What do dental plans normally cover?

(See Dental Glossary).

Dental policies cover seven types of dental services. Individual policies often cover only the first four in the first year of the policy. The last two are available in later years. Orthodontics is usually a rider for both individual and group policies. It can be selected when relevant. The seven basic types of dental services are:

  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.

Consumers’ top concern about dental care is cost. Dental benefits pay all or most of the cost of dental care. The seven types of dental care are grouped into three areas of coverage for payment purposes. The three areas of coverage are preventive, basic and major. 

Most plans cover 100% of preventive care. Preventive care usually includes an annual or twice yearly office visit for an exam, cleaning, x-rays and sealants. (NOTE: Sealants may be limited to certain age groups.)

Basic procedures are office visits for dental problems, extractions, fillings, root canals, and treatment for gum disease. You pay for part of these procedures as a co-payment, a set dollar amount (DHMOs) or co-insurance, a percentage of the cost (DPPOs and Dental Indemnity/ or Traditional Insurance).  A typical co-insurance amount is 80% or 70%. A DHMO policy will have a set dollar co-payment close to these percentages...

Major procedures are crowns, bridges, inlays, and dentures. They are usually covered at the highest coinsurance, such as 50%. DHMOs cover major procedures at a higher dollar co-payment. Root canals are also sometimes covered in this category rather than as a Basic procedure. So check your policy. Some carriers now cover implants under this category.

About half of dental PPOs, the predominant dental product in the market, have 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 an unused annual maximum over until the next year.  Whatever the annual maximum, only 4-7% of Americans (NADP Premium and Benefit utilization Trends Report, 2014—reflects 2013 data) with dental benefits hit their annual maximum.  This is a factor that employers weigh against the premium cost for higher annual limits.   NOTE:  DHMOs rarely have an annual maximum while most dental indemnity product annual limits parallel DPPO limits. 

About NADP

National Association of Dental Plans (NADP), a Texas nonprofit corporation with headquarters in Dallas, Texas, is the “representative and recognized resource of the dental benefits industry.” NADP is the only national trade organization that includes the full spectrum of dental benefits companies operating in the United States. NADP’s members provide Dental HMO, Dental PPO, Dental Indemnity and Discount Dental products to more than 177 million Americans, approximately 90 percent of all Americans with dental benefits.