Understanding Dental Insurance Benefits


We know how busy you are and how difficult dental insurance can be to understand. Therefore, we have listed some key words you need to understand when it comes to your benefits. Please feel free to contact our office with any questions you may have about your specific dental benefits.


Deductible – A deductible is the amount of money determined by your insurance plan that must be paid by you before your benefits begin each year. A typical dental deductible is 25, 50, or 75 dollars. Many plans waive this deductible for cleanings, exams, and x-rays.

Annual Maximum – Most insurance plans operate on a calendar year. The annual maximum is the amount of dental coverage a plan provides in a single year. A typical dental maximum can be 1,000, 1,500, and up to 2,000 dollars.

Percentages – The percentage an insurance company pays is often determined by the type of procedure you are having. Procedures are normally classified by the insurance company as preventive, basic, or major and the following are the percentages typically paid for each type of procedure.

Preventive 100% – Exams, X-rays, and Basic Cleanings

Basic 80% – Fillings, Deep Cleanings, and Root Canals (sometimes considered major)

Major 50% – Crowns, Bridges, Build-ups, and Dentures

Fee Schedule – Some plans’ coverage is determined by a fee schedule instead of a percentage method. When this is the case, insurance companies determine an amount they are willing to pay for each type of procedure instead of a percentage.

Exceptions – Most policies have some exceptions and we will try to explain some of the most common exceptions we see with insurance policies.

Frequencies – Insurance policies will usually only cover a procedure a certain amount of times during a specified time frame. For example, some bitewing x-rays are only covered once in a calendar year.

Waiting Periods – If your plan has a waiting period, you may have to wait 6-12 months before you are eligible for certain procedures.

Missing Tooth Clause – When this exception is included in your plan, coverage will not replace teeth that were missing before your policy began. For example, no benefits would be payable for a bridge that would replace a tooth that was missing before your policy began.

Usual and Customary – If your insurance benefits are based on percentages, then you may have an exception based on “usual and customary fees”. Insurance plans set a maximum fee for each procedure. For example, if a cleaning cost $80, but the insurance has a usual and customary fee they have set at $75, then even though the insurance states they pay 100% for cleanings, they will only pay $75.

Image courtesy of stockimages at FreeDigitalPhotos.net

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