restriction when shopping for dental insurance. 

Effective date

This type of restriction is like pre-existing conditions in that the policy will not likely cover any service provided before the date the policy becomes effective. 

If you purchase a policy or join a plan that has an effective date sometime after the date of purchase, you typically must wait until the effective date to have services covered. Read the policy and summaries carefully to verify the effective date so you do not get stuck with unexpected bills.


What dental insurance plan works best for you?

woman researching dental insurance plansThe dental insurance plan for you is likely the one that fits your needs and budget. You also want to consider what procedures you may need over the next two to three years, including filings and braces while also covering any costly or unexpected dental expenses that could come up, such as the need for crowns and implants. Higher tier plans typically provide more coverage for major procedures, allowing you to save money in the long run, but they may come with some increased monthly costs. You may also want to consider whether you’d like to keep your current dentist or if you’re open to change, as some dental practices may not be in the network of the dentist you select. Check out the variety of dental plans Guardian Direct offers based on your needs here.  

A PPO plan with affordable monthly costs may typically have fewer features, while a plan with higher monthly costs may likely offer more comprehensive dental coverage, as well as help provide financial protection just in case you need fillings, root canals, crowns, implants, or other major services such as child braces. DHMOs also typically cover a broad range of services but often offer less selection so you will need to decide if a DHMO or a PPO plan option that will work best for you.

Here is a list of questions you should ask when shopping for dental insurance plans.

  • How much are the monthly or annual premiums?
  • How much are the deductibles, copays, and coinsurance fees?
  • Is there a waiting period before I am covered for dental care?
  • Does the plan cover pre-existing conditions?
  • What is the annual maximum benefit?
  • Is the plan traditional insurance, a DHMO, a DPPO, or a discount plan?
  • Can I see a list of in-network dentists?
  • Can I choose my own dentist?
  • What categories of services does the policy cover and at what level (percentage or fee cap)?
  • Are there any services excluded from the plan’s coverage?
  • How does the plan cover emergency care or dental care when I am away from home?
  • Does the plan cover teledentistry services?


How to get dental insurance

There are several ways to purchase dental insurance. If you are like 90% of Americans8, you may get dental insurance through your employer as part of your benefits package, or as a voluntary benefit when you start a new job or during open enrollment, which usually occurs in the fall.

If you are self-employed and belong to a trade organization or other association, they may offer group dental insurance to their members.

If your employer doesn’t offer dental insurance, you can purchase individual dental insurance from a dental insurance company online. Limited options are available on healthcare.gov or your state’s ACA marketplace.

Employer-sponsored plans

a couple buying dental insurance onlineUsing the dental insurance sponsored by your employer may be the least expensive option for you. Large groups tend to pay lower monthly premiums.

The disadvantage of employer-sponsored plans is that they are usually a one-size-fits-all policy. Everyone in the company has the same level of coverage, the same deductibles, and the same restrictions—you cannot custom design a plan to fit your own needs.

Employer-sponsored plans vary with the types of plans offered. Some may be traditional insurance; others may be DHMOs or DPPOs. It is important to know if your dentist is in the network and, if not if there are some local reputable dentists from which you can choose.

Individual plans

Most dental insurance companies have policies available for individuals and families to purchase. Typically, one advantage of an individual dental insurance plan is that you have more flexibility in choosing the level of coverage, the amount of the deductibles and copays, and the dentists you can use. 

Using an insurance company’s website is usually the quickest way to sign up for coverage. You may even get to choose your payment method, frequency, and schedule for your premium payments.

To purchase individual dental insurance directly from a dental insurance company, you will likely need the following:

  • Zip code of your primary residence
  • Names and ages of all people who need to be covered
  • How much coverage you need
  • How much you are willing to pay each month
  • Consider if you need to cover just yourself or if your spouse or partner or your children also need coverage. You will need to know the ages of each party who needs to be insured before you can complete your quote
  • Payment information

 

This is not dental care advice and should not be substituted for regular consultation with your dentist. If you have any concerns about your dental health, please contact your dentist's office.

Links to external sites are provided for your convenience in locating related information and services. Guardian, its subsidiaries, agents and employees expressly disclaim any responsibility for and do not maintain, control, recommend, or endorse third-party sites, organizations, products, or services and make no representation as to the completeness, suitability, or quality thereof.

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Sources:

1. https://www.cda.org/Home/News-and-Events/Newsroom/Article-Details/offering-a-discount-dental-plan-in-the-practice-the-basics, 2020
2. https://www.dentalplans.com, accessed August 2020
3. https://www.medicaid.gov/medicaid/benefits/dental-care/index.html, accessed August 2020 
4. https://www.nadp.org/Dental_Benefits_Basics/Dental_BB_1.aspx, 2017
5. https://www.cdc.gov/healthywater/hygiene/disease/dental_caries.html, accessed August 2020
6. https://www.cdc.gov/oralhealth/basics/adult-oral-health/adult_older.htm, 2019
7. https://www.kff.org/medicare/state-indicator/total-medicare-beneficiaries, 2018
8. https://www.nadp.org/Dental_Benefits_Basics/Dental_BB_1.aspx, 2017

 

Dental

Individual dental insurance products are underwritten by The Guardian Life Insurance Company of America, New York, New York or by one of its wholly owned subsidiaries. Products are not available in all states. Policy limitations and exclusions apply. The actual limitations and exclusions that apply to your Dental Plan are governed by the policy forms approved for use in your state. Please refer to your policy for a complete list of limitations and exclusions. In the event of a conflict between this document and the language stated in your Guardian insurance policy, the language of the policy shall control. This policy provides DENTAL insurance only.

Dental provider networks vary by state, by market and by plan type

Rates are guaranteed for one year for your policy of benefits initially selected. Policies renew annually.

IMPORTANT INFORMATION ABOUT GUARDIAN’S DENTALGUARD INDEMNITY AND DENTALGUARD PREFERRED PPO PLANS

Dental PPO plans provide in-network and out-of-network benefits. Use of an in-network provider may result in reduce out of pocket costs.

Coverage is limited to those charges that are necessary to prevent, diagnose or treat dental disease, defect, or injury. Deductibles apply. Waiting periods may also apply for some services

Individual dental plans do not pay for: oral hygiene services (except as covered under preventive services), orthodontia (unless expressly provided for), cosmetic or experimental treatments, any treatment to the extent benefits are payable by any other payor or for which no charge is made, prosthetic devices unless certain conditions are met, and services ancillary to surgical treatment.

Individual dental plans limit benefits for diagnostic consultations and for preventive, restorative, endodontic, periodontic and prosthodontic services.

Listed services, exclusions and limitations do not constitute a contract and are a summary only.

IMPORTANT INFORMATION REGARDING DENTAL HMO BENEFITS

Dental HMOs provide Pre-Paid dental benefits through a network of participating general dentists and specialty care dentists. All covered services must be provided by the member’s Primary Care Dentist. Specialty care services are covered only when referred by the member’s Primary Care Dentist and approved in advance by the Dental DHMO.

Only those services listed in the Dental HMO plan are covered. Certain services are subject to annual or other periodic limitations. Where orthodontic benefits are specifically included, your policy provides for one course of comprehensive treatment per lifetime, per member. Dental HMOs do not provide orthodontic benefits if comprehensive orthodontic treatment or retention is in progress as of the member’s effective date. Listed services, exclusions and limitations do not constitute a contract and are a summary only.

Products Underwritten by Guardian Life Insurance Company of America

DENTAL PPO PLANS  Policy Form IP-DEN-16 ET. AL.

DENTAL HMO PLANS

      FLORIDA              Policy Form IP-1-MDG-DHMO-FL-OFF-17

      NEW YORK          Policy Form IP-MDG-NY-FP-OFF-17

 

Products Underwritten by Managed Dental Guard, Inc.

DENTAL HMO PLANS

      TEXAS                 Policy: IP-1-MDG-DHMO-TX-17

 

Products Underwritten by First Commonwealth Inc. through its Illinois subsidiaries*

DENTAL HMO PLANS

      ILLINOIS             Policy: IP-FCW-DHMO-IL-17

*First Commonwealth Insurance Company — (IL), First Commonwealth Limited Health Services Corporation — (IL), First Commonwealth of Illinois, Inc.

 

Information on the approved state and product specific online enrollment form numbers can be viewed here: Online Enrollment Form Numbers

 

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.
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