Dental insurance helps pay for exams, cleanings, fillings, crowns, and other oral care. Because most dental costs are predictable and preventable, dental plans are designed to encourage routine care while capping what the plan pays for expensive work. This guide covers plan types, the categories of dental treatment, scheduled and nonscheduled benefits, cost sharing, limitations that control cost and adverse selection, and how dental fits under the ACA.

How dental plans differ from medical plans

• Dental plans usually cap what the plan pays each year with an annual maximum per person. (Major medical plans instead cap what the insured pays, with an out-of-pocket maximum.)
• Preventive care is emphasized: exams and cleanings are commonly covered at 100%, often without a deductible, to catch problems early.
• Waiting periods and other limits discourage people from buying coverage only when they already need major work.

Plan types

• Indemnity (nonscheduled) plans reimburse a percentage of the dentist's charges, subject to plan allowances and usually after a deductible, and don't restrict the choice of dentist.
• Dental PPOs use a network of dentists who accept discounted fees; members can go out of network at higher cost.
• Dental HMOs (DHMOs) limit members to network dentists, who are paid by capitation (a fixed amount per member per month). Members usually pay little or nothing for many in-network services, with little or no out-of-network coverage.
• Integrated dental coverage is part of the medical plan, often sharing one deductible; a stand-alone dental plan is separate from the health plan.

Categories of treatment

Typical coinsurance pattern

A common design pays 100% for preventive, 80% for basic, and 50% for major services. The deductible is often waived for diagnostic and preventive care.

Orthodontics

Orthodontic coverage is often optional, usually treated as a separate category with its own lifetime maximum, and often limited to dependent children.

Scheduled, nonscheduled, and combination plans

• Scheduled (table of allowances) – pays a fixed dollar amount listed for each procedure; the patient pays any difference between the allowance and the dentist's fee.
• Nonscheduled (comprehensive) – pays a percentage of charges, usually after a deductible.
• Combination – uses a schedule for some services and percentages for others.

Limitations and cost controls

• Annual maximum – the most the plan pays per person per year.
• Deductibles and coinsurance.
• Waiting periods for major services, and limits on late enrollees.
• Missing tooth clause – excludes replacing teeth lost before coverage began.
• Least expensive alternative treatment (alternate benefit) – if a less costly, professionally acceptable treatment would work, the plan pays based on that treatment and the patient pays the difference.
• Predetermination of benefits – the dentist submits the treatment plan in advance so the patient learns what the plan will pay before major work begins.
• Coordination of benefits – when a person has two dental plans, payments are coordinated so they don't exceed the actual cost.

Dental and the ACA

Pediatric dental care is one of the ACA's ten essential health benefit categories. Adult dental is not.

Common exam traps

• Preventive is paid at the highest level, often with no deductible; major at the lowest.
• Scheduled = fixed dollar per procedure; nonscheduled = percentage of charges.
• Endodontics = root canals; periodontics = gums; prosthodontics = replacing teeth.
• Dental annual maximums cap the plan's payments, unlike a medical out-of-pocket maximum, which caps the insured's.
• DHMOs pay dentists by capitation and limit members to the network.
• Orthodontics usually has a separate lifetime maximum.
• Only pediatric dental is an ACA essential health benefit.

Quick recap

• Dental plans emphasize prevention and limit plan payments with annual maximums.
• Plan types: indemnity, dental PPO, DHMO; coverage may be integrated or stand-alone.
• Treatment categories: diagnostic/preventive, basic, major, plus the specialties (endodontics, periodontics, prosthodontics, oral surgery, orthodontics).
• Benefits are scheduled, nonscheduled, or combination; a common pattern is 100/80/50.
• Cost controls include waiting periods, missing tooth clauses, alternate benefit provisions, and predetermination.