Dental Insurance Terms Explained: A Patient-Friendly Guide

Dental insurance coverage and limits can be difficult to navigate for several reasons. There are differences between plans, annual maximums, coverage categories such as preventive and basic, and the complex terminology used by insurers. Your dental insurance may also have specific limitations or exclusions outlined in the fine print. To help our patients better understand their dental insurance plans, we’ve put together a guide to dental insurance terminology and common plan types.

Key Dental Insurance Terms You Should Know

Annual Maximum: The total amount that your dental insurance will pay for dental care during a single year. This may be for an individual or for a family member if you have family dental coverage.

Copay: The amount you pay toward a specific procedure or service. It is typically a percentage of the dentist’s fee. It is different than a deductible. Once your deductible is met, you are still responsible for any copays.

Deductible: Sometimes called your “out of pocket” costs, the deductible is the amount you have to pay toward dental care before your insurance begins to pay for anything.

In-Network: An in-network dentist has a contract with your insurance provider and has negotiated a lower fee for services they provide to policyholders. This results in lower costs for you.

Out-of-Network: When a dentist or doctor is out-of-network, they do not have a contract with your dental insurance plan and can charge non-negotiated rates for any services. If you see an out-of-network dentist, your insurance may pay less or nothing at all toward your treatment.

Pre-Authorization: A requirement for some procedures for the dentist to submit a treatment plan and receive the dental insurer’s approval. Without pre-authorization,  some procedures will not be covered by the dental insurance provider.

Premium: The amount you pay for your dental insurance coverage. You (or your employer, if it is a company-sponsored plan) may pay the premium monthly, quarterly, or annually.

Use It or Lose It: This means your coverage applies only to a single year. If you have any unused benefits left in your dental insurance (for instance, for a dental checkup and cleaning) that you have not used at the end of the year, they do not roll over into the following year. If you do not use it by December 31, you lose it.

Waiting Period: Many dental insurers have a waiting period before you can receive benefits for certain treatments, particularly more expensive ones such as dentures or root canals.

Types of Dental Insurance Plans

Preferred Provider Organization (PPO)

These are flexible dental insurance plans that let you choose from a network of preferred dental providers. You can go out-of-network if you want, but you will save more money with in-network dentists. Many people like the flexibility of PPO plans.

Health Maintenance Organization (HMO)

For an HMO, you must choose a primary care dentist from a list of in-network providers. If you need to see a specialist, you need a referral from your primary dentist. The premiums for an HMO tend to be lower than for a PPO, but the terms are less flexible.

Indemnity Plans or Fee-For-Service

These dental insurance plans offer you the most freedom. You can choose your own dentist and pay for everything out-of-pocket, then submit an insurance claim for reimbursement. Payment upfront makes these plans difficult for patients who are on a budget, but they allow you to see any dentist or specialist you like without referrals or network restrictions.

Dental Discount Plans

Discount plans are not actually dental “insurance,” but dental savings plans that offer discounts on dental care in exchange for a monthly membership fee. There are no deductibles or annual maximums. Many dental discount plans include preventive care at no additional cost beyond the membership fees, encouraging members to practice good preventive care.

At the practice of Dr. Brian H. Snyder, we offer three In-House Dental Membership Plans starting at just $38 a month with no deductibles or exclusions for pre-existing conditions. To learn more and find out which plan is best for you, please visit our Membership Plan page.

What is Typically Covered by Dental Insurance?

Coverage can vary widely from one dental policy to another, but most insurers follow general guidelines. They typically break coverage into three categories: preventive, basic, and major care.

• Preventive Care: Services focused on preventing dental problems include checkups, routine cleanings, and X-rays. Most plans cover preventive care fully, though a few may require small copayments.
• Basic Care: Common restorations such as fillings, tooth extractions, periodontal disease treatment, and root canals are usually covered at 80% once your deductible has been met.
• Major Care: This is coverage for more invasive and complex procedures such as bridges, dentures, crowns, and oral surgery for impacted wisdom teeth. Major care is usually only partially covered and at a lower percentage (often 50%) than basic care.

Some plans may also cover a portion of orthodontic care, while others may offer this as a rider on your policy.

What is Not Covered by Dental Insurance

Dental insurance is intended to help manage the costs of keeping your teeth and gums healthy during the calendar year it is paid for. There are certain procedures and services that it may not cover, including:

• Cosmetic procedures
• Pre-existing conditions
• Experimental treatments
• Medically unnecessary treatments
• Orthodontics in general, or for anyone over 18

Tips for Maximizing Your Dental Insurance

Your dental insurance is a benefit that can greatly reduce the cost of your dental care, but it has limitations. Being savvy about when and how you use it can help you maximize your benefits. Here are a few tips for getting the most out of your coverage:

• Don’t skip routine care. Preventive coverage gives you the most bang for your buck. See us regularly for checkups and dental cleanings, which are typically fully covered and can help protect you from needing basic or major dental restorations.
• Stay in– In-network dentists have discounted rates, resulting in lower out-of-pocket costs for you.
• Never skip referrals if needed. Even if you are certain that you need a root canal, do not see a specialist if your insurance plan requires a referral from your primary care dentist. Skipping the referral can be costly if your insurance carrier rejects your treatment.
• Know your plan limits. Read through your policy, including the fine print, to understand coverage limits and your financial obligations. You can contact your insurance company if you have questions. The staff at our office can also assist you.
• Use it or lose it. Remember, your benefits do NOT roll over with the New Year. If you have benefits that will expire at the end of the year, be sure you make plans to use them while they are still in effect.

At the office of Brian H. Snyder, DDS, we work with our patients to maximize their insurance benefits and ensure they receive the finest dental care in Coral Springs, FL. If you have questions about your dental insurance coverage and would like to discuss it with one of our helpful staff members, please feel free to contact us at Brian H. Snyder, D.D.S. Phone Number 954-753-4101.