Let’s be honest—when you’re juggling new school supply lists, sports signups, and getting back into a routine, the last thing you want to deal with are surprise dentist visits and confusing dental bills.
If you’re trying to figure out what your dental plan covers or whether you need to squeeze in that checkup before the end of your insurance year (whenever that may be), know that you’re not alone! We’ve been there too, so we put together this guide, which walks through some of the most common questions parents have about dental insurance.
Which dental procedures are usually covered by my employer plan?
While every dental plan has its quirks, there are some common patterns that show up across the board. Remember, however, that your dental procedure coverage depends on the work done and your specific dental insurance plan.
Common Dental Coverage Trends
- 100% is often covered by preventive care like cleanings, exams, and x-rays. Dental insurance typically focuses on keeping your teeth healthy before problems start.
- 70%-80% can be covered for fillings and simple procedures, like basic extractions. Basic services like these are often covered at a higher rate.
- 50% can be covered for more extensive procedures, such as crowns, root canals, or orthodontics. Depending on your plan, major procedures like these may not be covered.
If your kids need braces, always check the fine print of your policy. Some dental plans cover child orthodontia, but only under certain age limits or if it’s medically necessary.
How much will I pay out of pocket for dental procedures?
The amount you pay out of pocket for dental procedures will vary, but here are the three things that usually determine your costs:
- Deductible: What you pay out-of-pocket before your insurance starts sharing the bill. (This is usually a flat amount, like $50 per person.)
- Coinsurance: The way procedures are paid for is split between you and the insurance company after the deductible, like 80/20 or 50/50, depending on the type of service.
- Annual maximum: The most your plan will pay in a calendar year. Many plans cap this at around $1,000 to $2,000 per person.
Additionally, many plans limit how often certain services are covered. For example, cleanings may only be covered twice a year with one set of X-rays annually. Timing can make a difference!
Can I keep my dentist?
The short answer is that whether you can keep your dentist depends on your plan. Here’s a quick breakdown:
- PPO plans give you the most flexibility. You can visit an out-of-network dentist, but staying in-network can save you money.
- HMO plans are more restrictive. You usually have to stick with in-network dentists and may need referrals.
- Indemnity plans are the least common. With an indemnity plan, you can visit any dentist you want, but you often pay more upfront and are reimbursed later.
If you already love your family dentist, it’s worth checking to see if they’re part of your plan’s network.
Who pays the dental insurance premiums?
Many employers pay part (or even all) of the monthly premium for employee dental insurance coverage, typically ranging from 50% to 100%. If you add your spouse or kids, you’ll usually pay for the cost of their coverage.
Some companies offer what’s called a voluntary dental plan—where the premiums are entirely on you—but you still get access to group rates, which are usually better than buying dental insurance on your own.
Is a self-funded dental plan better than a fully insured one?
As someone who’s using the dental plan benefits, you probably won’t notice much of a difference between a self-funded and fully insured dental plan. Most of the differences are behind the scenes, but here’s what a fully insured dental plan and a self-funded dental plan can mean for you.
- Fully insured plans are what most people are used to. The insurance company handles everything.
- Self-funded plans are run by your employer, who pays out claims directly.
Overall, it’s good to know that self-funded plans might have more wiggle room in terms of benefits or limits, especially if your employer designs the plan in-house.
Why is dental insurance separate from health insurance?
Dental and health insurance actually evolved separately from one another. Historically, dental care was often viewed as unrelated to overall health, and health insurance typically focused on emergencies and major medical conditions.
We know now that oral health is a significant part of overall health, but that realization came a little too late for the insurance industry to consolidate the two types of insurance into one.
When can I sign up for dental insurance?
You can usually enroll for dental insurance at the following times:
- When you’re first hired
- During your company’s open enrollment period
- Or if you have a qualifying life event, like getting married, having a baby, or losing other coverage
Do my unused dental benefits roll over?
With most dental plans, your annual maximum is a “use it or lose it” situation. If you only used a portion of your benefit this year, the leftover amount usually disappears once the insurance year ends.
That said, some plans offer a rollover or carryover feature. It’s not common, but it’s worth asking your employer about, especially if you have dental work coming up that could be split across two years.
Additionally, if you’re using a Health Reimbursement Arrangement (HRA) or ICHRA, those funds might roll over depending on your employer’s rules.
How can I get the most out of my dental benefits?
When it comes to maximizing your dental benefits, a little planning goes a long way:
- Don’t skip your cleanings! They’re usually fully covered and help catch problems early.
- Time larger procedures around your annual maximum. If you’re close to the cap, ask your dentist if part of the work can wait until the new year.
- Double dip across calendar years. For example, start treatment in December, and finish in January if your benefits reset.
- Coordinate benefits if you and your spouse both have coverage. Sometimes, you can layer plans to reduce what you owe.
- Don’t be afraid to ask questions. Your dental office and insurance company are here to help you! A 10-minute call can save you a big headache (and a big bill).
As a whole, dental coverage can be surprisingly complex, considering it sounds so straightforward. But once you understand the basics—what’s covered, what it might cost, and when to take action—it’s much easier to plan care for yourself and your family.
