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What do dental plans normally cover?

There are seven basic areas of dental care that policies cover. With individual policies, often only the first four will be covered in the initial year of a policy with the last two available in later years. Orthodontics is usually a rider for both individual and group policies that can be selected when relevant.

  1. preventive care, i.e. cleaning, routine office visits;
  2. restorative care, i.e. fillings and crowns;
  3. endodontics, i.e. root canals;
  4. oral surgery - tooth removal and minor surgical procedures such as tissue biopsy and drainage of minor oral infections;
  5. orthodontics--retainers, braces, etc.
  6. periodontics - scaling, root planning and management of acute infections or lesions; and
  7. prosthodontics--dentures and bridges.

Dental benefits overcome consumers’ top concern about getting the care they need—cost. The seven types of procedures are broken into three areas of coverage for payment purposes, i.e. preventive, basic and major.

Most plans cover 100% of preventive care and apply co-payments, either as a dollar amount (DHMOs) or as a percentage (DPPOs and Dental Indemnity/ or Traditional Insurance) to other levels of care. Preventative care usually includes periodic oral evaluations, x-rays and sealants. (NOTE:  Sealants may be limited to certain age groups.)

Basic procedures, i.e. office visits, extractions, fillings, root canals, and periodontal treatment for gum disease, are typically covered at a lower percentage amount, for instance 80% (sometimes 60%), or with lower dollar co-payments in the case of a DHMO.

Major procedures, i.e. crowns, bridges, inlays, and dentures are usually covered at the lowest percentage, such as 50% or a higher dollar co-payment in the case of a DHMO. Root canals are also sometimes covered in this category rather than as a Basic procedure, so check your coverage. Some carriers now offer coverage for implants under this category of coverage.

Just under half of dental PPOs, the predominant dental product in the market, have a maximum annual benefit above $1500—half are less than $1500. Deductibles for these products are usually between $50 and $100. Some carriers now offer policies that roll some portion of 2-6% of Americans with dental benefits hit their annual maximum.
What do dental plans normally cover

In 2015, the portion of Americans hitting their annual maximum jumped to about 9%. If this change becomes a trend, it could be a key factor in employers increasing annual maximums. In most years, employers resist changing annual maximums because of higher premium costs for higher annual limits.  NOTE:  DHMOs rarely have an annual maximum while most dental indemnity product annual limits parallel DPPO limits.