Dental Insurance – What You Need to Know

Dental insurance is a form of health coverage that pays for some of the cost of a person’s dental care. These policies typically include deductibles and annual maximums.


When comparing plans, consider a DPPO that has larger networks than DHMOs (which only cover dentists who are part of the plan). Also look for a provider with whom you have a good relationship.

Preventive care

Dental insurance plans usually focus on preventive care, which helps keep the cost of care down by reducing the need for more expensive procedures. This is why most dental insurance policies offer at least some basic preventive services for free, such as semi-annual cleanings and exams, fluoride treatments and sealants for kids.

Most dental insurance policies also have a deductible, which is the amount that the insured must pay out of pocket before the plan starts to pay. This is unlike health insurance, where most plans have no deductible. Dental plans may also have copays, which are flat fees for certain visits / treatments and do not count toward the deductible.

Another common type of dental plan is a preferred provider organization (PPO). These are like health insurance PPOs, in that they come with a network of dentists who have agreed to provide services for a discounted rate to the insurer’s plan members. This is opposed to direct reimbursement plans, which usually only cover a percentage of the dentist’s fee after the plan pays out.

Dental insurance plans can be purchased through employers, state exchanges or directly from a dental insurance company. eHealth’s licensed insurance agents are available to help consumers compare dental plans and find the right one for them. We can explain the benefits and costs of each option, as well as help consumers determine their budget and coverage needs.

Basic care

Many dental plans have a deductible, which is the amount you must pay out of pocket before your plan begins to cover treatment costs. This deductible usually applies to preventive care such as annual cleanings, exams and x-rays, but it also may apply to other types of treatments such as fillings and crowns. Deductibles are different for each individual on the plan and for families, and they can vary from one dental insurance company to the next.

Dental health problems are largely preventable, and many dental insurance plans emphasize this with a large emphasis on preventive procedures. Preventive treatments include regular cleanings and exams as well as fluoride, sealants and other restorative services. DHMOs often limit coverage for these services, while DPPOs provide more choice and flexibility by providing the option to use dentists outside of their network at discounted fees. Most plans also have an annual maximum, which is the total dollar amount that your dental insurance will pay for covered services over a calendar year. Some plans may have a lifetime maximum as well.

Most dental plans classify treatments into categories of Major, Basic and Preventive/Diagnostic. This helps patients understand what procedures their plans will cover, although it can be confusing as some treatments are categorized as both Major and Basic at the same time. Also, some dental insurance plans impose limitations based on procedure classification rather than yearly limits.

Major care

Most dental insurance plans take a 100-80-50 approach to coverage, with preventive care like cleanings and exams covered at 100%, basic procedures like fillings are covered at 80% and major services like crowns and dentures are covered at 50%. The percentage that is left for the patient is known as coinsurance. The deductible is the amount that must be paid before the plan begins to pay for the procedure. Some plans also have a copay, which is a set dollar amount the patient must pay for services.

Dental-health issues, unlike most other illnesses and injuries, are largely preventable with regular visits to the dentist and appropriate treatments. Most dental insurance plans encourage their subscribers to seek these treatments by covering preventive services at 100%, while requiring them to pay a larger share of the cost for more serious treatments.

Most of the types of individual dental plans that are available for purchase have networks of approved dentists. For example, a DHMO, or dental preferred provider organization, only pays for treatments performed by in-network providers. If the subscriber chooses to visit a non-approved provider, they may have to pay an additional fee called coinsurance. Some plans have a deductible, while others do not, and some even have waiting periods for certain types of procedures. While these additional fees are not the main reason a person would seek out dental insurance, they should be considered when evaluating a specific plan.


In many cases, dental insurance plans provide low – or even $0 – out-of-pocket costs for preventive care such as cleanings and X-rays. For other procedures, there are a variety of cost structures. Some policies use a table or schedule of allowance, in which each service is assigned a dollar amount that the insurer will pay toward treatment, with any remaining fee charged to the patient. Others use a capitation model, in which the insurer pays contracted dentists a monthly sum per enrolled family or individual and then reimburses the patient for treatment received at that dentist.

All dental plans have a cap on the amount they will pay toward your costs during a plan year, which is called the annual maximum. It’s important to understand how these caps work, so you can anticipate your out-of-pocket costs. Many dental PPO plans have an annual maximum of $1,500, while some have a lifetime maximum for some services like orthodontics.

Experts recommend visiting your dentist at least twice a year for regular preventive care, such as an exam and cleaning. But, because of the way most dental insurance plans are structured, you may need to visit more frequently to make the coverage worth it. In addition, most dental insurance plans have time limits on other treatments, such as a series of X-rays that may be covered only every three years or two fillings in the same tooth within a year.